1. Integrated Care Program Inaugural Conference
Preliminary Study of an Implemented ICP for management of seizure ED presentations at SJH
Dr. Jennifer Williams
Integrated Care Program Inaugural Conference
Dublin Castle
Oct 6th 2015

2. Epilepsy in Ireland- Why is it important???
Commonest chronic neurological condition second only to stroke
Prevalence study estimated that 37,000 people in Ireland have the disorder
Point prevalence of 0.8% in line with other industrialised nations
Significant co-morbidities as well as societal and financial burden
A European study estimated that 15billion euro is spent each year on the treatment of epilepsy in Europe that equals the combined financial burden of breast and lung cancer
One third poorly controlled on medications presentations to emergency departments where care can be variable and not evidence based

3. Change
The best value care for all people with epilepsy in the right place at the right time, sharing the best information available

4. Birth of the Epilepsy Care programme
Quality
Access
Value

5. Using a seizure care pathway improved productivity with no increase in mortality or morbidity over 12 months follow-up.
Summary National Epilepsy Programme
18/09/2018

7. NASH NASH1- 2011 1st National UK epilepsy audit 127 hospitals
Total of 3,759 patients
1st 30 seizure presentations
Multiple care metrics
Wide variability
No consistency

8. Aims of the ICP Use evidenced based medicine to guide care
Reduce variability in care
To reduce unnecessary hospital admissions
To provide patient centred care
AAN and NICE guidelines for quality and standards of care incorporated into the pathway
Name:
Phone No:
MRN:
DOB:
Date of Attendance:

9. How the ICP is supposed to work in practice
ED Doctors fill in the Seizure ICP Discharge versus Admission
Info leaflet given to pt
Completed ICP placed in ANP referrals box
ANP’s phone patients within 10 days to triage
Patients’ given RAC date within 6 weeks of ED presentation
Completed ICP given to medical team as part of patients admission notes and tx plan
ICP is part of patients’ medical record

10. Established epilepsy or recurrent seizure First Seizure
Retrieve ICP from nurses station
Consider Status Epilepticus
Consider acute treatment
Treat underlying cause
Refer for admission
File ICP in medical notes
Consult neurology
Get witness account No
Non-convulsive seizure
Single self limiting seizure
Patient awake and alert at 90mins
Normal CT brain/Neurology Exam
Consider discharge
Place ICP in ANP box
Give patient advice leaflet
ANP phones within 10days
Yes

11. Timescale for assessments and treatments

12. Integrated Care Pathway Pages 5&6

13. Integrated care plan For Seizure Pages 7&8

14. Audit of seizure management in the ED at SJH
Methods
Aims
Find out the percentage of seizure presentations to the ED who get placed on the ICP
Compare the standards of care between ICP versus no ICP
Evaluate adherence to ICP
Report back to ED on findings and identify areas for improvement
A period from Sept 2014-June 2015
Triage lists were examined for all of these days retrospectively
456 patients who presented with: “seizure, epilepsy or fit” were identified
All pts scanned ED notes were reviewed

15. Patient Demographics M 66.2% %, F 33.7 % Average Age: 42 yr
20% documented that this was their first seizure
66% had prior seizures, 45% had a diagnosis of confirmed epilepsy
14% - no documentation as to whether this was their first seizure
73.9% (337) evaluated without ICP
26.1% (119) evaluated with ICP

16. Total ICP No ICP Admitted Appropriate? Pulse EWS Complete Neuro Exam
189 (41.4%)
34 (28.7%)
155 (45.9%)
Appropriate?
429 (94%)
111 (93.2%)
318 (94.3%)
Pulse
443 (97.1%)
119 (100%)
324 (96.1%)
Temp
424 (92.9)
113(94.9%)
311 (93.2%)
EWS Complete
0 (0%)
Neuro Exam
210 (46.1%)
108 (90.7%)
102 (30.3%)
Fundi
30 (6.5%)
22 (18.4%)
8 (2.3%)
Plantars
105 (23.2%)
75 (63%)
30 (8.9%)
Glucose
396 (86.8%)
113 (94.9%)
283 (83.9%)

17. Total ICP No ICP ECG (QT correction) Advice Page Given at Discharge
351 (76.9%)
106 (89%)
245 (72.7%)
Advice Page Given at Discharge
55 (12.1%)
55 (46.2%)
0 (0%)
Driving documented CT
199 (43.6%)
59 ( 49.5%)
140 (41.5%)
Scan Not Appropriate
20 (10%)
5 (8.4%)
15(10.7%)
ICP Complete
ICP followed
81 (17.7%)
81 (68%)
Re-admission with seizure
26 (13.7%)
1 (0.8%)
25 (7.41%)

18. What have we learned from this study????
Patients on ICP had better standards of care documented
Patients not on the ICP were 10 times more likely to re-present in the following months
The legal implications of driving were only documented in half of ICP patients and none of the non ICP patients
Only 1 in 3 patients presenting to the ED with a seizure was placed on the pathway
Potential savings in preventing repeat presentations to ED single seizure presentation to ED visit costs €268
€289,434

19. Where we need to go- DICE STUDY-1yr plan
Employ a faciliator for 1 year to address barriers and facilitarors to ICP use:
Human factors
ICP interface
Electronic versus paper
Regular training for new doctors
Enagement with ANPs and Triage
Use of incentives for use

20. Where we need to go nationally
National Audit of 10 hospitals using the Nash criteria
Part of the ESBASE programme (european Study of burden and care of epilepsy) St James’s, Beaumont, UCD are collaborators
Data to be used to create a priority for development of National Guideline through the National Clinical Effectiveness Commitee (NCEC)
Currently SJH researcher undertaking systenatic review of guidelines for epielpsy care

21. TAKE HOME MESSAGES
Variability in care for patients presenting to the ED with seizures
An evidence based ICP  better care
Reduced re-presentation to ED potential savings
This is a continuous process to improvements
Involves motivation and engagement with colleagues

22. Acknowledgements
Dr. Colin Doherty – Consultant Neurologist SJH and National Clinical Lead in Epilepsy RANP – Cora Flynn- Nurse Lead in Epilepsy Dr. Una Kennedy- Consultant in Emergency Medicine at SJH Dr Chiara Di Blassi- Research Fellow Jack Doherty- Data processing and analysis