- •Causes for repeat Emergency Department (ED) attendances for seizures are complex.
- •We undertook a review of reasons and interventions of seizure related ED attendance.
- •Findings suggests many factors for attendance are not directly seizure related.
- •Mental & social well-being & seizure management education influence ED attendance.
- •Various interventions were identified but none were holistic and person centred.
- Moran N.
- Poole K.
- Bell G.
- et al.
- 1Reports focusing partly or fully on seizures and EDs
- 2Reports focusing partly or fully on seizures and emergency care pathways, including Paramedic and Emergency Medical Services.
- 3Reports focusing at least partly on mitigation plans or EDs attendance reduction
- 1How many people attend EDs yearly due to epileptic seizures?
- 2How many are repeat attendances?
- 3What are the demographics of the attendees?
- 4What are the risk characteristics of the attendees?
- 5How many are receiving epilepsy specialist care?
- 6How many had a specialist review in the previous year?
- 7What measures are implementable to reduce repeat attendance and improve care?
|Dickson et al (2018) [|
|Cross-sectional study of emergency hospital care for adults with suspected seizures||Cross sectional study using hospital episodes statistics which looked at frequency, characteristics, geographical variation and costs.||Adults who attended an emergency department or who were admitted to hospital||Suspected seizures are the most common neurological cause of admissions and readmissions are common|
|Dixon et al (2015) [|
|National audit of seizure management in the UK||Quantitative analysis of data||Data from 4544 attendances across 154 trusts||Variability in care provided across the care pathway. Improvements in care required|
|Allard et al (2017) [|
|Frequency and factors associated with emergency department attendance for people with epilepsy in a rural UK area||Quantitative questionnaires||46 people with epilepsy||Approximately 1/3 attended the emergency department on three or more occasions and accounted for 65 % of total emergency department attendances reported|
|Noble et al (2012a) [|
|Characteristics of people with epilepsy who attend emergency departments||Prospective study. Questionnaires||85 people with epilepsy||Compared to the wider epilepsy population, emergency department attendees experienced more seizures, anxiety, had lower knowledge of epilepsy and its management and greater perceived epilepsy related stigma|
|Girot et al (2015) [|
|Use of emergency departments by people with epilepsy||Descriptive case series report of cases with epilepsy||448 people with epilepsy||People with known epilepsy are major consumers of pre and intra hospital emergency services|
|Balestrini et al (2013) [|
|Emergency room access for recurring seizures||Prospective comparative analysis of the clinical and social characteristics of two groups of participants||Participants were divided into two groups depending on whether they went to the emergency department after seizures. (n = 209)||Factors related to emergency department use may be demographic and clinical|
|Kumar et al (2018) [|
|Clinical correlates of negative health events (NHE) in a research sample of people with epilepsy.||Analysis of baseline data from a larger randomised epilepsy self-management clinical trial||120 people with epilepsy, who had experienced a NHE within the previous 6 months. These were defined as seizures, accidents or traumatic injury, self harm attempt, ED visit and hospitalizations.||More frequent seizures were associated with worse depression severity and quality of life. Higher seizure frequency was also associated with worse epilepsy related stigma|
|Bautista et al (2008) [|
|Factors associated with utilisation of healthcare resources among people with epilepsy||Interviews. Quantitative data||256 people with epilepsy||Seizure frequency and quality of life are major factors associated with health care use. Participants were interviewed following an admission to a hospital in the USA following a suspected seizure. Questions were used to examine the association between the use of health care resources, demographics and clinical variables.|
|Peterson et al (2019) [|
|Experiences of emergency department admissions of Australian people with epilepsy||Survey. Mixed methods analysis.||393 respondents completed the survey||The emergency department is not always the most appropriate place following a seizure. Misunderstanding around appropriate treatment continues.|
|Ridsdale et al (2012) [|
|Explanations given by people with epilepsy for using the emergency department||Qualitative. Semi-structured interviews||19 people with epilepsy||Use of emergency medical services was considered appropriate by participants when they were away from home or when someone nearby lacks knowledge of seizure management.|
|Sajatovic et al (2018) [|
|6 month randomised control trial on a remotely delivered group format self-management intervention for people with epilepsy (SMART)||RCT. The study involved 60 participants in the intervention arm and 60 participants in the control arm,||Assessments at screening, baseline, 10 weeks and 24 weeks. Comprised of 60−90 minute taught session and then seven group sessions delivered via telephone/computer, versus standard epilepsy care.||Intervention is associated with reduced health complications and improved mood, quality of life and health functioning. The taught session was facilitated by a nurse educator-peer educator dyad, which also provided an online element of the intervention with phone calls to participants, using a semi-scripted structure find out about participant welfare and to reinforce the content of the online materials. The study was limited as it was carried out in a single site, short duration and reliance on self-reported measures.|
|Pascual et al (2015) [|
|Outpatient education for people with epilepsy that use the emergency department||Quality improvement. Questionnaire||In total 90 participants were willing to receive one to one education by a physician and a nurse but not all watched the DVD (n = 50).||Decline in the number of emergency department visits in the four months after receiving the educational materials|
|Noble et al (2014) [||Clinical and cost-effectiveness of a nurse led self-management intervention to reduce visits to the emergency department for people with epilepsy||Quantitative (participants completed questionnaires on health service use and psychosocial well-being at baseline, 6 month and 12 month)||One emergency department provided the intervention plus treatment as usual and two emergency departments provided treatment as usual. 44 participants received the intervention and 41 received treatment as usual (treatment allocation not randomised)||This was a longer intervention and involved two, one-to-one sessions with a nurse, plus treatment as usual. Participants were also followed for 12 months after the intervention. There was no randomisation and only about a third of those invited to participate, agreed. Intervention did not result in a reduction of emergency department use but it did not cost more due to the reduction in hospital stay|
|Noble et al (2012b) [|
|The view of people with epilepsy on a self-management intervention||Nested qualitative study. Interviews.||20 people living with epilepsy that had received the self-management intervention||Intervention was acceptable and participants felt it addressed limitations to usual care. People with epilepsy that are using the ED more are having increased difficulties with the management of their epilepsy and the emotional aspects linked to this. Limited education provided in general around seizure safety, physical and psychological well-being and their relationship and how this impacted on their self-management and confidence.|
|Snape et al (2017) [|
|Developing and assessing the acceptability of epilepsy first aid training intervention for patients||Multi-method.||Baseline document review, semi-structured interviews and focus groups||People with epilepsy who visit ED reported a positive view of the intervention. Their feedback was used to develop the intervention which will be evaluated. Study incorporates a presentation with videos, and first aid training, where people with epilepsy and their carers can talk with each other.|
|Bradley et al (2016) [||Care delivery and self management strategies for adults with epilepsy||Systematic review||18 studies of 16 separate interventions||Limited evidence for the effectiveness of interventions to improve the health and quality of life for people with epilepsy. Specialist epilepsy nurse and self-management education have some benefit.|
|Noble et al (2016) [|
|Qualitative study of paramedics’ experiences of managing seizures||Semi-structured interviews||19 professionals from 5 different NHS trusts||Organisational, structural, professional and educational factors impact on decisions. Ambulance staff could play a key role in helping to reduce the conveyancing of people experiencing a seizure or those in the postictal phase but that current systems influence taking people to the emergency department as the default option|
|Sherratt et al (2017) [||Paramedics’ views on their learning needs of seizure management||Semi-structured interviews||19 professionals from 5 different NHS trusts||More training on the different types of seizures and guidance on which presentations should be conveyed to the emergency department, E-learning recommended. Little impact on the individual ambulance trusts directly but that it did impact on the emergency department and wider health service.|
|Burrell et al (2013) [||Decision-making by ambulance staff in managing people with epilepsy||Interviews||15 ambulance clinicians||Experience rather than training and guidelines impacted whether a case was transported to the emergency department.|
|Dickson et al (2017) [|
|Service Evaluation of new care pathway to epilepsy nurse specialists referral from Paramedics||11 months evaluation of adults with known epilepsy,||Eligible people who had called 999 for seizure. Urban setting.||Potential to safely reduce rates of transport to hospital. Paramedics only utilised the service in a small amount of eligible cases. Suggestive of the need for support tools to safety manage patients in the community.|
|Dickson et al (2016) [||Quantify the number of emergency telephone calls for suspected seizures in adults, the associated costs, and to describe the patients’ characteristics, their prehospital management and their immediate outcomes.||Quantitative cross-sectional study using routinely collected data and a detailed review of the clinical records of a consecutive series of adult patients, 1 months data was used resulting in 178 incidents||999 responses to adults following seizure within a predominantly urban area||The need for improved and more cost-effective emergency management of suspected seizures.|
|Male et al (2018) [|
|Exploring whether cases found the seizure care pathway of benefit or not||Semi-structured interviews||27 participants (individuals attending the emergency department for a seizure)||Has the potential to enhance care in the emergency department and at follow-up|
|Iyer et al (2012) [|
|Evaluation of a seizure care pathway in the emergency department||2 baseline audits (prospective and retrospective) and 12 month intervention study.|
Study looked at rapid access follow up clinic, educational sessions, phone and email support from an epilepsy nurse and information card provided.
|In the intervention study, 350 people with seizures and other forms of collapse followed the seizure care pathway||A seizure care pathway can improve the burden of seizure related admissions.|
A caution is that the use of retrospective data is not without problems due to potential recording errors but the use of prospective audit helped to validate some of retrospective data.
|Williams et al (2017) [|
|Identifying barriers to implementing an evidence based integrated care pathway for seizure management||Questionnaires||42 staff working in the emergency department (Nurses and Doctors)||10 barriers that were categorised into three main dependent categories; environmental, pathway design/operational and user related. All levels of clinical emergency department staff recognised the benefits of the care pathway but issues such as double documentation, being available in hard copy only, location of where they were stored, and clinician knowledge and behaviour impaired its smooth administration.|
|Williams et al (2018) [|
|Evaluating the utilisation and implementation of a seizure care pathway||Quantitative – seizure pathway utilisation rates and document analysis of care metrics at two time points||644 seizure presentations||Individuals placed on the care pathway had higher rates of neurological examination, documentation of safety and legal guidelines and lower rates of readmission.|
|Dickson et al (2017) [|
|Cross-sectional study of the hospital management of adults with a suspected seizure||Quantitative analysis of medical data||82 medical records were analysed – 30/82 were epilepsy; 5/82 were documented as psychogenic non-epileptic seizures (PNES) and 1/82 was epilepsy plus PNES||52/82 was not admitted following ED assessment, of which only 32 had documented referral or follow-up. 18/52 referred to epilepsy clinic, 13/52 referred to GP and 1/52 being referred to nurse specialist, and 19/52 with no referral documented. Of those admitted (n = 26), 7 were admitted for a different medical problem (e.g. chest infection; 3 were for social reason. Relationship between the Sheffield Early Warning Score (SHEWS) and Glasgow Coma Scale (GCS) for those on arrival with the discharge, with patients with an abnormal SHEWS or a reduced GCS are arrival were more likely to be admitted|
|Grainger et al (2016) [|
|Referral patterns following admission for a seizure||Observational study of routine hospital data||7 years of data||Most people admitted due to a seizure are not being referred to specialist services|
|Ziso et al (2017) [|
|Epilepsy management in older people||Quantitative – data analysed from 154 emergency departments across the UK.||Data of 1256 patients over 60 analysed||Older people presenting with seizures are more likely to be admitted and have imaging but less likely to be referred to specialist services|
|Minshall and Neligan (2014) [||Have the new GP contract and NICE guidelines improved clinical care of people with epilepsy||Quantitative analysis of 540 case notes||540 people on ASMs across 13 GP practices. Investigations into the case notes of 450 people on ASMs across 13 GP practices from April 2004 to April 2009,||Improvements were noted in review rates following the introduction of the GP contract but still significant unmet needs for people with epilepsy. Deficits also found in medication and treatment options, concordance issues, mental health oversight, bone density checks and advice to women of childbearing age.|
3.1 The current context of ED attendance for seizures
- Moran N.
- Poole K.
- Bell G.
- et al.
3.2 Care and treatment review
3.3 Educational interventions
- Noble A.
- Morgan M.
- Virdi C.
- Ridsdale L.
3.4 Ambulance staff
- Burrell L.
- Noble A.
- Ridsdale L.
- Burrell L.
- Noble A.
- Ridsdale L.
3.5 Care pathways
Declaration of Competing Interest
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