Seizure 2020, Vol 76, Editor’s Choice: Exploring epilepsy attendance at the emergency department and interventions which may reduce unnecessary attendances: A scoping review
At a time when the world’s attention is focused on the response of emergency medical services to the Covid-19 pandemic my Editor’s Choice from the current volume of Seizure is a scoping review by Lisa Burrows et al, summarizing research exploring interventions aimed at reducing unnecessary emergency department (ED) attendances by individuals with epilepsy (1).
In England (population 53 million) a high-income country with a universal public health system providing free access to routine and emergency health care and antiseizure medicines only 50% of patients with epilepsy become free of seizures (2). Those individuals with uncontrolled epilepsy are not the only ones who are at risk of frequenting EDs with seizures. One study suggested that, although three quarters of patients of the patients brought to an ED with a suspected seizure diagnosis had experienced and epileptic seizure only about one third of patients carried a diagnosis of epilepsy at the time of their admission (3). However it has been estimated that epileptic seizures lead to 60,000 ED (113 per 100,000), and 40,000 hospital admissions in England per year (76-148 per 100,000), making epileptic seizures one of the three commonest neurological causes for attendance in emergency departments (EDs) (4).
This means that a substantial proportion of seizure-associated ED attendances are related to an “ambulatory care sensitive condition”, i.e. they occurred in a context in which optimal ambulatory care may have prevented the need for the involvement of emergency services. Most presentations to EDs turn out to be related to problems which could have been managed outside EDs (such as resolved seizures) (5). Given that ED management by non-seizure experts often adds little to longer term seizure control but is associated with considerable expenditure and a risk of iatrogenic complications (such as hospital acquired infection!), it is important to explore how ambulatory care could be improved to avoid unnecessary admissions.
The scoping review by Burrows et al. is therefore of great clinical importance. Their overview of recent research is based 29 pieces of original research which could be subdivided into four themes: care pathways, conducting care and treatment reviews, educational interventions and role of ambulance staff. Although there is clearly more work to do some of these intervention have been welcome by patients and associated with reduced healthcare expenditure.
While the identification of demographic and clinical risk factors for repeated attendance to EDs due to seizures has allowed interventions to be focused on the third of patients who are responsible for two thirds of all epilepsy related admissions (6), the nature of these factors (including mental health problems, low educational attainment and social problems) means that successful intervention will be particularly challenging. However, the urgent (and increasing) need to use limited healthcare resourced most effectively means that the search for better and more effective interventions improving the effectiveness of ambulatory care and reducing epilepsy-related demands on emergency services must continue.
1) Burrows L, Lennard S, Hudson S, McLean B, Jadav M, Henley W, Sander JW, Shankar R. Interventions reducing unnecessary emergency department attendances for seizures: a scoping review. Seizure 2020, please add bibliographic details.
2) Dixon P, Kirkham J, Marson A, et al. National Audit of Seizure management in Hospitals (NASH): results of the national audit of epilepsy in the UK. BMJ Open 2015;5:e007325.
3) Dickson JM, Dudhill H, Shewan J, Mason S, Grunewald RA, Reuber M. Cross-sectional study of the hospital management of adult patients with a suspected seizure (EPIC2). BMJ Open. 2017;7(7),e015696. doi: 10.1136/bmjopen-2016-015696.
4) Dickson JM, Jacques R, Reuber M, Hick J, Campbell MJ, Morley R, et al. Emergency hospital care for adults with suspected seizures in the NHS in England 2007-2013: a cross-sectional study. BMJ Open 2018;8(10),e023352. doi: 10.1136/bmjopen-2018-023352
5) Dickson JM, Taylor LH, Shewan J, Baldwin T, Grünewald RA, Reuber M. A Cross-Sectional Study of the Pre-hospital Management of Adult Patients with a Suspected Seizure (EPIC1). BMJOpen 2016;6:e010573. doi:10.1136/bmjopen-2015-01057
6) Noble A, Goldstein L, Seed P et al. Characteristics of people with epilepsy who attend emergency departments: Prospective study of metropolitan hospital attendees. Epilepsia. 2012;53(10):1820-1828.