Dr Isobel Salter, Dr Sara Ali, Dr Jasavanth Basavaraju, Dr Hemalata Bentur, Dr Maysara Abdelaziz Whiston Hospital, Liverpool, UK EAP Congress 2015, Oslo
The nature of epilepsy means that it can be difficult to diagnose accurately. NICE* clinical guidelines are set to improve the diagnosis of epilepsy ensure that diagnosis and treatment are confirmed and reviewed as necessary. *NICE = National Institute for Health and Care Excellence
To assess compliance with NICE guidelines on the investigation, diagnosis and initial management of children with a new diagnosis of epilepsy in a large district hospital 3 main standards investigated 1) Time from referral of children with suspected epilepsy to being seen by a specialist (ideally within 2 weeks) 2) Time from referral to undertaking EEG (ideally 4 weeks) 3) Time from referral to undertaking neuroimaging, preferably MRI (Ideally within 4 weeks)
DIAGNOSIS MANAGEMENT REFERRAL PROLONGUED SEIZURES NICE Guidelines 1 Key Priorities CONSIDERATION OF GIRLS WITH CHILDBEARING POTENTIAL REVIEW STATUS EPILEPTICUS REPEATED SEIZURES
Retrospective audit All children referred as new patients to the epilepsy clinics 10 months period in 2014. Total of 65 patients identified after scrutiny of the medical records the final number of actual new epilepsy patients was 13 (20% of number referred)
15 13 New diagnosis of epilepsy Epilepsy (not new) Headaches/migraines 1 Tics 4 11 Sleep related events Reflex anoxic episodes 7 3 11 Did Not Attend Other
Age ranged from 4 months to 13 years (median 2.5yrs) No significant difference in gender Source: 7 (54%) referred by GP 6 (46%) referred by on call General Paediatric consultant following inpatient admission of the patient 6 (46%) were seen within two weeks 3 (23%) referred after their first seizure
Investigations 5 (38%) underwent EEG within 4 weeks. 7 (54%) underwent neuroimaging namely MRI. Of these 5 were within 4 weeks Of note, the subgroup who were inpatients (6) were more likely to get an earlier EEG and neuroimaging (50% had EEGs and 50% had CT scans)
In all cases: Implications of the disease were explained verbally, and leaflets and website links provided Treatment was discussed with parents and was timely Treatment options and ongoing trials were also discussed with parents where appropriate Titration plans for medication/s was well documented in clinic letters The Epilepsy Nurse Specialists were involved and contact numbers were provided to families The reason for investigations was explained Frequency of review was agreed
However no clear documentation of: An agreed written emergency care plan for management in case of prolonged or repeated seizures
1 Benign Rolandic Epilepsy 2 Partial Complex 1 Focal Fits 1 1 Hysparrythimia Tonic seizures
Only 46% of new epilepsy diagnoses (n=6) were seen within the 2 week target 38% (n=5) underwent EEG within 4 weeks 5 of 7 (71%) that needed MRI scan, had this within 4 weeks For all the above, target = 100%
Expected larger sample size 2 week target to be seen affected by UK GPs choose and book system Increased trend of being admitted after first afebrile seizure- noted nationally also Investigations time frames: General increased demand EEGs: previous practice was Epilepsy Nurse Specialist already having contact prior to clinic and arranging this, is no longer happening MRIs: added demand of younger patients requiring this under GA at tertiary hospital
Flow chart for managing children seen with afebrile seizure from the community or A&E New patient slots to be dedicated to new patients only (3) on a weekly basis Introducing a pathway covering all NICE key priorities The Epilepsy Nurse Specialist services to expand to meet the increasing requirements and set targets
1) The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care NICE Guidelines (CG 137) http://www.nice.org.uk/guidance/cg137