Ambulatory Emergency Care Pathways. First Seizure

Transcription

1 Ambulatory Emergency Care Pathways First Seizure Effective Date: February 2013

2 Content Summary Ref Title Description 1 Condition Details Identifies pathway details and clinical sign-off 2 Pathway Algorithm Identifies the pathway to follow to identify patients suitable for Ambulatory Care 3 Patient Criteria Criteria for patients appropriate for the pathway 4 Patient Information Identifies Patient Information leaflets for issue to patients regarding their pathway 5 KPIs Identifies how the pathways are measured

3 1. Condition Details Condition Details Summary HRG/ICD-10 Codes Data (Baseline using 2010/11 outturn) AA26Z / G400, G401, G402, G404, G406, G407, G408, G409, R568 Total Patients per Month (Avg)? Bed Days Utilised per Month (Avg)? 1: P 1: Pat hw ay Det ails Number of Beds Utilised per Month (Avg)? ay Details Average Length of Stay? Potential Percentage suitable for ambulatory care? 1: Pat hw Details Sign Off: Pathway Designed by Clinical Subject Matter Expert Signed Dr Jan Coebergh Print Pathway Approved by Specialty Lead Signed Print Pathway Approved by Emergency Department Lead Signed Dr Jacob Addo Print Pathway Authorised by Divisional Director Signed Dr Peter Wilkinson Print

4 2. Pathway Algorithm Patient Presents with: First Seizure (in Adults) (For use when the likely diagnosis is a first seizure. For use after hypoglycaemia has been excluded). History & Examination An episode of loss of consciousness with or without convulsive movement, with or without spontaneous recovery and no apparent trigger or cause. Obtain and record a description of the episode from the patient and eyewitness. Establish any history or previous episodes of loss of consciousness or altered behaviour. Establish any history of: previous history of treated epilepsy, lateral tongue biting, injury sustained during seizure. Consider Alternative Diagnosis look for evidence of vasovagal episodes, cardiac arrhythmias and hypoglycaemia, nonepileptic seizures. Red Flags GCS persistently <15, Focal Neurological signs, sudden onset headache, head injury, signs of Meningitis or encephalitis, Signs of raised intra-cranial pressure, Headache associated with seizures, pregnancy/post-partum, history of malignancy, patients on anti-coagulants, chronic alcoholic, features suggestive of Pregnancy induced Hypertension. Yes No Urgent CT Head Investigation Indicators: Focal neurological abnormality, persistent GCS < 15, or recent head injury? ADMIT Yes No Investigations: Urgent CT head FBC, U&E, Glucose, Mg, CA²+, LFT, CK, CRP Consider LP If suspicion of encephalitis, treat as such ECG and CXR Investigations: FBC, U&E, Glucose, Mg, CA²+, LFT, CK, CRP ECG No Investigation results normal and patient fully recovered? Yes Review by SpR or above. Decision to discharge? Discuss with senior (not all abnormal results require admission). Decision to admit? Discharge Patient Advise and document patient to stop driving and inform the DVLA. Advise patient to return to A&E if a further episode occurs. Fill in First Fit referral form and Fax to neurology clinic. Letter to GP Check ACP on CAS Card ADMIT

5 3. Patient Criteria Red Flags - Exclude the following Patients and Admit: GCS <15 (except for longstanding known dementia with GCS 14) Focal Neurological signs Sudden onset headache Signs of Meningitis (fever or reduced consciousness) or encephalitis (significant speech, memory or behavioural change) Signs of raised intra-cranial pressure Headache associated with seizures Pregnancy/post-partum History of malignancy Patients on anti-coagulants Chronic alcoholic Features suggestive of Pregnancy induced Hypertension Head injury Clinical Criteria that requires addressing same day for AECP, else Admit / Reconsider Diagnosis: Clinically thought to be a seizure (Grand Mal or Partial) First ever seizure Single seizure with full recovery Patient able to attend ambulatory services

6 Patient Information First Seizure Patient Information You came to A&E following a suspected seizure. You have been assessed and the team are happy that you can be discharged from hospital with arrangements for you to be seen by a specialist. What is a seizure? A seizure (also called a fit, an attack, a convulsion or a turn ) is a sudden, brief disruption of normal brain activity. The seizure may have different forms depending on whether this happens in all the brain or if the seizure is in a part of the brain. Anyone could have a single seizure; about 1 in 20 people will have a seizure at some point in their life. This is not the same as having epilepsy. What happens next? Your GP will be sent a discharge letter informing them of your attendance at A&E which will also ask them to arrange an appointment for you to be seen by a neurologist as an outpatient at the First Fit Clinic. If you do not hear anything after a week, please contact your GP. When you attend your outpatient appointment if would be helpful if you could be accompanied by someone who witnessed your seizure, or a video of the event. When you are seen by a neurologist in outpatient clinic they will be able to provide you with further information and answer any questions you have. Until you are seen by a specialist, it is advised that you take note and follow the advice below. For your safety; You must not drive or operate dangerous machinery until you have seen the neurologist. You should avoid any dangerous work or leisure activities until you have seen the neurologist, this includes activities such as swimming, cycling on busy road or using ladders. Consider situations where having a seizure could have serious consequences such as standing close to train platforms or roads. It is a good idea to avoid the use of bath/shower without supervision/someone else in the house and to leave the bathroom door unlocked. It may be safer to take a shower. Avoid the consumption of alcohol. You should inform your employer that you have had a seizure. If you have another fit or seizure you should return to A&E. It is a good idea to inform your family/friends that you have had a seizure and make sure they know what to do in case you have another seizure First Aid during a Seizure Once a seizure starts, it will usually stop on its own after a few minutes. Following the advice below:

7 Do: Watch the seizure carefully and if possible let it run its natural course. Keep calm and note the time the seizure starts and how long it lasts. Clear a space around the person, removing any sharp, hot or hard objects. Cushion the person s head with whatever is available. Loosen any tight clothing round the neck and gently remove glasses if worn. Turn the person onto their side into the recovery position once the convulsions stop. Stay with the person, if possible, until any confusion passes. Do not: Do not move the person while the seizure is happening unless there is an immediate danger (e.g. in a busy road, at the top of stairs, in water, near a fire or hot radiator). Do not try to restrain the person. Do not attempt to lift the person up. Do not put anything between the teeth or into the mouth. Do not give any medication while the seizure is happening. Do not leave the person until they have recovered. You should dial 999 if: One seizure follows another without any recovery in between. The seizure lasts longer than five minutes or the person remains unconscious for a longer time than is usual. The seizure is a different type or pattern of seizure to what the person normally has. The person has been badly injured. The person has difficulty breathing. You do not know the person s history. Or you are at all unsure. What can I do if I become worried about my condition? If at any point you are concerned, please see your GP or contact NHS Direct on The information in this leaflet is not intended to replace the advice given to you by your doctor or the service looking after you.

8 First Seizure Referral Form To be completed for patients presenting at A&E with a First Seizure, and faxed to the Neurology Department at St Peter s Hospital. Fax Number: Patient details Name: Sex: DOB: Tel: [Affix Label] GP Details GP: Surgery Address: Carer s name: Carer s Tel: Is Hospital transport required? Yes/No GP Code: Clinical Summary Summary Presenting Event (eye witness account when available): Please refer to NICE guidance appendix D Current Medications: Significant Medical History: Name of Referrer: Date & Time: CT Head? Yes No ECG Findings:

9 4. KPIs KPIs Description How it will be measured Baseline (2010/11) At Min % At Max % Core KPIs Reduction in the number of patients requiring a stay of more than 24 hours (i.e. a 0-Day LoS) PAS Reduction in the Avg number of Bed Days utilised for the condition PAS Reduction in Bed Numbers PAS Other KPIs Scope Governance Scope: Patients entering the AECP Pathway at St. Peter s Hospital Governance: Reports to the Unscheduled Care Programme Board and Divisional Performance Review Meetings Above Min and Max figures are part year effects for 2011/12 based on month of implementation