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

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

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

Birth of the Epilepsy Care programme Quality Access Value

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

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

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:

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

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

Timescale for assessments and treatments

Integrated Care Pathway Pages 5&6

Integrated care plan For Seizure Pages 7&8

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

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

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%)

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%)

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

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

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

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

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