1. Epilepsy Care Planning in Psychiatric Inpatient settings:
the 'Yellow Card’
Dr Valerie Murphy PhD MRCPsych, Dr Gautam Gulati MRCPsych, Dr Sebastan Luppe MD MRCP & Dr Elijah Chaila MRCPI
Introduction
Baseline audit of need
Epilepsy is frequently co-morbid with psychiatric illness and over represented in people with intellectual disabilities (1). A patient with epilepsy may present a challenge from a diagnostic, therapeutic and risk related viewpoint for the psychiatrist. The seizure disorder could be presenting as mental illness such as in the psychoses of epilepsy (2). Conversely, seizures could be mistaken as evidence of psychiatric illness (3). Medication used for seizure control may have psychiatric sequelae (4) and psychiatric medication may interact with anti-epileptic drugs (5) or alter seizure threshold. From a risk related viewpoint, those with comorbid epilepsy have specific risks to consider including but not limited to areas such as bathing and using electrical equipment (NICE, 2016). We describe the development of a novel diagnosis triggered tool to inform epilepsy care planning in psychiatric inpatient units.
To analyse existing practice in relation to epilepsy related documentation, care planning and risk assessment, we conducted a baseline audit across 6 Irish psychiatric wards, with ethical approval. We audited the case records in each centre for anyone with a known or suspected diagnosis of epilepsy on a given date. We found type of seizure was documented in 40% of cases, investigations in 40%, epilepsy medication in 100%, as needed epilepsy medication in 20%, a description of seizure patterns in 0%, risk assessments around bathing in 0%, risk assessments around managing prolonged or serial seizures in 0% of records reviewed. We plan to re-audit these settings after introduction of the yellow card.
Methods
Conclusions
We reviewed relevant guidance from the Epilepsy Society (epilspsysociety.org.uk) and the National Institute of Healthcare Excellence (2016) and operationalise key recommendations to develop a ‘yellow card’ for the patient record in approved centres. This card summarises key aspects of the patient’s epilepsy at a glance and serve as a useful aide-memoire to consider assessment and risks for people with epilepsy in a psychiatric setting. The document was compiled in consultation with an Epilepsy Nurse Specialist, an Occupational Therapist and Consultant Neurologists. The “yellow card” with a distinctive colour, would be easy to identify in the patient record, and likely improve the reliability of information gathering, with potential positive diagnostic, therapeutic and risk management implications. We are presently piloting the ‘yellow card’ scheme in approved centres across six Irish counties and one UK based setting.
Epilepsy is frequently co-morbid with psychiatric illness. Psychiatric medication may lower seizure thresholds. Recording seizure patterns helps distinguish them from psychiatric symptoms. Those with a diagnosis of epilepsy present with greater risks in activities of daily living. Bathing and showering and prolonged/serial seizures in particular present serious risks ; a risk assessment may help reduce adverse outcomes. However our baseline audit across 6 psychiatric wards found that current levels of documentation, risk assessment and care planning across psychiatric wards were not in keeping with best practice. We describe the development of a simple, easy to use diagnosis triggered tool to help improve outcomes for those with epilepsy in psychiatric settings. We are in the process of piloting this tool across psychiatric inpatient settings in 6 Irish counties and four UK NHS wards.
The Yellow Card
Author Affiliations
Acknowledgements
VM: Department of Psychiatry, University College Cork & HSE South, Ireland
GG: Department of Psychiatry, University College Cork & HSE Mid-West, Ireland
SL: Cardiff University and Department of Neurology, North Bristol NHS Trust
EC: Department of Neurology, University Hospital Limerick
Dr Deirdre Smithwick, Department of Psychiatry, Ennis General Hospital
Dr Noreen Moloney, Department of Psychiatry, Ennis General Hospital
Dr Diarmuid O’Sullivan, Department of Psychiatry, University Hospital Limerick
Ms Rosaline O’Sullivan, St Stephen’s Hospital, Glanmire, Cork
Mr Ian Murphy, Department of Occupational Therapy, University Hospital Limerick
Ms Olivia O’Sullivan, Epilepsy Nurse Specialist, University Hospital Limerick
References
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