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G ROUP M EMBERS :
DR GAIL REID DM (YEAR 3.5)
DR OLSHEATH BOWEN DM (YEAR 1.5)
DR PETER ANDRE SOLTAU (YEAR 2.5)
OBJECTIVES
• “Get a copy of the UHWI ED seizure protocol”
• “Will need to evaluate a minimum of 60
patients”
• ”If the pat...
FIRST TIME SEIZURES
• The physician must seek to establish that the
attack was truly a seizure
• If there is any persisten...
FIRST TIME SEIZURES
• Generally speaking patients with a first time seizure
may be referred for follow up with EEG and CT ...
FIRST TIME SEIZURES
• Most patients with a simple febrile seizure who recover fully and
have a focus for their fever e.g. ...
REASONS FOR TOPIC
SELECTION
• Patient Safety
• Cost (CT Brain = Ja $40,000)
• Litigation (missing serious pathology)
AIMS
• To document % compliance of the management
of first time seizures in the ED as per clinical
protocols for the Emerg...
MATERIALS & METHODS
• This clinical policy audit was directed by the
Emergency Medicine Division of the UHWI

• It was con...
STUDY SUBJECTS
• Patients were identified via a manual search of
UHWI Accident &Emergency (A&E) log books, a
discharge col...
DATA COLLECTION
Data abstracted from the medical records included:
•

Docket/file #

•

Gender

•

Age

•

Past medical hi...
DATA COLLECTION
• The data were collected on a pre-designed data
abstraction form and then were entered into a standard
sp...
RESULTS
• During the period of October 1, 2012 through October 1,
2013, 133 cases were identified with a possible diagnosi...
GENDER & AGE
• 27 Females : 16 Males

• Age range 1 – 92 years old
AGE
• Total of 16 paediatric patients

• 11 % of patients were age 1 or below
• 25 % of patients were age 3 or below
• 31 ...
DURATION OF SEIZURE
• In 18 patients (40% of cases) the duration was unable to
be assessed due to poor documentation
• 15 ...
SEIZURE PATTERN
• 7 patients were found to have status epileptics
• 4/7 patients had CT in the ED
• 5 patients had persist...
WAS CT INDICATED IN THE ED ?
• 20 patients – CT indicated in the ED

• In 2 of these patients CT was not done in the ED
• ...
PROTOCOL FOLLOWED
FOR CT IN ED
• In 35 cases the protocol was followed

• In 4 cases the protocol was not followed
• In 5 ...
IF CT WAS NOT INDICATED, WAS
PROTOCOL FOLLOWED FOR FOLLOW
UP?
• In 5 cases protocol was not applicable e.g. patients
admit...
FOLLOW UP FOR REVIEW
• 7 patients were to be followed up for
review, however there is no
documentation as to CT being orde...
LIMITATIONS
Legibility of log book entries
Inability to get dockets from docket library
Missing notes from docket :Inabili...
RECOMMENDATIONS
A copy of clinical protocol book to be placed in A&E for
quick referencing
Encourage staff to keep up to d...
CONCLUSION
• High rate of compliance with protocol for CT
scans in the ED for patients with first time
seizures
• Poor doc...
CT ordered as
outpatient?

Follow up for CT
review ?

no
no
yes
no
no
no
no
no
no
no
no
no
no
no
no
n/a
no
yes

yes
no
no
...
CT Scanning For First Time Seizures At UHWI Clincal policy audit Group 3 dr bowen, dr reid, dr soltau
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CT Scanning For First Time Seizures At UHWI Clincal policy audit Group 3 dr bowen, dr reid, dr soltau

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Clinical Audit

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  • 4/7 status patients had CT in the dept4/5 with altered mental status had CT done in the ED, 7 UNSURE
  • In case, the protocol was followed however the patient required CT in ED and not as outpatient
  • Transcript of "CT Scanning For First Time Seizures At UHWI Clincal policy audit Group 3 dr bowen, dr reid, dr soltau"

    1. 1. G ROUP M EMBERS : DR GAIL REID DM (YEAR 3.5) DR OLSHEATH BOWEN DM (YEAR 1.5) DR PETER ANDRE SOLTAU (YEAR 2.5)
    2. 2. OBJECTIVES • “Get a copy of the UHWI ED seizure protocol” • “Will need to evaluate a minimum of 60 patients” • ”If the patients met the criteria for CT or not as per UHWI protocol, then if CT was done or not.”
    3. 3. FIRST TIME SEIZURES • The physician must seek to establish that the attack was truly a seizure • If there is any persistent alteration of mental status or neurological deficit a CT brain should be done in the emergency department and reviewed • CT Scan may be done as outpatient if patient returns to normal neurological status Prepared by Dr Eric Williams
    4. 4. FIRST TIME SEIZURES • Generally speaking patients with a first time seizure may be referred for follow up with EEG and CT brain to the Neurology Clinic at UHWI or a private neurologist depending on patient preference. • There is no need to start antiepileptic drugs in these patients • These patients must be reviewed within 2 weeks of discharge from the ED (in order to expedite the management as a result of an abnormal investigation) Prepared by Dr Eric Williams
    5. 5. FIRST TIME SEIZURES • Most patients with a simple febrile seizure who recover fully and have a focus for their fever e.g. otitis media, UTI, simple LRTI should receive antipyretic measures and have fever reduced in the ED • They do not require antiepileptic drugs • The specific infection should be treated. These patients should be followed up by the paediatrician in Room 2 or their private paediatrician within 24--‐48 hours. They do not usually require a CT scan Paed Emerg Management guidelines by Prof Gray UWI
    6. 6. REASONS FOR TOPIC SELECTION • Patient Safety • Cost (CT Brain = Ja $40,000) • Litigation (missing serious pathology)
    7. 7. AIMS • To document % compliance of the management of first time seizures in the ED as per clinical protocols for the Emergency Department • To improve compliance of the management of first time seizures in the
    8. 8. MATERIALS & METHODS • This clinical policy audit was directed by the Emergency Medicine Division of the UHWI • It was conducted at the Emergency Department (ED) of a 500-bed university affiliated, tertiary care hospital in Mona, Kingston, Jamaica • We reviewed medical records of all patients who had been diagnosed with first time seizure/ ? First time seizure from October 1, 2012 through October 1, 2013
    9. 9. STUDY SUBJECTS • Patients were identified via a manual search of UHWI Accident &Emergency (A&E) log books, a discharge column diagnosis for “seizure”, specifically “first time seizure” triggered a docket number collection and docket trace via docket library through the medical records department of the UHWI.
    10. 10. DATA COLLECTION Data abstracted from the medical records included: • Docket/file # • Gender • Age • Past medical history • Duration of seizure • Febrile seizure • Focal seizure • Status epilepticus • Persistent alteration of mental status • Neurological deficit • CT scan done in Emergency Department • CT scan ordered as outpatient • If follow up was arranged for CT review.
    11. 11. DATA COLLECTION • The data were collected on a pre-designed data abstraction form and then were entered into a standard spreadsheet (Excel 2010, version 14.0.7106.5003; Microsoft Corporation, Redmond, WA).
    12. 12. RESULTS • During the period of October 1, 2012 through October 1, 2013, 133 cases were identified with a possible diagnosis of first time seizure from the A&E log books • A total of 133 dockets were requested from the docket office/library, however only 83 (62%) were located and upon in depth review by three investigators to determine the patients who met the criteria this resulted in 44 (33%) patients with a diagnosis of first time seizure
    13. 13. GENDER & AGE • 27 Females : 16 Males • Age range 1 – 92 years old
    14. 14. AGE • Total of 16 paediatric patients • 11 % of patients were age 1 or below • 25 % of patients were age 3 or below • 31 % of patients were age 5 or below • No patient below age 2 had any medical illnesses while all patients (6) defined as elderly (age 60-65 and above) had at least 1 medical illness, most commonly hypertension
    15. 15. DURATION OF SEIZURE • In 18 patients (40% of cases) the duration was unable to be assessed due to poor documentation • 15 patients – lasted less than 5 minutes • 19 Patients – lasted 5 minutes or less • 5 Patients – lasted 10 minutes or more
    16. 16. SEIZURE PATTERN • 7 patients were found to have status epileptics • 4/7 patients had CT in the ED • 5 patients had persistence of mental status changes • 4/5 with altered mental status had CT done in the ED • 4 had documented neurological deficit • All 4 had CT in the ED • 4 patients had focal seizures • All 4 had CT in the ED
    17. 17. WAS CT INDICATED IN THE ED ? • 20 patients – CT indicated in the ED • In 2 of these patients CT was not done in the ED • 21 patients – CT not indicated in ED • 2 of these patients had CT done in the ED • 3 patients – Unsure if CT done in ED
    18. 18. PROTOCOL FOLLOWED FOR CT IN ED • In 35 cases the protocol was followed • In 4 cases the protocol was not followed • In 5 cases it was unclear
    19. 19. IF CT WAS NOT INDICATED, WAS PROTOCOL FOLLOWED FOR FOLLOW UP? • In 5 cases protocol was not applicable e.g. patients admitted, CT already done • In 4 cases – unsure • Did not identify any case or patient in which follow up protocol was followed • In one case, the protocol was followed however the patient required CT in ED and not as outpatient
    20. 20. FOLLOW UP FOR REVIEW • 7 patients were to be followed up for review, however there is no documentation as to CT being ordered as outpatient
    21. 21. LIMITATIONS Legibility of log book entries Inability to get dockets from docket library Missing notes from docket :Inability to locate notes of seizure presentation when docket retrieved Documentation : Insufficient note taking by physicians/ medical staff : poor history taking Any patient who was not recorded in the log book would have been excluded (?#)
    22. 22. RECOMMENDATIONS A copy of clinical protocol book to be placed in A&E for quick referencing Encourage staff to keep up to date with clinical policy book, e.g. in academic meetings/ death conferences Addition of electronic records Encourage legibility of log book entries
    23. 23. CONCLUSION • High rate of compliance with protocol for CT scans in the ED for patients with first time seizures • Poor documentation by physicians : seizure duration, follow up, CT as outpatient • Poor compliance with follow up protocol • Need for continued medical education
    24. 24. CT ordered as outpatient? Follow up for CT review ? no no yes no no no no no no no no no no no no n/a no yes yes no no no yes no yes no yes no yes yes no no yes n/a no neuro clinic patient transferred KPH n/a N/A ? n/a n/a n/a no n/a ? n/a Protocol followed for follow up N/A no no no N/A no N/A no N/A N/A N/A N/A no no no ? no yes CT indicated in ED? Protocol followed N/A ? N/A N/A ? N/A N/A N/A no N/A no N/A ? Yes ? No No Yes No Yes No No yes no unavailable no yes no yes no yes yes yes yes no no no ? no no Requested, no documentation no yes no yes no yes no yes no no admitted pedi, complex partial N/A No no yes ? no no no no no no ? no no ? ? no no ? no N/A N/A N/A N/A N/A ? no N/A ? ? no N/A No No yes Yes yes yes yes no no no no no no yes no no yes yes yes yes yes no no yes no no no yes yes yes yes yes yes yes yes yes yes no yes yes yes yes n/a Admitted / n/a n/a ? n/a admitted pedi n/a no n/a ? referred pedi ? n n n n n n ? n n ? ? n n yes no yes no yes no yes no yes yes yes yes no yes no yes no Yes CT done in ED ? yes yes ? yes yes yes yes yes yes yes yes yes yes no yes ? yes no ? ? yes ? no yes yes yes yes yes yes
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