Transcript Document
Specialist Nurse Led Assessment for Suspected First Seizures Attending the Emergency Unit Vicki Myson – Epilepsy Nurse Specialist Malisa Pierri - Epilepsy Nurse Specialist Ruth Jordan – Project Manager Chronic Conditions Episodes of transient loss of consciousness are experienced by up to ½ of the UK population Syncope Seizure Psychological •Triaging events can be difficult •Patients can see a range of clinicians •Misdiagnosis is common and can be fatal What do the experts say…….. “All individuals with a recent onset suspected seizure should be seen within 2 weeks by a specialist. This is to ensure precise and early diagnosis and initiation of therapy appropriate to their needs.” NICE, October 2004 Epilepsy Service Development Directive, WAG, March 2009 How were we doing in Cardiff? UCL = 95.5% •“First seizure” clinic held once a week •Large numbers of missed appointments Mean = 35.4% LCL = -24.7% •Some patients waiting as long as 10 weeks for review What the Project Involved • Steering Group • Service Mapping • Results Based Accountability (RBA) THE WELSH EPILEPSY UNIT Service Description: The Welsh Epilepsy Unit is a tertiary referral centre for specialist epilepsy services in South Wales. The immediate catchment population covered is 700,000, but many referrals are also taken from elsewhere in Wales. The Unit offers a multidisciplinary approach to epilepsy care and offers a very broad range of services to people with epilepsy, their families and carers. DEFINED SERVICE USERS Patients with a first suspected seizure or unexplained blackout HEADLINE PERFORMANCE MEASURES DATA DEVELOPMENT AGENDA 1. 2. 3. 4. 1. % on inappropriate treatment 2. % have clinic letters sent within one week of clinic 3. Why patients DNA first seizure clinic % % % % seen by a specialist within 2 weeks DNA first seizure clinic have diagnostic tests within 4 weeks follow the correct pathway HOW ARE WE DOING? % S een b y a S p eci al i st w i t hi n 2 W eeks % have d i ag no st i c t est s w i t hi n 4 w eeks % D N A F i r st S ei z ur e C l i ni c 30% 25% 35% 15% 100% 30% 25% 20% B as el i ne 20% B as el i ne P r edi c t i on 15% P r edi c t i on Cur v e t o t ur n 10% Cur v e t o t ur n 80% 25% B as el i ne 5% 0% 2007 2008 2009 2010 2011 2012 P r edi c t i on 15% Cur v e t o t ur n 10% P r edi c t i on 40% Cur v e t o t ur n 5% 5% 20% 0% 0% 0% 2007 2008 2009 2010 2011 2012 STORY BEHIND THE BASELINES Clinic capacity – 1 clinic per week with 5 patient slots Unpredictable demand Small MDT – unable to cover absence to prevent clinic cancellation Low frequency of clinics causes delay if appointment not suitable Clinic booked by Epilepsy Unit admin staff – if admin staff on leave clinic slots not filled Consultant triage’s fax referrals – delay if unavailable Patient anxiety Stigma attached to Epilepsy Patients put off by unit name – diagnosis seems pre-determined Concerns re implications e.g. diving B as el i ne 60% 20% 10% % f o l l o w co r r ect p at hw ay 2007 2008 2009 2010 2011 2012 2007 2008 2009 2010 2011 2012 PARTNERS WHO CAN HELP US DO BETTER Emergency Unit/MEAU, Radiology, Neurophysiology, Medical records, A&C staff, Consultants, Ambulance Trust, Cardiology, Psychology, Care of the Elderly, Neurosurgery, Prison, Voluntary Sector, CELT, Practice Nurses, Family members/ witnesses, Drug and Alcohol Services, Occupational Health, Referral Management Centre, Obstetrics. WHAT WE PROPOSE TO DO TO IMPROVE PERFORMANCE Develop nurse led Emergency Unit assessment service Develop nurse led first seizure clinics Enable specialist nurse referral for EEG Change the name of the Epilepsy unit The New Service • January 2010 • Extended role of epilepsy nurse into A&E • Protocols & pathway of care established • Communication & promotion programme • Audit & evaluation from the outset Old Pathway 1st Seizure A&E Review Discharge WAIT Faxed Referral Waiting List Appt 1st Seizure Clinic WAIT Refer Treatment Refer on New Pathway 1st Seizure A&E Review ESN Review Discharge Referral Cardiology WAIT Investigations Clinic Diagnosis WAIT Investigations Follow Up clinic Diagnosis Impact UCL = 104.5% UCL = 95.5% Mean = 60.9% Mean = 35.4% LCL = 17.3% LCL = -24.7% UCL = 42.84 UCL = 24.47 Mean = 21.64 Mean = 11.46 LCL = 0.44 LCL = -1.55 Outcomes UCL = 9.97 Mean = 5.05 UCL = 3.01 Mean = 2 LCL = 0.99 LCL = 0.13 Comparison of Pathway Length for Patients on the New and Old First Seizure Pathway Time to Diagnosis = 111 days Average Old Pathw ay Time to Diagnosis = 30 days Average New Pathw ay Patients on Old Pathw ay No. Days Until Seen by Specialist No. Days Until Confirmed Diagnosis Patients on New Pathw ay 0 50 100 150 200 No. Days 250 300 350 Lessons Learnt • RBA provides a framework for service improvement and performance management • Services can be changed with little or no additional cost • Reciprocal education programme with A&E staff • Increased skill base • Positively working in a different way • Links with others clinical teams • Learning & reacting to data changes Future Developments & Roll Out • Nurse Led 1st Seizure clinic • Primary care access • Other conditions within organisation • Share the learning to support implementation elsewhere • CCM Demonstrator website • Local, National & International presentations • ESNA • Publish articles • RBA toolkit • RCN Neurosciences Forum Conclusions • Unique nursing service into A&E • Reduced patient waiting times & unnecessary hospital admissions • Patients receive timely accurate advice & information • Clear pathway of care between specialities • It’s not just epilepsy . . . . And now imagine.....