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First Seizure Management:
Meeting the Two Week Deadline
– The Cardiff and Vale Approach
Vicki Myson – Epilepsy Nurse Specialist
Ruth Jordan – Project Manager Cardiff CCM
Demonstrator
Epilepsy SDD
“Health Communities will ensure that
NICE guidance for the diagnosis and
management of the epilepsies is
implemented and audited”
NICE Guidelines
“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
How were we doing in Cardiff?
How were we doing in Cardiff?
How were we doing in Cardiff?
Now What?
• Service Mapping to understand the
patient pathway
Now What?
Discharge
WAIT
First seizure/
unexplained
blackout
EU/MEAU
Reviewed by EU/
MEAU clinicians
(ECG, bloods and
poss, CT scan)
EU patients
referred to
Epilepsy team via
fax as per
pathway
Referral received by
secretary/receptionist
who allocates
appointment and
informs patient
First fit clinic in
epilepsy unit.
Seen by SpR.
Working diagnosis
WAIT
Refer for
further
investigations
Start treatment
Refer on eg
Cardiology,
clinical
psychology
Investigation e.g.
EEG, MRI
WAIT
Follow-up clinic
Now What?
• Service Mapping to understand the
patient pathway
• Use of Results Based Accountability
(RBA) to help understand the issues
and develop solutions
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
What we did…..
• Extended Specialist Nursing Service
into A&E
• Bleep
• Communication exercise
• Service Commenced January 2010
The New Pathway
Discharge
WAIT
First seizure/
unexplained
blackout
EU
Reviewed by EU
clinicians
(ECG, bloods and
poss, CT scan)
ESN’s review
patients in EU
PROVISIONAL
DIAGNOSIS
Refer for
further
investigations
Refer on eg
Cardiology
Investigation e.g.
EEG
Follow-up clinic
FIRM DIAGNOSIS
The New Pathway
Discharge
WAIT
First seizure/
unexplained
blackout
EU
Reviewed by EU
clinicians
(ECG, bloods and
poss, CT scan)
ESN’s review
patients in EU
PROVISIONAL
DIAGNOSIS
Refer for
further
investigations
Investigation e.g.
EEG
Follow-up clinic
FIRM DIAGNOSIS
Refer on eg
Cardiology
Discharge
WAIT
First seizure/
unexplained
blackout
EU/MEAU
Reviewed by EU/
MEAU clinicians
(ECG, bloods and
poss, CT scan)
EU patients
referred to
Epilepsy team via
fax as per
pathway
Referral received by
secretary/receptionist
who allocates
appointment and
informs patient
First fit clinic in
epilepsy unit.
Seen by SpR.
Working diagnosis
WAIT
Refer for
further
investigations
Start treatment
Refer on eg
Cardiology,
clinical
psychology
Investigation e.g.
EEG, MRI
WAIT
Follow-up clinic
It’s early days, but…….
And……..
• Anecdotally
– Admission avoided for a number of patients
– Increased education and awareness for A&E staff
– Quicker patient discharge from A&E
– Increased staff satisfaction in A&E
– Minimal negative affect on ESN’s workload
– Early provisional diagnosis enables prioritisation to
appropriate clinic
Lessons Learnt
• Requires ongoing communication and training in A&E
due to the high turnover rate of staff rotations
• Promotion is essential
• Data is powerful
• Highlighted the need for further education regarding
epilepsy “myths” and differential diagnosis
• Services can be changed with little or no additional
cost
Thank You!
Any Questions?