Drs S &T Arun-Castro, Dr E Williams FY2Dr Fleur Cantle ED Consultant

King’s College Hospital December 2014

Why audit?• Common presentation at Emergency Departments

• population risk of febrile seizure is ~3%. • risk of febrile seizure recurrence ~ 33%

• 1% will have had an afebrile seizure by age 16 yrs • 50% presenting with afebrile seizure will have a recurrence

• Management of the fitting child is an important area for quality improvement in PEM

1 Baumer JH Arch Dis Child 2004; 89: 278-280 Evidence based guideline for post seizure management in children presenting acutely to secondary care.

Background

• intercollegiate standards developed

• generic standards for the initial managementof febrile and afebrile seizures

• First National audit of standards

Objectives

• identify current performance in EDs against clinical standards

• facilitate quality improvement in PEM

Inclusion criteria

• inclusion:• <16 years of age + febrile or afebrile seizure includes actively fitting or post-fit presentations • exclusions:• >16 years • known history of seizures + written personal management plan

4 Standards1. Manage all fitting children as per APLS or EPLS algorithm

(exceptions:children with known history of seizures and a written management plan)

2. Take a careful eyewitness history to ascertain possible cause and document in the patient’s clinical record

3. Check blood glucose and document in the patient’s clinical record

4. Parent information leaflets should be given to parents/carers providing clear safety net advice for all children discharged from the ED.

Methodology

• Data collection: 40 Cases selected from ED records

• retrospectively• no patient identifiable information input to• RCEM online data collection system

Results

• No. of consecutive cases :40• Start date: August 2014• End date: January 2015

demographicsQ3 Patien

t age < 12 months 3

1-2 years old 18

3-5 years old 6

6-11 years old 9

12-15 years old 4< 12

months1-2 years

old3-5 years

old6-11 years

old12-15

years old

0

2

4

6

8

10

12

14

16

18

20

< 12 months1-2 years old3-5 years old6-11 years old12-15 years old

Q4Patient sex Male 23

Female 17 MaleFemale

demographicsQ5 Method of arrival Ambulance 33

Self-presented 7GP or other HCP referral 0

Ambulance

Self-presented

GP or other HCP referral

actively fitting on arrival?

Q6 Was the patient actively fitting on arrival in the ED? Yes 3

No 37

If answer to Q6 is yes, was the seizure managed according to APLS or EPLS algorithm?

Yes 3

Partially 0No 0

Was the patient actively fitting on arrival in the ED? YesWas the patient actively fitting on arrival in the ED? No

Yes Partially No0

0.5

1

1.5

2

2.5

3

3.5

Series1

History takingQ7 Was an

eyewitness history taken and recorded in the patient's clinical record?

Yes 39

Partially 0

No 1

YesPartiallyNo

Q8 Was the type of seizure established and recorded in the patient's clinical record?

Simple partial 0Complex partial 3Absence 1Grand mal 18Other 0

Not recorded 18

Simple partial

Complex partial

Absence Grand mal Other Not recorded

0

2

4

6

8

10

12

14

16

18

20

Simple partialComplex partialAbsenceGrand malOtherNot recorded

Past seizure hxQ9 Had the

patient experienced any previous seizures?

First known seizure 20

Previous episodes - no diagnosis

6

Previous episodes - diagnosis reached

12

Unknown/Not recorded 2 First known seizure Previous episodes - no

diagnosisPrevious episodes - diagnosis reached

Unknown/Not recorded

Had the patient experienced any previous seizures?

0

5

10

15

20

25

Seizure durationQ10 Was the duration of

the seizure established and recorded in the patient's clinical record?

Yes - ≥5 minutes duration 14

Yes – less than 5 minutes 25

Not recorded 1

Yes - ≥5 minutes duration Yes - <5 minutes duration Not recordedWas the duration of the seizure established and recorded in the patient's clinical record?

0

5

10

15

20

25

30

ObservationsQ12 Was the patient's

temperature measured as part of an initial assessment and recorded in the patient's clinical record?

Yes - ≥37.8°C 15

Yes - <37.8°C 24

Not recorded 1

Q13 Was GCS/AVPU assessment done as part of an initial assessment and recorded in the patient's clinical record?

Yes 39

GCS Not recorded 1Q14 Was a blood glucose

measurement taken as part of an initial assessment and recorded in the patient's clinical record?

Yes – taken in ED 16Yes - taken pre-hospital and recorded in ED notes

4

Not recorded 2Q15 If there was evidence of

hypoglycaemia, was this this treated appropriately?

Yes 1No 3Not applicable 34Not recorded 2

Yes - ≥37.8°CYes - <37.8°CNot recorded

YesGCS Not recorded

YesNoNot appli-cableNot recorded

Febrile

convu

lsion

1st Afeb

rile se

izure

Afebrile

seizu

re (ae

tiology unkn

own)

Trauma

Epilep

sy

Infection

Toxic

ology

Metabolic

Other0

2

4

6

8

10

12

14

Presumed aetiologyQ16 Was the presumed

aetiology recorded in the patient's clinical record?

Febrile convulsion 121st Afebrile seizure 4Afebrile seizure (aetiology unknown) 4Trauma 0Epilepsy 7Infection 9Toxicology 0Metabolic 0

Other 4

Antipyretics if ?febrile convulsionQ16 If answer to

Q16 is 'febrile convulsion', were antipyretics administered?

Yes 7

No 2

Unknown/Not recorded 0

ED OutcomeWhat was the outcome? PICU or HDU 2

in-hospital paediatric service

5

CDU or ED observation ward

5

Discharged 28Patient died 0

Admitted to PICU or HDU Admitted to in-hospital paediatric service

CDU or ED observation ward Discharged Patient died

What was the outcome?

0

5

10

15

20

25

30

Written Discharge advice?If the patient was discharged, were the patient's parents/carers provided with written safety information?

Yes 3No 1Previously provided 1

Not recorded 23

YesNoPreviously providedNot recorded

Summary• 40 cases• 70% discharged • 25 % admit Paeds/CDU • 5 % admit ITU

King’s Vs. Standards:1. APLS seizure guidelines used appropriately2. Eye witness Hx : most describe - few “call it”3. Obs generally documented4. need to improve discharge advice5. 50% of cases first seizure –

Supports need for first seizure clinic

QI Interventions

1. Discharge advice sheet for febrile seizures

2. Teaching for juniors -(med students/ FY2 ED / Paeds STs)

1. Focused ED hx taking for seizures/ALTEs2. When and what to investigate 3. Seizure pattern recognition

3. Service provision – First seizure review clinic

Drs S &T Arun-Castro, Dr E Williams FY2Dr Fleur Cantle ED Consultant

King’s College Hospital December 2014