rcem 2014 paediatric seizure audit kch aruncastro 27th march v2
TRANSCRIPT
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