Seizure (2005) 14, 58—61

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An audit of first seizures presenting to anAccident and Emergency Department

Himanshu Bhatta, Manjit S. Matharua, Katherine Hendersonb,Richard Greenwooda,*

aDepartment of Neurology, Homerton Hospital, London E9 6SR, UKbDepartment of Accident and Emergency, Homerton Hospital, Homerton Row, London E9 6SR, UK

KEYWORDSAudit;First fit;Epilepsy;General hospital

Summary

Objectives: To investigate whether patients presenting after a first seizure to anAccident and Emergency (A&E) department were being managed according to con-sensus recommendations.Design: Retrospective audit.Setting: UK District General Hospital over 6 months.Methodology: Hand search of Accident and Emergency notes for diagnoses of ‘‘sei-zure’’, ‘‘fit’’, ‘‘epilepsy’’ and ‘‘epileptic fit’’, followed by scrutiny of hospital andGeneral Practice (GP) medical notes.Results: Eighty three percent of patients discharged from the A&E department with aletter to take to their general practitioners, but only 20% of those referred directly tothe neurology clinic, were lost to follow-up. Of the patients seen as out-patients by aneurologist, the median waiting time to clinic was 22 weeks, 18 weeks longer thanrecommended. The average time to having an MRI scan and EEG performed were 12and 15 weeks, respectively. Twenty percent of patients seen by a neurologist were notfelt to need further investigation for epilepsy.Conclusions and recommendations: All patients presenting after a first seizure shouldbe directly referred to a neurology clinic from the A&E department. The currentlyproposed target time to specialist review is unrealistic without significant resourceimprovements. The provision of diagnostic guidelines and telephone advice by theneurology team prior to discharge from A&E may avoid unnecessary investigation.# 2004 BEA Trading Ltd. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: +44 20 8510 7970;fax: +44 20 8510 7318.

E-mail address: richard.greenwood@homerton.nhs.uk(R. Greenwood).

1059-1311/$ — see front matter # 2004 BEA Trading Ltd. Publisheddoi:10.1016/j.seizure.2004.10.003

Introduction

Epilepsy accounts for a significant amount of neu-rological disease in the UK, with a prevalence ofbetween 5 and 10 per 1000 of the population.1 Inmost developed countries, incidence rates rangefrom 40 to 70 per 100,000.2

by Elsevier Ltd. All rights reserved.

An audit of first seizures 59

The diagnosis of epilepsy has important physical,psychosocial and economic implications for thepatient. It is, therefore, important that the diag-nosis is correct. It has been shown that a diagnosis ofepilepsy, made by non-specialists is incorrect in asignificant proportion of cases.3,4 It has, therefore,been recommended that patients with a suspecteddiagnosis of epilepsy should be seen by a neurologistor an epilepsy specialist before the diagnosis ismade.5,6

Recent consensus papers have suggested thatafter a suspected first seizure patients should beseen by a neurologist within 4 weeks of the event,and then have an electroencephalogram (EEG)within 4 weeks and magnetic resonance imaging(MRI) of the brain within 3months.1,7,8 These recom-mendations are likely to shape future national guide-lines so there is a need to assess how achievable theyare in practice. This paper presents the results of aretrospective audit of the current management ofsuspected first seizures presenting to an Accidentand Emergency Department in a District GeneralHospital, to examine whether additional resourceis required to achieve these recommendations.

Methods

All A&E cards of patients presenting consecutivelybetween 1st May and 31st October 2002 were hand-searched to identify those patients presenting witha diagnosis recorded as ‘‘seizure’’, ‘‘fit’’, ‘‘epi-lepsy’’, or ‘‘epileptic fit’’. Those patients who hadnot reported a similar previous event constitutedthe ‘‘first fit’’ study cohort. Their hospital or general

Figure 1 Management of patients presenting

practice (GP) medical records were then retrievedand scrutinized either by one of the authors (H.B.) orby the patient’s General Practitioner after tele-phone contact by H.B.

Information about admissions, methods of refer-ral to neurology clinics and time intervals toappointments for clinic follow-up, MRI scanning,and EEG were retrieved from computer systems inthe hospital and its linked Neurophysiology Depart-ment in a local Neuroscience Centre. Data wererecorded on a standard proforma.

Results

During the 6 month study period 25,220 patientspresented to the A&E Department, 158 (0.6%) aftera ‘‘seizure’’, ‘‘fit’’, ‘‘epilepsy’’, or ‘‘epileptic fit’’,and 38 (24%) of these after a ‘‘first fit’’ (Fig. 1). Ofthese 38 patients, 14 were admitted and 24 patientswere discharged.

Nine of the 38 patients (24%) were thought tohave had an alcohol related seizure. Of these, sevenwere admitted; three discharged themselves fromhospital shortly after admission, whilst the otherfour were discharged within 3 days with follow-up ina general medical rather than neurology clinic withno out-patient investigations booked.

Five of the 14 patients admitted were found tohave intracerebral pathology. Two patients had hadischaemic strokes and were admitted to the strokeunit. One patient had an intracerebral arteriove-nous malformation, and two an acute intracerebralhaemorrhage; all three were transferred to the localneurosurgical unit.

after a first seizure to the A&E department.

60 H. Bhatt et al.

Of the 24 patients who were discharged homefrom A&E, 12 were given letters to take to theirgeneral practitioners, all advising referral to theirlocal neurology departments, and 10 were referreddirectly to the hospital Neurology Clinic. Both of thepatients who had no follow-up arrangements madewere reported to have had alcohol-related seizures.

Ten of the 24 patients discharged from A&E werefollowed-up in the hospital neurology clinic; eightpatients were directly referred from A&E and two bytheir general practitioners. The clinical characteris-tics of patients who were directly referred to aneurology clinic from A&Ewere compared with thosegiven GP letters and no obvious differences werefound: on admission all patients were either des-cribed as ‘‘Alert and Orientated’’ or were documen-ted to have a Glasgow Coma Scale (GCS) score of 15/15; all had had one documented seizure; none weredocumented to have had a head injury; and no othermedical problems were referred to in the notes. Oncontacting the General Practitioners of the 12patients for whom follow-up in a Neurology Clinicwas recommended, there was no documentation toshow that they had seen a neurologist at any otherunit.

Two of the 10 patients referred directly from theA&E Department did not attend the Neurology clinicand were discharged; two of the remaining eightpatients referred from the A&E department werethought to have had syncopal episodes and nofurther neurological investigations were arranged.The waiting time from first seizure to attending theNeurology Clinic ranged from 6 to 44 weeks (n = 12)with a median value of 22 weeks (mean 21.6 weeks);it took an average (mean) of 12 weeks (range 5—22weeks, n = 10, median = 12 weeks) from referral tohave a MRI scan and 15 weeks (range 5—20 weeks,n = 10, median = 16 weeks) for a resting EEG.

Discussion

Over a 6 month period 25,220 patients presented toan inner city A&E Department, 158 (0.6%) after anevent diagnosed as ‘‘seizure’’, ‘‘fit’’, ‘‘epilepsy’’, or‘‘epileptic fit’’, 38 (24%) of whom were thought tohave had a ‘‘first fit’’. Nine of the 38 patients (24%)were thought to have had an alcohol related ‘‘firstfit’’; involvement of specialist neurology serviceswas only requested for the other 29 patients.

Twenty four of the 38 patients (63%) were dis-charged from A&E after presenting with a ‘‘first fit’’.Half these patients (12 of 24) were sent home withletters requesting a neurology referral by their GP;10 (83%) were lost to neurological follow-up. Bycontrast, of the 10 patients (42%) directly referred

from A&E to the neurology clinic, only two (20%)were lost to follow-up. There was no obvious clinicaldifference between patients who were and were notreferred directly to a neurology clinic. If the major-ity of patients attending an A&E Department after a‘‘firstfit’’are tobe seenbyaneurologist, and the 20%of incorrect diagnoses seen in our sample are to beavoided, then direct referral to the neurology clinicfrom the A&E department appears to be mandatory.

In our population of patients discharged from A&Eafter a ‘‘first fit’’, it took a median of 22 weeks for aNeurology review, 18 weeks longer than the sug-gested interval of 4 weeks in the literature,1,5,10 nopatient was seen within the recommended intervalof 4 weeks. The clinic to MRI interval was 12 weeks,which met the suggested time interval, whilst theclinic to EEG interval was 15 weeks, 11 weeks longerthan suggested. At present in the UK, median wait-ing times for routine new patient appointments inNeurology Clinics range from 12 to 51 weeks.9

Our audit suggests the need for a significantchange in practice if patients are to be seen within4 weeks of a first fit. Possible solutions include eitherseeing these patients urgently, displacing otherswith urgent needs, or allocating additionalresources to the management of people with estab-lished epilepsy, for example by a Clinical NurseSpecialist in epilepsy,10 to free up time for earlyconsultant contact with patients after a ‘‘first fit’’for diagnosis, investigation, and treatment.

Other improvements in service provision shouldinclude a reduction in the interval from ‘‘first fit’’ toMRI and EEG. This could be done by booking theinvestigations directly from the Accident and Emer-gency (A&E) Department, although this audit sug-gests that about 20% of these patients would haveunnecessary investigations. Initial review in A&E bya neurology registrar is likely at best to delay A&Edischarge and often to be unavailable, but diagnos-tic guidelines for A&E medical staff and occasionalbut regular review of their use by the neurologyteam, with telephone contact as needed, mayreduce this number.

This retrospective audit suggests that there couldbe a considerable shortfall in achieving standardsderived from guidelines currently suggested for themanagement of patients after a first seizure withoutsignificant change in practice, partially comprisingresource improvements.

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An audit of first seizures 61

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