Clinical Audit

1. G ROUP M EMBERS :
DR GAIL REID DM (YEAR 3.5)
DR OLSHEATH BOWEN DM (YEAR 1.5)
DR PETER ANDRE SOLTAU (YEAR 2.5)

2. OBJECTIVES
• “Get a copy of the UHWI ED seizure protocol”
• “Will need to evaluate a minimum of 60
patients”
• ”If the patients met the criteria for CT or not as
per UHWI protocol, then if CT was done or
not.”

4. FIRST TIME SEIZURES
• The physician must seek to establish that the
attack was truly a seizure
• If there is any persistent alteration of mental
status or neurological deficit a CT brain should be
done in the emergency department and reviewed
• CT Scan may be done as outpatient if patient
returns to normal neurological status
Prepared by Dr Eric Williams

5. FIRST TIME SEIZURES
• Generally speaking patients with a first time seizure
may be referred for follow up with EEG and CT brain to
the Neurology Clinic at UHWI or a private neurologist
depending on patient preference.
• There is no need to start antiepileptic drugs in these
patients
•
These patients must be reviewed within 2 weeks of
discharge from the ED (in order to expedite the
management as a result of an abnormal investigation)
Prepared by Dr Eric Williams

6. FIRST TIME SEIZURES
• Most patients with a simple febrile seizure who recover fully and
have a focus for their fever e.g. otitis media, UTI, simple LRTI
should receive antipyretic measures and have fever reduced in the
ED
• They do not require antiepileptic drugs
• The specific infection should be treated. These patients should be
followed up by the paediatrician in Room 2 or their private
paediatrician within 24--‐48 hours. They do not usually require a CT
scan
Paed Emerg Management guidelines by Prof Gray UWI

7. REASONS FOR TOPIC
SELECTION
• Patient Safety
• Cost (CT Brain = Ja $40,000)
• Litigation (missing serious pathology)

8. AIMS
• To document % compliance of the management
of first time seizures in the ED as per clinical
protocols for the Emergency Department
• To improve compliance of the management of
first time seizures in the

9. MATERIALS & METHODS
• This clinical policy audit was directed by the
Emergency Medicine Division of the UHWI
• It was conducted at the Emergency Department
(ED) of a 500-bed university affiliated, tertiary
care hospital in Mona, Kingston, Jamaica
• We reviewed medical records of all patients who
had been diagnosed with first time seizure/ ?
First time seizure from October 1, 2012 through
October 1, 2013

10. STUDY SUBJECTS
• Patients were identified via a manual search of
UHWI Accident &Emergency (A&E) log books, a
discharge column diagnosis for
“seizure”, specifically “first time seizure”
triggered a docket number collection and docket
trace via docket library through the medical
records department of the UHWI.

11. DATA COLLECTION
Data abstracted from the medical records included:
•
Docket/file #
•
Gender
•
Age
•
Past medical history
•
Duration of seizure
•
Febrile seizure
•
Focal seizure
•
Status epilepticus
•
Persistent alteration of mental status
•
Neurological deficit
•
CT scan done in Emergency Department
•
CT scan ordered as outpatient
•
If follow up was arranged for CT review.

12. DATA COLLECTION
• The data were collected on a pre-designed data
abstraction form and then were entered into a standard
spreadsheet (Excel 2010, version 14.0.7106.5003;
Microsoft Corporation, Redmond, WA).

13. RESULTS
• During the period of October 1, 2012 through October 1,
2013, 133 cases were identified with a possible diagnosis
of first time seizure from the A&E log books
• A total of 133 dockets were requested from the docket
office/library, however only 83 (62%) were located and
upon in depth review by three investigators to determine
the patients who met the criteria this resulted in 44 (33%)
patients with a diagnosis of first time seizure

14. GENDER & AGE
• 27 Females : 16 Males
• Age range 1 – 92 years old

15. AGE
• Total of 16 paediatric patients
• 11 % of patients were age 1 or below
• 25 % of patients were age 3 or below
• 31 % of patients were age 5 or below
• No patient below age 2 had any medical illnesses while all
patients (6) defined as elderly (age 60-65 and above) had
at least 1 medical illness, most commonly hypertension

16. DURATION OF SEIZURE
• In 18 patients (40% of cases) the duration was unable to
be assessed due to poor documentation
• 15 patients – lasted less than 5 minutes
• 19 Patients – lasted 5 minutes or less
• 5 Patients – lasted 10 minutes or more

17. SEIZURE PATTERN
• 7 patients were found to have status epileptics
• 4/7 patients had CT in the ED
• 5 patients had persistence of mental status
changes
• 4/5 with altered mental status had CT done in the
ED
• 4 had documented neurological deficit
• All 4 had CT in the ED
• 4 patients had focal seizures
• All 4 had CT in the ED

18. WAS CT INDICATED IN THE ED ?
• 20 patients – CT indicated in the ED
• In 2 of these patients CT was not done in the ED
• 21 patients – CT not indicated in ED
• 2 of these patients had CT done in the ED
• 3 patients – Unsure if CT done in ED

19. PROTOCOL FOLLOWED
FOR CT IN ED
• In 35 cases the protocol was followed
• In 4 cases the protocol was not followed
• In 5 cases it was unclear

20. IF CT WAS NOT INDICATED, WAS
PROTOCOL FOLLOWED FOR FOLLOW
UP?
• In 5 cases protocol was not applicable e.g. patients
admitted, CT already done
• In 4 cases – unsure
• Did not identify any case or patient in which follow up
protocol was followed
• In one case, the protocol was followed however the patient
required CT in ED and not as outpatient

21. FOLLOW UP FOR REVIEW
• 7 patients were to be followed up for
review, however there is no
documentation as to CT being ordered
as outpatient

22. LIMITATIONS
Legibility of log book entries
Inability to get dockets from docket library
Missing notes from docket :Inability to locate notes of seizure
presentation when docket retrieved
Documentation : Insufficient note taking by physicians/ medical
staff : poor history taking
Any patient who was not recorded in the log book would have
been excluded (?#)

23. RECOMMENDATIONS
A copy of clinical protocol book to be placed in A&E for
quick referencing
Encourage staff to keep up to date with clinical policy book,
e.g. in academic meetings/ death conferences
Addition of electronic records
Encourage legibility of log book entries

24. CONCLUSION
• High rate of compliance with protocol for CT
scans in the ED for patients with first time
seizures
• Poor documentation by physicians : seizure
duration, follow up, CT as outpatient
• Poor compliance with follow up protocol
• Need for continued medical education

25. CT ordered as
outpatient?
Follow up for CT
review ?
no
no
yes
no
no
no
no
no
no
no
no
no
no
no
no
n/a
no
yes
yes
no
no
no
yes
no
yes
no
yes
no
yes
yes
no
no
yes
n/a
no
neuro clinic
patient transferred
KPH
n/a
N/A
?
n/a
n/a
n/a
no
n/a
?
n/a
Protocol
followed for
follow up
N/A
no
no
no
N/A
no
N/A
no
N/A
N/A
N/A
N/A
no
no
no
?
no
yes
CT indicated
in ED?
Protocol
followed
N/A
?
N/A
N/A
?
N/A
N/A
N/A
no
N/A
no
N/A
?
Yes
?
No
No
Yes
No
Yes
No
No
yes
no
unavailable
no
yes
no
yes
no
yes
yes
yes
yes
no
no
no
?
no
no
Requested, no
documentation
no
yes
no
yes
no
yes
no
yes
no
no
admitted pedi, complex partial
N/A
No
no
yes
?
no
no
no
no
no
no
?
no
no
?
?
no
no
?
no
N/A
N/A
N/A
N/A
N/A
?
no
N/A
?
?
no
N/A
No
No
yes
Yes
yes
yes
yes
no
no
no
no
no
no
yes
no
no
yes
yes
yes
yes
yes
no
no
yes
no
no
no
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
no
yes
yes
yes
yes
n/a
Admitted / n/a
n/a
?
n/a
admitted pedi
n/a
no
n/a
?
referred pedi
?
n
n
n
n
n
n
?
n
n
?
?
n
n
yes
no
yes
no
yes
no
yes
no
yes
yes
yes
yes
no
yes
no
yes
no
Yes
CT done in ED ?
yes
yes
?
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
no
yes
?
yes
no
?
?
yes
?
no
yes
yes
yes
yes
yes
yes