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Essay about Epilepsy Pathway Case Study

use of the Epilepsy Pathway used in an Accident & Emergency Department (AED) at a local Trust 1. 0Introduction: 1. 1 Background Epilepsy is a common neurological disorder characterised by recurring seizures. Different types of epilepsy have different causes. Accurate estimates of incidence and prevalence are difficult to achieve because identifying people who may have epilepsy is difficult. Epilepsy has been estimated to affect between 362,000 and 415,000 people in England.

In addition, there will be further individuals, estimated to be 5-30%, so amounting to up to another 124,500 people, who have been diagnosed with epilepsy, but in whom the diagnosis is incorrect. (NICE CG) Epilepsy is common and each presentation to AED represents a “failure” in control. Anecdotally it is known that care of epilepsy is variable and that there are many patients who are unknown to the specialists and who have not had the opportunity to be optimally controlled.

Whilst there are many research studies in epilepsy that have summarised much of the evidence regarding treatment options for patients, little is known about the organisation and delivery of epilepsy care across the UK. National Institute of Clinical Excellence (NICE) has produced Clinical Guidelines which state that “Following a first seizure it is recommended that all adults having a first seizure should be seen as soon as possible (2 weeks) by a specialist in the management of the epilepsies to ensure precise and early diagnosis and initiation of therapy as appropriate to their needs”*.

NICE have also recommended that patients with known epilepsy/recurrent seizures are referred to tertiary services within 4 weeks for further assessment*. At our Trust, we have a process whereby ‘first fit’ patients are placed on the Adult Seizure Pathway and once completed, they are placed in a tray for the neurologists secretary to book them into a ‘first fit clinic. However, despite having this system in place which should allow all patients with a possible diagnosis of epilepsy to be seen within 2 weeks of their referral * but it doesn’t work very well therefore as a Trust we are non-compliant with this guideline.

For patients with known epilepsy, the patients are also placed on the Adult Seizure pathway and once completed; the patient is referred to Epilepsy Services as a sticker with their patient identifiable information is placed in the Epilepsy Referrals book for the patient to be seen by tertiary services. National Audit of Seizure Management in Hospitals (NASH) seeks to identify any variation in patient care and identify some of the resource and organisational factors that may account for this. Nationally, the results of the NASH audit have shown only 55% of patients with known epilepsy were referred to a neurologist or epilepsy specialist*.

The results for our Trust have shown that for adults presenting with known epilepsy only 6% were referred to an epilepsy service*. The result of the NASH audit for our Trust has identified areas for improvement within the Trust. These results clearly show that although a system has been set up whereby the AED would notify the specialist services of attendances (so early follow up can be arranged) this doesn’t happen. This has also been highlighted as a patient safety issue by the person responsible for epilepsy within the AED department and subsequent focus groups.

There isn’t sufficient evidence from the notes when conducting the NASH audit that all elements of management and treatment have been addressed. It will also ensure consistency in the patient care we provide. We would like to improve patient experience by providing an effective epilepsy pathway that also ensures we are compliant with the necessary guidelines. There is a lot of enthusiasm and interest from all levels of the Trust to support this project and be compliant with NICE guidelines.

Figure 1 elow shows the overall number of patients who have presented with Epilepsy/Seizure (according to Extramed-AED system) against total referrals (first fit referrals and community referrals). The data collected indicates that there are gaps between those patients who should be referred after attendance in AED and those who are actually referred. The referral process is clearly stated on the adult seizure pathway. We would expect that there would be a small percentage of patients where it would not be appropriate to refer them to Bradford community services who reside outside the catchment area.

These patients will be referred to their GP. Therefore this highlights that there the system currently being used isn’t working well and so agrees to the results of the NASH audit. Figure 1: A line graph to show patients who have presented with Epilepsy/Seizure (according to Extramed) against First Fit Referrals and Community Referrals from December 2014 to October 2015 1. 2 Aims: To improve compliance with the pathway for adult patients attending emergency services with a new diagnosis of epilepsy or seizures in patients with known epilepsy by 30% by June 2016.

2. Methodology: 2. 1 Stakeholder Engagement: Including the right people on a process improvement team is critical to a successful improvement effort therefore we first formed a team who would work together to drive this project forward. The team included a Project Lead (Consultant Neurologist), Expert Clinician (AED Consultant), Expert Nurse (AED Advanced Nurse Practitioner & Community Services Nurse), Project Manager, Quality Improvement Lead and Data Analyst. With a team from different services, it allows us to ensure we are looking at the epilepsy service from all perspectives.

It was important to involve people who were working on the ‘shop floor’ as they can enhance and boost change. 2. 2: Process Mapping: Once the team was formed, a process mapping exercise was undertaken. This involved mapping out the patient journey, the relevant procedures and administrative processes from the time the patient is admitted to AED to being discharged. Process mapping allows you to follow the process through from start to finish. The map shows how things are and what happens, rather than what should happen.

Process mapping provides an opportunity for multidisciplinary involvement. This helps anyone involved see other people’s views and roles therefore it gives everyone a chance to understand the issues and so reduces resistance to change proposals. However what people say they do and what they actually do can be quite different. It is an opportunity to highlight areas of concern/issues and you identify areas for improvement. This is great however lots of ideas for improvement can be overwhelming, and so the follow-up doesn’t always meet expectations of the stakeholders.

The process can also identify areas of the process that previously had been hidden. However the process doesn’t take into consideration the Contributory Factors Framework* which looks at how human factors (environmental, organisational and job factors, and individual characteristics) can influence people and their behaviour at work. Setting up a process mapping session can also be an effort to set up as it is difficult to arrange a time when everyone is available therefore there can be a delay in getting the process going.

Also if people can’t attend the session then their views are missed and they aren’t able to engage fully. Figure 2 shows the initial process map that was created using different coloured post it notes. It shows the patient journey from entering AED to being discharged. Having different members of the multidisciplinary team present allowed for a successful process mapping session. Figure 3 shows an electronic version of the process map. This was colour coded so it was easy to see the different roles the nursing, medical and administrative te

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