Risk characteristics of alcohol and/or drug misuse in repeat emergency department attendees for seizures: a case-control study.

BACKGROUND: There is a bi-directional relationship between seizures and substance misuse, i.e., alcohol and recreational drugs. Seizures and substance misuse are recognised separately to influence increased emergency department (ED) admissions and early death. There is however no understanding of the cumulative influence of these matters on repeat ED attenders for seizures esp. as a third are likely to re-attend within the year. This case-control study compares the characteristics of people with substance misuse to those without substance misuse presenting recurrently with seizures to the ED. METHODS: From a single ED serving a rural population in the Southwest of England, data of all people presenting more than once with a seizure over a 4-year period were examined. The diagnosis of alcohol or drug misuse, deaths, demographic characteristics, and service use were captured. RESULTS: Of 450 repeat attenders, 95 had a recorded history of alcohol and/or drug problems. Those with substance misuse had double the mortality when adjusted for age and gender compared to those without. They were also more likely to be male, younger in age, have mental health issues, live in socially deprived neighborhoods, not take anti-seizure medications and not have had a specialist review in epilepsy services in the previous year. Nearly a quarter of those with addiction issues died in the 4-year period. DISCUSSION: Service provision for this vulnerable group may need to be modelled along different lines to traditional approaches, such as an assertive outreach community-based service as provided for chronic psychiatric and addiction management.

Seizures and emergency department: characteristics and factors of repeat adult attendees.

BACKGROUND: To identify risk factors and characteristics for the repeated attendance at an emergency department (ED) following a seizure. METHODS: A retrospective cohort study was conducted using non-identifiable data of individuals attending ED at least twice between 2015 and 2018, following a seizure. Data were drawn from the patient administration system of an English rural medium-sized teaching district general hospital emergency department (ED), serving a population of 566,000 people. It was analysed for bio-psycho-social features associated with repeat attendances. RESULTS: Of 3522 seizure-related attendances in the four years, 450 people were identified to be repeaters attending on two or more occasions (range 2-12). Just over a quarter (27%) were 18-29 years old. Higher likelihood of re-attendance was associated with social deprivation and no fixed abode. Mental illness was a significant co-morbidity influencing repeat attendances. Nearly half (47%) had no recorded anti-seizure medication (ASM). Three fifth (60%) were on general medication and a quarter (25%) on psychotropics. Nearly a quarter (22%) had alcohol and recreational drug concerns. Just over a quarter (28%) had no previous epilepsy diagnosis. Nearly a fifth (n = 85, 19%) died during the study period. CONCLUSION: People who present repeatedly with seizures at ED are at significant risk of death over a four-year period and require pro-active clinical follow-up. People who are homeless or from socially deprived areas are over-represented in this group, as are those with alcohol problems, co-morbid mental health conditions and compliance issues. This suggests enhanced targeted intervention for this cohort is needed.

Potential impact of national recommendations to use short course antibiotic therapy on antibiotic use in the emergency department of a UK hospital: retrospective observational study.

BACKGROUND AND IMPORTANCE: The National Institute for Health and Care Excellence (NICE) antimicrobial prescribing guidelines for common infections recommend short course antimicrobial therapy in order to reduce antibiotic associated harm. OBJECTIVE: To quantify the opportunity to reduce antibiotic use in an emergency department (ED) through adoption of these short antibiotic course recommendations. DESIGN, SETTINGS AND PARTICIPANTS: A retrospective observational study in an ED in the UK with 95 000 attendances a year. Patients managed in the ED between 1 December and 31 December 2019 with the following infections were identified: acute otitis media, human and animal bites, pyelonephritis, lower urinary tract infections, cellulitis, cough, infective exacerbation of chronic obstructive pulmonary disease, pneumonia, sore throat, sinusitis, and diverticulitis. OUTCOME MEASURE: Excess antibiotic use due to either a protracted course length, or not meeting criteria for antibiotics. RESULTS: 395 patients (260 adults and 135 children) were identified. Of the 1215 days of antibiotic therapy, 198 (16%) were excess because of protracted course lengths. In terms of antibiotic defined daily doses (DDD), there were 1201.5 antibiotic DDD prescribed, of which 232 (19%) DDD were excess because of protracted course lengths. If both protracted courses and unnecessary antibiotic use were included, then 321 (27%) DDD were excess. Excess antibiotic use and total antibiotic use by infection group were: 123/546 (23%) DDD in lower respiratory tract infection, 46/59 (79%) in upper respiratory tract infection, 44/231 (19%) in upper and lower urinary tract infection, 0/113 (0%) cellulitis, 77/180 (43%) bites, and 30/40 (75%) diverticulitis. Excess antibiotic use, as a proportion of all antibiotic use in the ED, was 321/4291 (7.5%) DDD, and of whole hospital antibiotic use, the ED's excess use was 321/33 566 (0.96%). CONCLUSION: Adoption of NICE antibiotic prescribing guidelines for common infections has the potential to reduce total antibiotic use in the ED by 7.5% and contribute to the hospital-wide antibiotic stewardship programme.

Exploring epilepsy attendance at the emergency department and interventions which may reduce unnecessary attendances: A scoping review.

BACKGROUND: Repeat attendances to emergency departments for seizures, impacts on the individual and burdens health care systems. We conducted a review to identify implementable measures which improve the management of people with epilepsy reducing healthcare costs and their supportive evidence. METHODS: A scoping review design using suitable search strategy as outlined by PRISMA-ScR was used to examine seven databases: MEDLINE, EMBASE, CINAHL, AMED, PsychINFO, HMIC and BNI. A manual search of the COCHRANE database and citation searching was also conducted. A thematic analysis was conducted to explore the context and reasons of emergency department attendance for seizures, particularly repeat attendances and the strategies and measures deployed to reduce repeat attendances. RESULTS: Twenty-nine reports were included, comprising of a systematic review, a randomised control study, a multi-method study, quantitative studies (n = 17), qualitative studies (n = 6), an audit, a survey and a quality improvement project. Thematic analysis identified four broad areas for reducing repeat attendances. These were developing care pathways, conducting care and treatment reviews, providing educational interventions and role of ambulance staff. CONCLUSION: The findings indicate varied reasons for attendance at ED following seizure, including mental health and knowledge of seizure management and lack of education. Implementations of care pathways in ED have been found to reduce admission related costs.

Frequency and factors associated with emergency department attendance for people with epilepsy in a rural UK population.

Attendance at UK Emergency Departments (EDs) for people with epilepsy (PWE) following a seizure can be unnecessary and costly. The characteristics of PWE attending a UK rural district ED in a 12-month period were examined to foster better understanding of relevant psycho-social factors associated with ED use by conducting cross-sectional interviews using standardized questionnaires. Of the total participants (n=46), approximately one-third of the study cohort attended ED on three or more occasions in the 12-month study period and accounted for 65% of total ED attendances reported. Seizure frequency and lower social deprivation status were associated with increased ED attendance while factors such as knowledge of epilepsy, medication management, and stigma were not. Similarities in frequency of repeat attendees were comparable to a study in urban population but other factors varied considerable. Our findings suggest that regular ED attendees may be appropriate for specific enhanced intervention though consideration needs to be given to the fact that population characteristics may vary across regions.