National Audit of Seizure management in Hospitals (NASH): results of the national audit of adult epilepsy in the UK.

OBJECTIVES: About 100,000 people present to hospitals each year in England with an epileptic seizure. How they are managed is unknown; thus, the National Audit of Seizure management in Hospitals (NASH) set out to assess prior care, management of the acute event and follow-up of these patients. This paper describes the data from the second audit conducted in 2013. SETTING: 154 emergency departments (EDs) across the UK. PARTICIPANTS: Data from 4544 attendances (median age of 45 years, 57% men) showed that 61% had a prior diagnosis of epilepsy, 12% other neurological problems and 22% were first seizure cases. Each ED identified 30 consecutive adult cases presenting due to a seizure. PRIMARY AND SECONDARY OUTCOME MEASURES: Details were recorded of the patient's prior care, management at hospital and onward referral to neurological specialists onto an online database. Descriptive results are reported at national level. RESULTS: Of those with epilepsy, 498 (18%) were on no antiepileptic drug therapy and 1330 (48%) were on monotherapy. Assessments were often incomplete and witness histories were sought in only 759 (75%) of first seizure patients, 58% were seen by a senior doctor and 57% were admitted. For first seizure patients, advice on further seizure management was given to 264 (27%) and only 55% were referred to a neurologist or epilepsy specialist. For each variable, there was wide variability among sites that was not explicable. For the sites who partook in both audits, there was a trend towards better care in 2013, but this was small and dwarfed by the intersite variability. CONCLUSIONS: These results have parallels with the Sentinel Audit of Stroke performed a decade earlier. There is wide intersite variability in care covering the entire care pathway, and a need for better organised and accessible care for these patients.

Feasibility and impact of a computer-guided consultation on guideline-based management of COPD in general practice.

BACKGROUND: Applying guidelines is a universal challenge that is often not met. Intelligent software systems that facilitate real-time management during a clinical interaction may offer a solution. AIMS: To determine if the use of a computer-guided consultation that facilitates the National Institute for Health and Clinical Excellence-based chronic obstructive pulmonary disease (COPD) guidance and prompts clinical decision-making is feasible in primary care and to assess its impact on diagnosis and management in reviews of COPD patients. METHODS: Practice nurses, one-third of whom had no specific respiratory training, undertook a computer-guided review in the usual consulting room setting using a laptop computer with the screen visible to them and to the patient. A total of 293 patients (mean (SD) age 69.7 (10.1) years, 163 (55.6%) male) with a diagnosis of COPD were randomly selected from GP databases in 16 practices and assessed. RESULTS: Of 236 patients who had spirometry, 45 (19%) did not have airflow obstruction and the guided clinical history changed the primary diagnosis from COPD in a further 24 patients. In the 191 patients with confirmed COPD, the consultations prompted management changes including 169 recommendations for altered prescribing of inhalers (addition or discontinuation, inhaler dose or device). In addition, 47% of the 55 current smokers were referred for smoking cessation support, 12 (6%) for oxygen assessment, and 47 (24%) for pulmonary rehabilitation. CONCLUSIONS: Computer-guided consultations are practicable in general practice. Primary care COPD databases were confirmed to contain a significant proportion of incorrectly assigned patients. They resulted in interventions and the rationalisation of prescribing in line with recommendations. Only in 22 (12%) of those fully assessed was no management change suggested. The introduction of a computer-guided consultation offers the prospect of comprehensive guideline quality management.

Survey of early discharge schemes from the 2003 UK National COPD Audit.

BACKGROUND: Early discharge for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) has been shown to be effective by clinical trials. To evaluate its implementation and efficacy in clinical practice, data concerning early discharge schemes (EDS) from the 2003 National COPD Audit were collected and analysed. METHODS: All acute Trusts in the UK were surveyed in Autumn 2003 by two means: one a questionnaire relating to organisation of care and second an audit of 40 clinical cases admitted with AECOPD. RESULTS: Data were available for both organisation of care and clinical activity for 233 units, of which 103 (44%) had EDS. Models of care included admission prevention in the accident and emergency department (5%), rapid discharge in <48h (27%), assisted discharge occurring 2 days or more after admission (24%) and combinations of these (12%). There was wide variation in organisation of care overall. 30% of patients in units with EDS were discharged early from hospital. Units with EDS had an average LOS 1-day shorter with no increase in readmission rate (32% vs. 32%) as for those without an EDS and no increase in mortality. CONCLUSIONS: There is wide variation in the availability of EDS for AECOPD in the UK, with increasing implementation of schemes. Thirty percent of patients can effectively be put into EDS which is higher than the figure of 25% from randomised controlled trials (RCTs). Mortality and readmission rates are the same as for units where no EDS is available and similar to results reported in RCTs. EDS therefore appears to be effective in routine clinical practice.