Diagnostic testing in nontrauma patients presenting to the emergency department with recurrent seizures: A systematic review

Development of clinical prediction model to guide the use of CT head scans for non-traumatic Thai patient with seizure: A cross-sectional study

The aim of this study was to develop clinical predictor tools for guiding the use of computed tomography (CT) head scans in non-traumatic Thai patients presented with seizure. A prediction model using a retrospective cross-sectional design was conducted. We recruited adult patients (aged ≥ 18 years) who had been diagnosed with seizures by their physicians and had undergone CT head scans for further investigation. Positive CT head defined as the presence of any new lesion that related to the patient's presented seizure officially reported by radiologist. A total of 9 candidate predictors were preselected. The prediction model was developed using a full multivariable logistic regression with backward stepwise elimination. We evaluated the model's predictive performance in terms of its discriminative ability and calibration via AuROC and calibration plot. The application was then constructed based on final model. A total of 362 patients were included into the analysis which comprising of 71 patients with positive CT head findings and 291 patients with normal results. Six final predictors were identified including: Glasgow coma scale, the presence of focal neurological deficit, history of malignancy, history of CVA, Epilepsy, and the presence of alcohol withdrawal symptom. In terms of discriminative ability, the final model demonstrated excellent performance (AuROC of 0.82 (95% CI: 0.76-0.87)). The calibration plot illustrated a good agreement between observed and predicted risks. This prediction model offers a reliable tool for effectively reduce unnecessary use and instill confidence in supporting physicians in determining the need for CT head scans in non-traumatic patients with seizures.

'Knowledge exchange' workshops to optimise development of a risk prediction tool to assist conveyance decisions for suspected seizures - Part of the Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) project

PURPOSE

Suspected seizures present challenges for ambulance services, with paramedics reporting uncertainty over whether or not to convey individuals to emergency departments. The Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) project aims to address this by developing a risk assessment tool utilizing structured patient care record and dispatch data. It proposes a tool that would provide estimates of an individual's likelihood of death and/or recontact with emergency care within 3 days if conveyed compared to not conveyed, and the likelihood of an 'avoidable attendance' occurring if conveyed. Knowledge Exchange workshops engaged stakeholders to resolve key design uncertainties before model derivation.

METHOD

Six workshops involved 26 service users and their significant others (epilepsy or nonepileptic attack disorder), and 25 urgent and emergency care clinicians from different English ambulance regions. Utilizing Nominal Group Techniques, participants shared views of the proposed tool, benefits and concerns, suggested predictors, critiqued outcome measures, and expressed functionality preferences. Data were analysed using Hamilton's Rapid Analysis.

RESULTS

Stakeholders supported tool development, proposing 10 structured variables for predictive testing. Emphasis was placed on the tool supporting, not dictating, care decisions. Participants highlighted some reasons why RADOSS might struggle to derive a predictive model based on structured data alone and suggested some non-structured variables for future testing. Feedback on prediction timeframes for service recontact was received, along with advice on amending the 'avoidable attendance' definition to prevent the tool's predictions being undermined by potential overuse of certain investigations in hospital.

CONCLUSION

Collaborative stakeholder engagement provided crucial insights that can guide RADOSS to develop a user-aligned, optimized tool.

Pathology testing in non-trauma patients presenting to the emergency department with recurrent seizures

OBJECTIVE

Excessive pathology testing is associated with ED congestion, increased healthcare costs and adverse patient health outcomes. This study aimed to determine the frequency, yield and influence of pathology tests among patients presenting to the ED with atraumatic recurrent seizures.

METHODS

This was a retrospective cohort study conducted at a level 4 adult ED in Australia and included atraumatic patients presenting to ED with recurrent seizures over a 4-year period (2017-2020). The primary outcome was the frequency of pathology tests. Additionally, the proportion of abnormal pathology test results and the association between pathology tests and change in management were assessed.

RESULTS

Of the 398 eligible presentations, 346 (86.9%, 95% confidence interval [CI] 83.3-89.9%) underwent at least one pathology test. In total 18.3% (n = 517) of pathology tests had an abnormal result which led to 15 changes in ED management among 12 presentations. Patients who had an abnormal pathology test result were more likely to undergo a change in antiepileptic drug management (odds ratio 2.08, 95% CI 1.23-3.65; P = 0.008).

CONCLUSION

Most patients presenting to the ED with atraumatic recurrent seizures underwent pathology tests. Abnormalities were frequently detected but were uncommonly associated with change in management. Abnormal pathology test results were associated with changes in antiepileptic drug management although rarely led to acute changes in patient management. This study suggests that pathology tests may be excessively requested in this population.