First fit management and referral, with a view to developing an

improved referral form.

Dr Rebecca Monkman. BSc, MBchB (Hons)
Acute Medicine. Gloucester Royal Hospital.

first fit
idiopathic
epilepsy
4%

other/non
specific
5%

epileptic
seizures
29%

Aim
The context of this audit was to focus on first fit management and
referral within the Emergency Department (ED). The aim of this audit
was to evaluate patients presenting to ED between February and July
2012 of whom attended both sites at Gloucestershire Trusts (Cheltenham
District General Hospital and Gloucester Royal Hospital), to review
their management and referral in the objective to design a new First Fit
referral Form and improve this system. This was effectively established
and utilised within both departments on the system Patient First. The
second cycle of the audit was carried out between July and September
2013 to measure any improvement in both the management in terms of
investigations of these patients and their subsequent referral thereafter.

first fit
other/non
specific
1%

generalised
idiopathic
epilepsy
21%

first fit
epileptic
seizure
40%

Figure 1: proportion of patients presenting with seizure in ED between

February and July 2012.

Background
First seizures usually present to ED. One fundamental challenge seen in
Emergency Medicine is to recognise if this is an actual epileptic seizure
or from other pathology including complex migraines or cardiac in
origin for example. Therefore it has been a previous challenge not only
to rule out possible differentials, but to also categorise those patient who
are electives for first fit referral. One of the main issues have been in
light of many unnecessary referrals, therefore this is one fundamental
aspect to encourage new protocols to clarify the type of patient that
should be referred, and differentiate epileptic versus non-epileptic
seizures on the basis of their investigations in ED.

120
100
80
60
40
20
0

Methods
The audit team extrapolated those patients of who presented with
seizures by coding analysis, which was broken down by review of notes
and utilisation of Patient First to identify ED clerking, investigations,
and referral pathway of those patients of whom presented with first fit.

Results
260 patients initially presented within the first cycle. Therefore the reaudit cycle identified the first 260 patients presenting again from July
2013. Initially 64.1% of patients presenting to ED with their first fit
were referred to First Fit clinic. The majority of patients received ECG
(98.1%), BM (94.3%), Blood glucose (88.2%), FBC (99.8%), U&E
(99.8%) in the departments. However the main areas that were lacking
were LFTs (64.9%) and calcium levels (56.7%). Lumbar Punctures and
Computer Tomography (CT) scans were also low (17.3% and 67.3%
respectably) however the need for these investigations were based on
clinical decision. One main area that needed more attention was a full
neurological examination. Interestingly only 64.5% of patients were
advised (with documentation) about DVLA and driving regulations.
The re-audit cycle highlighted more clarity on investigations requested
in ED and there were less inappropriate referrals to First Fit clinic. There
were more referrals to appropriate teams including Alcohol Liaison and
Learning Disability teams. DVLA advice was also given (and/or
documented) more frequently.

pre new referal form

re audit when referal form in use.

Figure 2: assessment parameters of first fit on admission in ED before and

after the introduction of the new first fit protocol.

Outcomes and Implementation

On the basis of these results has set the standards for a quickly accessible
and more clarified referral form that highlighted baseline investigations
required to make a more substantial diagnosis before referral to the first
fit clinic. This is a valuable tool for ED especially with such large turnaround of doctors, and has been more beneficial when accessed quickly
on Patient First systems and also as a printed copy. This new protocol
has therefore reduced not only the time wasted for unnecessary referrals
but also the cost and valuable resources to the NHS. Furthermore,
patients of whom have the correct referral to the speciality required
would therefore ultimately receive more effective and quicker treatment.
These standards can be easily reproducible by other trusts.