Supporting the ambulance service to safely convey fewer patients to hospital by developing a risk prediction tool: Risk of Adverse Outcomes after a Suspected Seizure (RADOSS)-protocol for the mixed-methods observational RADOSS project.

INTRODUCTION: Ambulances services are asked to further reduce avoidable conveyances to emergency departments (EDs). Risk of Adverse Outcomes after a Suspected Seizure seeks to support this by: (1) clarifying the risks of conveyance and non-conveyance, and (2) developing a risk prediction tool for clinicians to use 'on scene' to estimate the benefits an individual would receive if conveyed to ED and risks if not. METHODS AND ANALYSIS: Mixed-methods, multi-work package (WP) project. For WP1 and WP2 we shall use an existing linked data set that tracks urgent and emergency care (UEC) use of persons served by one English regional ambulance service. Risk tools are specific to clinical scenarios. We shall use suspected seizures in adults as an exemplar.WP1: Form a cohort of patients cared for a seizure by the service during 2019/2020. It, and nested Knowledge Exchange workshops with clinicians and service users, will allow us to: determine the proportions following conveyance and non-conveyance that die and/or recontact UEC system within 3 (/30) days; quantify the proportion of conveyed incidents resulting in 'avoidable ED attendances' (AA); optimise risk tool development; and develop statistical models that, using information available 'on scene', predict the risk of death/recontact with the UEC system within 3 (/30) days and the likelihood of an attendance at ED resulting in an AA.WP2: Form a cohort of patients cared for a seizure during 2021/2022 to 'temporally' validate the WP1 predictive models.WP3: Complete the 'next steps' workshops with stakeholders. Using nominal group techniques, finalise plans to develop the risk tool for clinical use and its evaluation. ETHICS AND DISSEMINATION: WP1a and WP2 will be conducted under database ethical approval (IRAS 307353) and Confidentiality Advisory Group (22/CAG/0019) approval. WP1b and WP3 have approval from the University of Liverpool Central Research Ethics Committee (11450). We shall engage in proactive dissemination and knowledge mobilisation to share findings with stakeholders and maximise evidence usage.

Cancer patients' needs assessment in primary care: study protocol for a cluster randomised controlled trial (cRCT), economic evaluation and normalisation process theory evaluation of the needs assessment tool cancer (CANAssess).

INTRODUCTION: Unmet needs in patients with cancer and their carers are common but poorly identified and addressed. The Needs Assessment Tool-Cancer (NAT-C) is a structured consultation guide to identify and triage patient and carer unmet needs. The NAT-C is validated, but its effectiveness in reducing unmet patient and carer needs in primary care is unknown. METHODS AND ANALYSIS: Cluster randomised controlled trial with internal pilot and embedded process evaluation to test the clinical and cost effectiveness of the NAT-C in primary care for people with active cancer in reducing unmet patient and carer need, compared with usual care. We will recruit 1080 patients with active cancer (and carers if relevant) from 54 general practices in England.Participating practices will be randomised 1:1 to either deliver an NAT-guided clinical consultation plus usual care or to usual care alone. Consenting participants with active cancer and their carers (if nominated) will be asked to complete study questionnaires at baseline, 1 and 3 months for all, 6 months except for those recruited outside of the last 3 months of recruitment, and attend an NAT-C appointment if allocated to an intervention practice. An internal pilot will assess: site and participant recruitment, intervention uptake and follow-up rates. The primary outcome, the proportion of patients with an unmet need on the Supportive Care Needs Survey Short Form 34 at 3 months postregistration, will be analysed using a multilevel logistic regression. Mixed-methods process evaluation informed by Normalisation Process Theory will use quantitative survey and interview data from clinicians and key stakeholders in cancer care to develop an implementation strategy for nationwide rollout of the NAT-C if the intervention is cost-effective. ETHICS AND DISSEMINATION: Ethical approval from London-Surrey REC (20/LO/0312). Results will be peer-reviewed, published and made available to research participants. TRIAL REGISTRATION NUMBER: ISRCTN15497400.

Developing patient-centred, feasible alternative care for adult emergency department users with epilepsy: protocol for the mixed-methods observational 'Collaborate' project.

INTRODUCTION: Emergency department (ED) visits for epilepsy are common, costly, often clinically unnecessary and typically lead to little benefit for epilepsy management. An 'Alternative Care Pathway' (ACP) for epilepsy, which diverts people with epilepsy (PWE) away from ED when '999' is called and leads to care elsewhere, might generate savings and facilitate improved ambulatory care. It is unknown though what features it should incorporate to make it acceptable to persons from this particularly vulnerable target population. It also needs to be National Health Service (NHS) feasible. This project seeks to identify the optimal ACP configuration. METHODS AND ANALYSIS: Mixed-methods project comprising three-linked stages. In Stage 1, NHS bodies will be surveyed on ACPs they are considering and semi-structured interviews with PWE and their carers will explore attributes of care important to them and their concerns and expectations regarding ACPs. In Stage 2, Discrete Choice Experiments (DCE) will be completed with PWE and carers to identify the relative importance placed on different care attributes under common seizure scenarios and the trade-offs people are willing to make. The uptake of different ACP configurations will be estimated. In Stage 3, two Knowledge Exchange workshops using a nominal group technique will be run. NHS managers, health professionals, commissioners and patient and carer representatives will discuss DCE results and form a consensus on which ACP configuration best meets users' needs and is NHS feasible. ETHICS AND DISSEMINATION: Ethical approval: NRES Committee (19/WM/0012) and King's College London ethics Committee (LRS-18/19-10353). Primary output will be identification of optimal ACP configuration which should be prioritised for implementation and evaluation. A pro-active dissemination strategy will make those considering developing or supporting an epilepsy ACP aware of the project and opportunities to take part in it. It will also ensure they are informed of its findings. PROJECT REGISTRATION NUMBER: Researchregistry4723.

Emergency hospital care for adults with suspected seizures in the NHS in England 2007-2013: a cross-sectional study.

AIMS: To quantify the frequency, characteristics, geographical variation and costs of emergency hospital care for suspected seizures. DESIGN: Cross-sectional study using routinely collected data (Hospital Episode Statistics). SETTING: The National Health Service in England 2007-2013. PARTICIPANTS: Adults who attended an emergency department (ED) or were admitted to hospital. RESULTS: In England (population 2011: 53.11 million, 41.77 million adults), suspected seizures gave rise to 50 111 unscheduled admissions per year among adults (≥18 years). This is 47.1% of unscheduled admissions for neurological conditions and 0.71% of all unscheduled admissions. Only a small proportion of admissions for suspected seizures were coded as status epilepticus (3.5%) and there were a very small number of dissociative (non-epileptic) seizures. The median length of stay for each admission was 1 day, the median cost for each admission was £1651 ($2175) and the total cost of all admissions for suspected seizures in England was £88.2 million ($116.2 million) per year. 16.8% of patients had more than one admission per year. There was significant geographical variability in the rate of admissions corrected for population age and gender differences and some areas had rates of admission which were consistently higher than the average. CONCLUSIONS: Our data show that suspected seizures are the most common neurological cause of admissions to hospital in England, that readmissions are common and that there is significant geographical variability in admission rates. This variability has not previously been reported in the published literature. The cause of the geographical variation is unknown; important factors are likely to include prevalence, deprivation and clinical practice and these require further investigation. Dissociative seizures are not adequately diagnosed during ED attendances and hospital admissions.

Cross-sectional study of the hospital management of adult patients with a suspected seizure (EPIC2).

OBJECTIVE: To determine the clinical characteristics, management and outcomes of patients taken to hospital by emergency ambulance after a suspected seizure. DESIGN: Quantitative cross-sectional retrospective study of a consecutive series of patients. SETTING: An acute hospital trust in a large city in England. PARTICIPANTS: In 2012-2013, the regions' ambulance service managed 605 481 emergency incidents, 74 141/605 481 originated from Sheffield (a large city in the region), 2121/74 141 (2.9%) were suspected seizures and 178/2121 occurred in May 2012. We undertook detailed analysis of the medical records of the 91/178 patients who were transported to the city's acute hospital. After undertaking a retrospective review of the medical records, the best available aetiological explanation for the seizures was determined. RESULTS: The best available aetiological explanation for 74.7% (68/91) of the incidents was an epileptic seizure, 11.0% (10/91) were psychogenic non-epileptic seizures and 9.9% (9/91) were cardiogenic events. The epileptic seizures fall into the following four categories: first epileptic seizure (13.2%, 12/91), epileptic seizure with a historical diagnosis of epilepsy (30.8%, 28/91), recurrent epileptic seizures without a historical diagnosis of epilepsy (20.9%, 19/91) and acute symptomatic seizures (9.9%, 9/91). Of those with seizures (excluding cardiogenic events), 2.4% (2/82) of patients were seizing on arrival in the Emergency Department (ED), 19.5% (16/82) were postictal and 69.5% (57/82) were alert. 63.4% (52/82) were discharged at the end of their ED attendance and 36.5% (19/52) of these had no referral or follow-up. CONCLUSIONS: Most suspected seizures are epileptic seizures but this is a diagnostically heterogeneous group. Only a small minority of patients require emergency medical care but most are transported to hospital. Few patients receive expert review and many are discharged home without referral to a specialist leaving them at risk of further seizures and the associated morbidity, mortality and health services costs of poorly controlled epilepsy.

Non-epileptic attack disorder: the importance of diagnosis and treatment.

A 50-year-old woman was taken to hospital by emergency ambulance during her first seizure. She was admitted to hospital, treated with intravenous diazepam, diagnosed with epilepsy and started on antiepileptic drug (AED) therapy. This was ineffective so she was referred to a tertiary centre where she underwent video EEG and was diagnosed with non-epileptic attack disorder. Her experience of the diagnosis was positive; it allowed her to understand what was happening to her and to understand the link between her seizures, adverse childhood experiences and the death of her mother. She stopped taking AEDs and she was referred to a psychologist which led to a significant improvement in her functioning and quality of life. We present this case as a good example of the benefits of accurate diagnosis, clear explanation and access to specialist care.

Multiple vitamin deficiencies in a patient with a history of chronic alcohol excess and self-neglect in the UK.

We report a case of inadequate diet (caused by extreme self-neglect and alcohol excess) which led to chronic severe deficiencies of vitamins A, D and E. At presentation the patient had widespread follicular hyperkeratosis of the skin, keratomalacia of both eyes and a severe cognitive impairment. He responded well to treatment including high dose parenteral vitamins, but lasting impairments in his vision and cognition have caused permanent disability.