For seizure patients, stop 'revolving-door syndrome'
For seizure patients, stop 'revolving-door syndrome'
Emergency cases are on the rise
Epilepsy-related hospitalizations rose 43% from 95,000 in 2000 to 136,000 in 2005, with 66% of these patients admitted through the ED, says a new report from the Agency for Healthcare Research and Quality.1
ED nurses at Tallahassee (FL) Memorial Hospital's Bixler Emergency Center saw 32% fewer patients with epilepsy or seizure diagnosis from 2000 to 2003, but cases are on the rise again, reports Sheri Cook, RN, CEN, emergency services educator. "In the first half of 2007, we saw 100 patients, about 2.6 times more of this group of folks then we did in our all-time low of 68 patients in 2003," she says. It's possible that a growing number of uninsured patients is resulting in poor compliance with medications, says Cook.
Children younger than 2 are one of the groups with the greatest number of new onset seizures, says Karen Delrue, RN, MSN, CEN, clinical nurse specialist for emergency services at Spectrum Health in Grand Rapids, MI. "For children, the cause is most frequently related to a febrile event," she says. "Any seizure in children is a very traumatic event for the child's parents, so particular care needs to be extended to address their fears and anxiety."
Be aware of the potential for child abuse and the possibility that the seizure is the result of injury, Delrue says. "ED nurses need to always be evaluating what they see and what they are told. Activate the child protection team if you have any suspicions that something is not quite right," she adds.
Adults over 65 years old also are at high risk for developing seizures, especially those with history of head injury, stroke, central nervous system (CNS) infections, and degenerative CNS disorders such as Alzheimer's and multiple sclerosis, Delrue says. "New onset of seizures in the older population will require a detailed medical work-up to determine the underlying cause," she says.
For patients who arrive actively seizing, get as accurate a history as possible to determine if this is a new onset, if there is a history, and how long has the seizure activity been occurring, Delrue says. Do the following to improve care of seizure patients in your ED:
• Protect the patient from injury.
Paul Schoenberg, RN, CEN, director of the Emergency Trauma Center at St. Cloud (MN) Hospital, says some seizures can be quite violent. "Ensuring the patient does not hurt themselves is important," he says.
Pad side rails if possible, especially if you are having difficulty getting the patient's seizure activity under control or if the patient is in status epilepticus, advises Cook.
• Measure blood glucose levels.
Severe hypoglycemia, if untreated, can cause seizures, Cook explains. "Also, during a seizure, the brain is using up glucose at an alarming rate," she says.
ED nurses may not see the urgency in testing glucose levels for a patient with seizures or epilepsy, but this is a missed opportunity, says Cook. "With diabetes on the rise in the U.S., it is not uncommon for our patients to have dual diagnoses, or for the patient to have a new diagnosis of diabetes," she says. "The best rule of practice is to check the sugar quickly, no matter the patient's history."
• If the patient is on anticonvulsants via infusion pump, monitor the patient's electrocardiogram, blood pressure, and respirations continually.
"I find that my more seasoned nurses have a good understanding of the use and precautions with this group of drugs. Some of us are even old enough to remember that [phenytoin] was originally used as an antiarrhythmic, and it can be cardiac toxic if given too rapidly, hence the pump and the cardiac monitor," says Cook.
• Give thorough discharge instructions.
"Drug interactions and scheduling are very important in this patient population and cannot be overstressed," says Cook. "Education is key to reduce the 'revolving-door syndrome' that we sometimes see with this group of patients."
For example, a young man told ED nurses he couldn't afford "designer seizure medications" because he had lost his health benefits and was taking half the prescribed amount to make his medication last longer.
The patient was given phenytoin intravenously and discharged with a prescription for oral phenytoin, but he couldn't afford to fill it and asked if he could keep taking his old medications until they ran out, says Cook. In the end, ED nurses paid for the man's prescription and referred him to a local clinic that could refill medications for free or at a reduced rate.
If patients have their seizures well controlled, they might stop taking their medications because they don't like the side effects, adds Cook.
Don't assume patients with a long history of seizures "know it all," says Cook. "Start by saying, 'You might already know this,' so they don't feel you are taking down to them," she suggests. "I find without fail, every time I give discharge information to my patients, they find a new gem of information."
- Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Hospitalizations for epilepsy and convulsions, 2005; HCUP Statistical Brief No. 46. January 2008.
For more information on patients with seizures in the ED, contact:
- Sheri Cook, RN, CEN, Emergency Services Educator, Bixler Emergency Center, Tallahassee (FL) Memorial Hospital. Phone: (850) 431-4167. E-mail: [email protected].
- Karen Delrue, RN, MSN, CEN, Clinical Nurse Specialist, Emergency Services, Spectrum Health, Grand Rapids, MI. Phone: (616) 391-1914. Fax: (616) 391-1995. E-mail: [email protected].
- Paul Schoenberg, RN, CEN, Director, Emergency Trauma Center, St. Cloud (MN) Hospital.
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