Short‐term Outcome of Seizure Patients Who Refuse Transport after Out‐of‐hospital Evaluation

Abstract

Abstract. Objective: To determine the short-term outcome of patients with a known seizure disorder who have a seizure, are evaluated by out-of-hospital care providers, and refuse transport. Methods: This was a prospective study conducted over a 15-month period. Philadelphia Fire Department paramedics contacted a medical command physician whenever they encountered a patient with a known seizure disorder who had had another seizure and was refusing transport. After confirming that the patient had the mental capacity to refuse care and understood the associated risks, the physician recorded the patient's name, address, and telephone number. Beginning three days later, a registered nurse attempted to reach the patient by telephone and administer a brief questionnaire about his or her medical outcome. Patients not reached by telephone were sent a certified letter. The names of patients lost to follow-up were compared with medical examiner records to confirm that they had not died during the follow-up period. Results: Of 63 patients enrolled in the study, 52 (82.5%) were reached in follow-up. Of these, three (5.8%) had another seizure within 72 hours and recontacted 911. One of these patients (1.9%) was hospitalized. Twenty (38.5%) patients contacted their primary care physicians. There were no deaths, including patients lost to follow-up. Conclusions: Most patients (94.2%) who were evaluated by out-of-hospital care providers for a seizure and refused transport had no further seizure activity in the subsequent 72 hours. However, because there is a risk of recurrence, out-of-hospital care providers and medical command physicians should ensure that patients understand the risks of refusal.

Decision-making by ambulance clinicians in London when managing patients with epilepsy: a qualitative study

“…Ninety-four per cent of those followed up had no further seizure activity within this period. There were also no reported deaths or serious complications 22. This suggests that the risk may actually be much lower than that perceived.…”

Pre-hospital care after a seizure: Evidence base and United Kingdom management guidelines

“…A very large proportion of patients after a seizure appear to be transported to hospital 2 but those with a known seizure disorder who have a simple seizure may be suitable for home management without adverse outcome. 11 There is very little research into alternative care pathways or criteria that could be used to support paramedics to manage patients in the community without transporting to an ED after a simple seizure. More research is needed to improve care for these patients and to improve the cost-effectiveness of the healthcare systems within which they are treated.…”

“…10,11 16 further articles/sources which were considered relevant by the authors but not captured by the original search were also included. 4,[7][8][9][12][13][14][15][16][17][18][19][20][21]38,40 Articles referenced but not captured within the original search were used to complement the review and included those which highlight the scale of the problem, 4,7-9 papers which do not relate directly to pre-hospital services 10,[13][14][15][16][17][18]38,40 or seizure management itself 11,19,20 and one article on simple febrile seizures. 21 There is an extensive literature on the management of the seizure patient after arrival in the ED, however, this is beyond the scope of this review.…”

“…46 Patients with known seizure disorders who have a seizure in the community and refuse transport have minimal risk of recurrence or adverse outcome. 11 Nevertheless, a large proportion of patients after a seizure are taken to EDs. A recent qualitative study of decision-making in 15 emergency ambulance clinicians in the UK has explored factors influencing transfer of PWE.…”

Prehospital Care for the Adult and Pediatric Seizure Patient: Current Evidence-based Recommendations

“…Since most patients will not require any medications once they are not actively seizing, there is not sufficient evidence to support routine IV access. The incidence of a second seizure within 72 hours has been reported to be approximately 6% and benzodiazepines administered intramuscularly (IM) are an effective treatment 13. Continuous pulse oximetry should be used to monitor oxygenation, and end-tidal CO 2 monitoring, if available, should be used to detect hypoventilation in postictal patients until they have returned to their baseline mental status.…”