Original Article
Neurology liaison services in the acute medical receiving unit
Scottish Medical Journal 58(4) 234–236 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933013507872 scm.sagepub.com
I Morrison1, R Jamdar2, P Shah3, M Fisher4 and JP Leach3
Abstract Introduction: Guidelines from the Association of British Neurologists and National Health Service Quality Improvement Scotland suggest that neurologists should be involved in the early management of patients presenting to hospital with acute neurological illness. Aim: We chose to evaluate whether regular neurology review in an acute medical receiving unit in a busy city hospital was feasible, and whether it would have an impact on patient care. Methods: Over a 5-week period from Monday to Friday, all neurology patients admitted to an acute medical receiving unit were identified and all headaches and blackouts were reviewed. Results: Fourteen (24%) were headache patients, 37 (63%) presumed seizure and 8 (13%) had another neurological illness. Diagnosis was made by the admitting physician in six headache patients (43%). The remaining eight headache patients were diagnosed by the visiting neurologist and two physician diagnoses were revised. The diagnosis made by the admitting physician was clarified by the visiting neurologist in 13 blackout patients (35%) and nine other diagnoses were revised (24%). Appropriate outpatient follow-up or transfer was arranged. Conclusion: These results suggest that a daily neurology review service is useful in medical receiving units by clarifying diagnoses, directing tests and limiting inappropriate follow-up.
Keywords Acute neurology, headache, epilepsy
Introduction Acute neurological problems (including stroke) are increasingly common in secondary care, accounting for 20% of acute medical admissions and up to 40% of patients on medical wards.1,2 National Health Service Quality Improvement Scotland (NHS QIS) guidelines stress the importance rapid access to neurology advice and care during the earliest stages of hospital admission,3 which supports the aims of the Association of British Neurologists that neurology services should contribute to the care of patients with acute neurological problems.4 One would expect that such a service would have a substantial impact on patient care, by improving diagnostic accuracy and reducing stay in hospital.5 However, current NHS priorities are more concerned with outpatient waiting time targets and may not be perceived as being compatible with accommodating such a daunting workload.6
We chose to explore whether provision of a daily, acute neurology liaison service in medical receiving unit for a large teaching hospital was feasible with modification to existing services, and whether this would have any impact on patient care or efficiency of bed usage. This expansion was in addition to the early triage and management already provided for acute stroke and head injuries.
1
ST6 Neurology, Department of Neurology, Institute of Neurological Sciences, Glasgow, UK 2 Consultant in Acute Medicine, Department of Acute Medicine, Glasgow Royal Infirmary, Glasgow, UK 3 Consultant Neurologist, Department of Neurology, Institute of Neurological Sciences, Glasgow, UK 4 Consultant Physician and Honorary Professor, Department of Acute Medicine, Glasgow Royal Infirmary, Glasgow, UK Corresponding author: Ian Morrison, Department of Neurology, Ninewells Hospital, Dundee DD1 9SY, UK. Email: [email protected]
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Table 1. Summary of diagnosis and management plan for patients admitted by physicians, with subsequent revision by liaison neurologist. Admitting physician diagnosis
Treatment and follow-up by admitting physician
8 ‘exclude subarachnoid haemorrhage’
None
2 idiopathic intracranial hypertension 4 migraine 11 alcohol seizure
Refer neuro outpatients
5 status epilepticus 3 seizures occurring in acute stroke 5 first seizure
Refer neuro outpatients None Urgent neurology inpatient review Stroke unit
First seizure clinic
13 no clear diagnosis seizure ?cause
Refer for neurology ward review
3 (non-stroke) motor weakness 2 haemorrhage/ ischaemic stroke 1 viral meningitis
Refer for neurology ward review Refer for neurology ward review Refer for neurology telephone opinion Refer for neurology ward review
1 probable malignant cranial neuropathy 1 drug related epilepsy
Neurologist diagnosis
Treatment and follow-up by neurologist
1 subarachnoid haemorrhage 1 low pressure/viral headache 1 primary exertional headache 2 trigeminal autonomic cephalalgia 3 likely migraine 1 idiopathic intracranial hypertension with migraine 1 migraine 4 likely migraine 10 alcohol seizure 1 subdural haemorrhage 5 usual epilepsy with benzodiazepine excess prior to admission 2 stroke 1 syncope
2 trigeminal autonomic cephalalgias referred to neuro 1 subarachnoid haemorrhage transferred
3 first seizure 2 syncope 2 pseudoseizures 1 usual epilepsy 3 delirium secondary to sepsis 2 heroin withdrawal 2 alcohol withdrawal seizures 1 tramadol overdose with Huntington’s chorea 2 first seizure
Idiopathic intracranial hypertension referred to neuro outpatients Started on prophylaxis and discharged Subdural haemorrhage transferred Usual neuro outpatients 2 stroke unit 1 Cardiology clinic 3 2 2 1 1
first seizure clinic Cardiology clinic first seizure usual neuro clinic new neuro clinic
Refer for neurology telephone opinion
Methods The study was undertaken in Glasgow Royal Infirmary, a large University teaching hospital with 1077 beds serving a population of 161,000 people in a predominantly deprived area of Glasgow (NHS Greater Glasgow and Clyde unpublished data). Over a 5-week period in August and September, a Specialty Trainee 6 (ST6) in neurology (IM) attended the medical receiving unit in the morning from Monday to Friday. All admissions whose primary presentations
were neurological were identified from medical summaries provided to nursing staff by the admitting physician. Patients with headache and presumed seizure were reviewed by the ST6, while other neurological diagnoses were documented but not reviewed.
Results Over the 25-day study period, 5425 patients (approximately 217 per day) attended the Accident and Emergency department, with 934 (average 37 per day)
Downloaded from scm.sagepub.com at UNIV TORONTO on July 18, 2015
236
Scottish Medical Journal 58(4)
subsequently admitted to the acute medical receiving unit. Fifty-nine patients (6%) were identified as having a neurological cause for their primary presentation (average 2.4 patients per day). Of this group, 14 (24%) were headache patients, 37 (63%) presumed seizure and 8 (13%) had another neurological illness (summarised in Table 1). The admitting physicians diagnosed headaches as: ‘exclude subarachnoid haemorrhage’ (eight patients), ‘idiopathic intracranial hypertension’ (two patients) and ‘migraine’ (four patients). Neurology review resulted in diagnosing all ‘exclude subarachnoid haemorrhage’ patients (including identifying one definite bleed), and revising the diagnosis in ‘idiopathic intracranial hypertension’ patients, both of whom had migraine causing their presentation. Presumed seizures were classified by admitting physicians as: ‘alcohol seizure’ (11 patients), ‘status epilepticus’ (five patients), ‘seizures secondary to stroke’ (three patients), ‘first seizure’ (five patients) and ‘seizure -?cause’ (13 patients). Neurology review revised diagnosis in one alcohol seizure who had a subdural haemorrhage, and all ‘status epilepticus’ patients, who had benzodiazepine excess following treatment of a single seizure. Syncope was diagnosed in three patients – one patient ‘seizures secondary to stroke’ and two ‘first seizure’. Diagnosis was established in all ‘seizure -?cause’. Outpatient review was requested for 11 patients (six headache patients and five ‘presumed seizure’ patients). Following neurology ward review, seven patients were deemed not to require outpatient neurology follow-up (five headache and two ‘presumed seizure’). Patients diagnosed by the neurologist with subarachnoid and subdural haemorrhage were transferred to neurosurgery. Eight patients were identified as having a neurological illness (excluding stroke) accounting for their presentation, which would require further neurology review.
Discussion Our 5-week study demonstrated that, in a large city teaching hospital, 6% of medical admissions were neurological. This is considerably less than other series published in this area.1,2 However, we chose to specifically exclude acute stroke from our study, as this was already managed by specialist services. Input by a neurologist established the correct diagnosis in 71% of headache patients and 60% of ‘presumed seizure’ patients. In addition, two acute neurosurgical problems requiring immediate intervention (subdural and subarachnoid haemorrhages) were identified early and onward referral made quickly, limiting potential morbidity.
Appropriate outpatient follow-up was also organised, with seven new outpatient appointments avoided over a 5-week period, equivalent to one neurology outpatient clinic per month. Patients requiring neurological follow-up could be seen as ‘returns’ rather than new patients (10 patients over 5 weeks), equating to one neurology outpatient clinic every 6 weeks. Providing such a daily service required between 60 and 90 min of clinical time per day, with considerable benefit to patient care. In addition, the presence of regular neurology input in the acute medical receiving unit had educational benefits for both medical and nursing staff. Although our study was only conducted for a limited period in a single centre, it demonstrates that provision of an acute neurology service is feasible and should not be overwhelming. Combined with provision for rapid access outpatient clinics described previously,7 it is possible to develop acute neurology services that would greatly improve patient care, with the potential to reduce hospital admissions and stays, and reduce unnecessary follow-ups. We would argue that this model is good for individual patients and for the wider NHS. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of conflicting interests None declared.
References 1. Morrow JI and Patterson VH. The neurological practice of a district general hospital. J Neurol Neurosurg Psychiatry 1987; 50: 1397–1401. 2. Playford ED, Crawford P and Monro PS. A survey of neurological disability at a district general hospital. Br J Clin Pract 1994; 48: 304–306. 3. National Health Service Quality Improvement Scotland. Neurological Health Services, http://www.scottishneurological.org.uk/content/res/final_QIS_standards.pdf (2009). 4. Association of British Neurologists. Acute neurological emergencies in adults. London: Association of British Neurologists, 2002. 5. Steiger MJ, Enevoldson TP, Hammans SR, et al. Influence of obtaining a neurological opinion on the diagnosis and management of hospital inpatients [letter]. J Neurol Neurosurg Psychiatry 1996; 61: 653–654. 6. Carroll C and Zajicek J. Provision of 24 hour acute neurology care by neurologists: manpower requirements in the UK. J Neurol Neurosurg Psychiatry 2004; 75: 406–409. 7. Chapman FA, Pope AE, Sorenson D, et al. Acute neurological problems: frequency, consultation patterns and the use of a rapid access neurology clinic. J R Coll Physicians Edinb 2009; 29: 296–300.
Downloaded from scm.sagepub.com at UNIV TORONTO on July 18, 2015
Neurology liaison services in the acute medical receiving unit
Scottish Medical Journal 58(4) 234–236 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933013507872 scm.sagepub.com
I Morrison1, R Jamdar2, P Shah3, M Fisher4 and JP Leach3
Abstract Introduction: Guidelines from the Association of British Neurologists and National Health Service Quality Improvement Scotland suggest that neurologists should be involved in the early management of patients presenting to hospital with acute neurological illness. Aim: We chose to evaluate whether regular neurology review in an acute medical receiving unit in a busy city hospital was feasible, and whether it would have an impact on patient care. Methods: Over a 5-week period from Monday to Friday, all neurology patients admitted to an acute medical receiving unit were identified and all headaches and blackouts were reviewed. Results: Fourteen (24%) were headache patients, 37 (63%) presumed seizure and 8 (13%) had another neurological illness. Diagnosis was made by the admitting physician in six headache patients (43%). The remaining eight headache patients were diagnosed by the visiting neurologist and two physician diagnoses were revised. The diagnosis made by the admitting physician was clarified by the visiting neurologist in 13 blackout patients (35%) and nine other diagnoses were revised (24%). Appropriate outpatient follow-up or transfer was arranged. Conclusion: These results suggest that a daily neurology review service is useful in medical receiving units by clarifying diagnoses, directing tests and limiting inappropriate follow-up.
Keywords Acute neurology, headache, epilepsy
Introduction Acute neurological problems (including stroke) are increasingly common in secondary care, accounting for 20% of acute medical admissions and up to 40% of patients on medical wards.1,2 National Health Service Quality Improvement Scotland (NHS QIS) guidelines stress the importance rapid access to neurology advice and care during the earliest stages of hospital admission,3 which supports the aims of the Association of British Neurologists that neurology services should contribute to the care of patients with acute neurological problems.4 One would expect that such a service would have a substantial impact on patient care, by improving diagnostic accuracy and reducing stay in hospital.5 However, current NHS priorities are more concerned with outpatient waiting time targets and may not be perceived as being compatible with accommodating such a daunting workload.6
We chose to explore whether provision of a daily, acute neurology liaison service in medical receiving unit for a large teaching hospital was feasible with modification to existing services, and whether this would have any impact on patient care or efficiency of bed usage. This expansion was in addition to the early triage and management already provided for acute stroke and head injuries.
1
ST6 Neurology, Department of Neurology, Institute of Neurological Sciences, Glasgow, UK 2 Consultant in Acute Medicine, Department of Acute Medicine, Glasgow Royal Infirmary, Glasgow, UK 3 Consultant Neurologist, Department of Neurology, Institute of Neurological Sciences, Glasgow, UK 4 Consultant Physician and Honorary Professor, Department of Acute Medicine, Glasgow Royal Infirmary, Glasgow, UK Corresponding author: Ian Morrison, Department of Neurology, Ninewells Hospital, Dundee DD1 9SY, UK. Email: [email protected]
Downloaded from scm.sagepub.com at UNIV TORONTO on July 18, 2015
Morrison et al.
235
Table 1. Summary of diagnosis and management plan for patients admitted by physicians, with subsequent revision by liaison neurologist. Admitting physician diagnosis
Treatment and follow-up by admitting physician
8 ‘exclude subarachnoid haemorrhage’
None
2 idiopathic intracranial hypertension 4 migraine 11 alcohol seizure
Refer neuro outpatients
5 status epilepticus 3 seizures occurring in acute stroke 5 first seizure
Refer neuro outpatients None Urgent neurology inpatient review Stroke unit
First seizure clinic
13 no clear diagnosis seizure ?cause
Refer for neurology ward review
3 (non-stroke) motor weakness 2 haemorrhage/ ischaemic stroke 1 viral meningitis
Refer for neurology ward review Refer for neurology ward review Refer for neurology telephone opinion Refer for neurology ward review
1 probable malignant cranial neuropathy 1 drug related epilepsy
Neurologist diagnosis
Treatment and follow-up by neurologist
1 subarachnoid haemorrhage 1 low pressure/viral headache 1 primary exertional headache 2 trigeminal autonomic cephalalgia 3 likely migraine 1 idiopathic intracranial hypertension with migraine 1 migraine 4 likely migraine 10 alcohol seizure 1 subdural haemorrhage 5 usual epilepsy with benzodiazepine excess prior to admission 2 stroke 1 syncope
2 trigeminal autonomic cephalalgias referred to neuro 1 subarachnoid haemorrhage transferred
3 first seizure 2 syncope 2 pseudoseizures 1 usual epilepsy 3 delirium secondary to sepsis 2 heroin withdrawal 2 alcohol withdrawal seizures 1 tramadol overdose with Huntington’s chorea 2 first seizure
Idiopathic intracranial hypertension referred to neuro outpatients Started on prophylaxis and discharged Subdural haemorrhage transferred Usual neuro outpatients 2 stroke unit 1 Cardiology clinic 3 2 2 1 1
first seizure clinic Cardiology clinic first seizure usual neuro clinic new neuro clinic
Refer for neurology telephone opinion
Methods The study was undertaken in Glasgow Royal Infirmary, a large University teaching hospital with 1077 beds serving a population of 161,000 people in a predominantly deprived area of Glasgow (NHS Greater Glasgow and Clyde unpublished data). Over a 5-week period in August and September, a Specialty Trainee 6 (ST6) in neurology (IM) attended the medical receiving unit in the morning from Monday to Friday. All admissions whose primary presentations
were neurological were identified from medical summaries provided to nursing staff by the admitting physician. Patients with headache and presumed seizure were reviewed by the ST6, while other neurological diagnoses were documented but not reviewed.
Results Over the 25-day study period, 5425 patients (approximately 217 per day) attended the Accident and Emergency department, with 934 (average 37 per day)
Downloaded from scm.sagepub.com at UNIV TORONTO on July 18, 2015
236
Scottish Medical Journal 58(4)
subsequently admitted to the acute medical receiving unit. Fifty-nine patients (6%) were identified as having a neurological cause for their primary presentation (average 2.4 patients per day). Of this group, 14 (24%) were headache patients, 37 (63%) presumed seizure and 8 (13%) had another neurological illness (summarised in Table 1). The admitting physicians diagnosed headaches as: ‘exclude subarachnoid haemorrhage’ (eight patients), ‘idiopathic intracranial hypertension’ (two patients) and ‘migraine’ (four patients). Neurology review resulted in diagnosing all ‘exclude subarachnoid haemorrhage’ patients (including identifying one definite bleed), and revising the diagnosis in ‘idiopathic intracranial hypertension’ patients, both of whom had migraine causing their presentation. Presumed seizures were classified by admitting physicians as: ‘alcohol seizure’ (11 patients), ‘status epilepticus’ (five patients), ‘seizures secondary to stroke’ (three patients), ‘first seizure’ (five patients) and ‘seizure -?cause’ (13 patients). Neurology review revised diagnosis in one alcohol seizure who had a subdural haemorrhage, and all ‘status epilepticus’ patients, who had benzodiazepine excess following treatment of a single seizure. Syncope was diagnosed in three patients – one patient ‘seizures secondary to stroke’ and two ‘first seizure’. Diagnosis was established in all ‘seizure -?cause’. Outpatient review was requested for 11 patients (six headache patients and five ‘presumed seizure’ patients). Following neurology ward review, seven patients were deemed not to require outpatient neurology follow-up (five headache and two ‘presumed seizure’). Patients diagnosed by the neurologist with subarachnoid and subdural haemorrhage were transferred to neurosurgery. Eight patients were identified as having a neurological illness (excluding stroke) accounting for their presentation, which would require further neurology review.
Discussion Our 5-week study demonstrated that, in a large city teaching hospital, 6% of medical admissions were neurological. This is considerably less than other series published in this area.1,2 However, we chose to specifically exclude acute stroke from our study, as this was already managed by specialist services. Input by a neurologist established the correct diagnosis in 71% of headache patients and 60% of ‘presumed seizure’ patients. In addition, two acute neurosurgical problems requiring immediate intervention (subdural and subarachnoid haemorrhages) were identified early and onward referral made quickly, limiting potential morbidity.
Appropriate outpatient follow-up was also organised, with seven new outpatient appointments avoided over a 5-week period, equivalent to one neurology outpatient clinic per month. Patients requiring neurological follow-up could be seen as ‘returns’ rather than new patients (10 patients over 5 weeks), equating to one neurology outpatient clinic every 6 weeks. Providing such a daily service required between 60 and 90 min of clinical time per day, with considerable benefit to patient care. In addition, the presence of regular neurology input in the acute medical receiving unit had educational benefits for both medical and nursing staff. Although our study was only conducted for a limited period in a single centre, it demonstrates that provision of an acute neurology service is feasible and should not be overwhelming. Combined with provision for rapid access outpatient clinics described previously,7 it is possible to develop acute neurology services that would greatly improve patient care, with the potential to reduce hospital admissions and stays, and reduce unnecessary follow-ups. We would argue that this model is good for individual patients and for the wider NHS. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of conflicting interests None declared.
References 1. Morrow JI and Patterson VH. The neurological practice of a district general hospital. J Neurol Neurosurg Psychiatry 1987; 50: 1397–1401. 2. Playford ED, Crawford P and Monro PS. A survey of neurological disability at a district general hospital. Br J Clin Pract 1994; 48: 304–306. 3. National Health Service Quality Improvement Scotland. Neurological Health Services, http://www.scottishneurological.org.uk/content/res/final_QIS_standards.pdf (2009). 4. Association of British Neurologists. Acute neurological emergencies in adults. London: Association of British Neurologists, 2002. 5. Steiger MJ, Enevoldson TP, Hammans SR, et al. Influence of obtaining a neurological opinion on the diagnosis and management of hospital inpatients [letter]. J Neurol Neurosurg Psychiatry 1996; 61: 653–654. 6. Carroll C and Zajicek J. Provision of 24 hour acute neurology care by neurologists: manpower requirements in the UK. J Neurol Neurosurg Psychiatry 2004; 75: 406–409. 7. Chapman FA, Pope AE, Sorenson D, et al. Acute neurological problems: frequency, consultation patterns and the use of a rapid access neurology clinic. J R Coll Physicians Edinb 2009; 29: 296–300.
Downloaded from scm.sagepub.com at UNIV TORONTO on July 18, 2015
