COMPLIANCE WITH A STANDARD FOR THE EMERGENCY DEPARTMENT MANAGEMENT OF EPILEPTICS WHO PRESENT AFTER AN UNCOMPLICATED CONVULSION

We conducted a retrospective chart review to determine whether the treatment of uncomplicated convulsions in emergency department patients with a history of epilepsy complied with a clinical standard and whether the degree of compliance with the standard was related to the treating physician's specialty or postgraduate year of training. The standard specified items to be included in the medical record and appropriate diagnostic tests. A medical record score was defined by the presence of seven essential and seven desirable items obtained from the history and the physical examination. Only anticonvulsant levels and a serum glucose, when not ordered as part of a chemistry profile, were considered appropriate for all patients when drawn. A computed tomography head scan was deemed appropriate for patients whose neurologic status deteriorated or failed to return to baseline within one hour or who had a recent history of significant head trauma. The appropriateness of all other tests was evaluated by review of the medical record. One hundred consecutive ED visits by adult epileptics for an uncomplicated convulsion were considered. Patients ranged in age from 18 to 88 years (median, 28 years). Medical record scores ranged from 7 to 82 (median, 43). ED time ranged from eight to 539 minutes (median, 174.5 minutes). Ancillary services charges ranged from $0 to $1,774 (median, $181.50). Only 27.4% of these charges were for tests deemed appropriate. There was a significant relationship between the ED time and ancillary services charges (Spearman correlation = .5152, P < .0001). The median ancillary service charge was significantly less for patients seen by emergency medicine than by internal medicine residents ($82 vs $213, P = .0054). Median ancillary service charges did not significantly differ by resident postgraduate year of training (PGY 1 or 2, $213; PGY 3 or 4, $175; P = .1413). Results of the study were that physician documentation did not meet our expectations, there was an association of the use of diagnostic tests and ED time, there was a difference in the performance of resident physicians by specialty, with emergency physicians ordering fewer diagnostic tests, and there was no significant difference in the ordering of diagnostic tests by postgraduate year of resident training. © 1990 American College of Emergency Physicians.