7.1 Local implementation

Implementation of national clinical guidelines is the responsibility of local NHS organisations and is an essential part of clinical governance. It is acknowledged that not every guideline can be implemented immediately on publication, but mechanisms should be in place to ensure that the care provided is reviewed against the guideline recommendations and the reasons for any differences assessed and, where appropriate, addressed. These discussions should involve both clinical staff and management. Local arrangements may then be made to implement the national guideline in individual hospitals, units and practices, and to monitor adherence. This may be done by a variety of means including patient-specific reminders, continuing education and training, and clinical audit. Managed Clinical Networks for epilepsy are being developed.

7.2 Key points for audit

Diagnosis

• time to specialist assessment following first seizure
• proportion of first seizure patients seeing an epilepsy specialist
• time to EEG
• time to brain imaging
• proportion of patients having MRI and CT
• proportion of patients seeing an epilepsy nurse specialist when diagnosis discussed
• proportion of patients and carers receiving written information when diagnosis discussed
• accuracy of diagnosis of epilepsy, seizure classification and epilepsy syndrome classification
• appropriateness of EEG requests.

Treatment

• proportion in which treatment recommended by a specialist with an interest in epilepsy
• proportion of patients seizure free
• number on monotherapy, two, three and four drugs
• drug appropriate for seizure type(s)
• information on adverse AED effects given and documented
• drugs levels only done for appropriate indications
• discussion of AED withdrawal or continuation in those seizure free more than 2 years
• surgery considered in those established to be drug resistant
• existence and use of local protocol for management of status epilepticus.

Contraception, pregnancy and HRT

• documentation of:
  - contraceptive advice
  - preconceptual counselling
  - risks of epilepsy and antiepileptic drugs in pregnancy
  - advice about care of baby and breastfeeding
• proportion of pregnant women taking folic acid appropriately
• proportion of infants given vitamin K1 at birth
• proportion of pregnant women receiving appropriate ultrasound scanning.

Models of care

• extent to which data on measures above routinely shared between primary and secondary care
• proportion of patients in primary care
  - receiving structured annual review
  - with documentation within past year of:
  - seizure frequency
  - last seizure
  - drug adverse effects
  - review of medication
• access to epilepsy nurse specialist
• secondary care
  - availability and speed of access to specialist first seizure clinics
  - availability and speed of access to specialist epilepsy clinic
  - availability and speed of access to subspecialty joint clinics (teenage, pregnancy)
  - availability and speed of access to specialist investigations.