Prehospital management of functional neurological disorder

Functional neurological disorders (FNDs) present unique challenges in emergency medicine. Patients with an established diagnosis of FND often represent to EDs with acute exacerbations of existing symptoms or for evaluation of new concerns.1, 2 However, these visits may not be appropriate or beneficial. The high-stress environment of the ED can exacerbate symptoms, and frequent visits may reinforce the disorder's manifestations. Hospital avoidance for FND patients can yield significant benefits. For the patient, it reduces exposure to potentially triggering environments and avoids unnecessary medical interventions. For acute services, it alleviates the burden on already overstretched resources, ensuring that critical care is available for those with life-threatening conditions. I have had the privilege of running the Gold Coast Horizons Program, an outpatient paediatric and adolescent FND clinic for several years and, in collaboration with our ED and Queensland Ambulance Service (QAS), have developed several strategies that have demonstrated a reduction in ED utilisation. These are discussed in further detail below. An effective approach in supporting prehospital care for patients with FND involves the development of individualised ambulance management plans once a formal diagnosis has been made and a treatment plan initiated. Most commonly when functional episodes, like seizures or weakness, occur in the community, and the patient cannot be physically moved, the ambulance is required to take the patient to ED. With the utilisation of an individual management plan, an ambulance can return a patient home to recover in their own environment. The development of an ambulance management plan requires shared agreement with the patient and caregivers that recovery at home is the best environment (i.e. there are no persisting medical concerns), and that there is an established plan for ongoing FND treatment to support recovery and rehabilitation. The management plan should confirm the diagnosis, provide a description of typical symptoms/episodes and suggested management, include a plan to return home to manage symptoms, and a provision that if the presentation does not fit the usual description, or if there are acute medical concerns, the patient should be transported to ED. Collaboration with local ambulance services is essential. The Gold Coast Horizons team, in partnership with QAS and local schools, has successfully implemented individualised ambulance plans for young people with FND.3 This initiative has led to significant reductions in hospital presentations by allowing patients to recover at home following episodes, thereby easing the burden on emergency services, and improving patient outcomes. The collaboration required active communication with the director of QAS, but once established, the approach to implement an ambulance plan was simple. This collaboration highlights the benefits of a coordinated approach, including reduced patient distress, earlier school and community reintegration and better utilisation of emergency resources. Developing a school management plan for young people with FND has proven beneficial and requires a collaborative approach involving the young person, their family, and the school.4 The plan begins with a thorough diagnosis and a clear description of typical FND events. FND education is crucial, particularly emphasising that episodes are safe and do not necessitate an emergency response. Providing FND educational resources and facilitating discussions with school nurses and lead teachers often significantly boosts the confidence of school staff in managing these events.5 Practical strategies to manage functional episodes are shared, encouraging students to return to class once an episode resolves, rather than being sent home. The plan also outlines specific criteria when a parent should be called for support, and clarifies standard emergency procedures apply for any atypical events or staff concerns. An example of a school plan can be found at FND Hope.6 Our experience shows schools are generally eager to learn and support students with FND, building their skills and confidence in managing functional events. Consequently, students feel more assured about returning to school and can improve their functioning more rapidly. Despite the above-outlined measures, some patients with FND will still represent to EDs. In such cases, it is important to recognise symptom recovery should not be the sole criterion for discharge. Engaging in shared decision-making with the patient can facilitate earlier discharge, focusing on their ability to manage symptoms at home. Utilising ambulance transfers to home for recovery can also be effective, allowing patients to leave the hospital environment and return to a more supportive setting. It is important to spend time evaluating the patient and carer's understanding and perceptions of the diagnosis, and address any stigma or misconceptions and any persistent medical worry. If a patient or carer feels medically 'unsafe', presentations will continue. Clinicians may carry mixed feelings when faced with an FND presentation, including feelings of helplessness, anger, or irritation.1 On the other hand, patients and carers may feel offended, dismissed, helpless and angry. Promoting an FND culture of care within your ED can improve clinician confidence in diagnosing and discussing FND with patients, and reduce iatrogenic stigma experienced by patients and caregivers.7 The provision of FND factsheets and educational resources is useful in validating the diagnosis and supporting understanding.8 FND Australia is a reputable online resource with educational videos and printable factsheets.9 In my service I have successfully collaborated with ED colleagues to provide regular education sessions with staff about FND, particularly on the latest neuroscience, making a diagnosis and communicating it, and treatment strategies. The feedback from ED colleagues is that there is improved confidence and empathy in supporting patients with FND. It has also strengthened referral pathways and supported early intervention in the outpatient setting. Supporting patients in finding a local practitioner to lead their FND management is vital. This could be a GP, paediatrician, or neurologist with an interest in FND. Building strong relationships with these practitioners can enhance referral pathways and ensure timely follow-up for patients. In conclusion, managing FND effectively requires a coordinated approach that extends beyond the ED. The implementation of individualised ambulance plans and school management strategies can significantly reduce unnecessary ED presentations and improve patient outcomes. By fostering strong collaborations between healthcare providers, local ambulance services and educational institutions, patients with FND can receive appropriate care in less triggering environments, such as their homes and schools. Additionally, promoting a culture of care within the ED, coupled with continuous education for staff, enhances clinician confidence and patient support. These strategies not only alleviate the burden on emergency services but also empower patients and caregivers, leading to improved management of FND and more efficient allocation of healthcare resources. None declared.