In France, epileptic seizures account for approximately 1.6% of emergency department (ED) admissions, nearly 60% of which involve patients with known epilepsy. At least half of these patients could potentially be managed on an outpatient basis. Despite established national guidelines, data on actual ED practice patterns and guideline adherence remain scarce.

To evaluate the management of adult patients presenting with suspected epileptic seizures across French EDs, and to identify clinical and organisational determinants of hospitalisation.

The EPI-Lepsie study was a national, multicentre, prospective observational study. Consecutive adult patients (age ≥ 18 years) admitted to 93 French EDs over a three-day period (18–21 May 2021) with suspected epileptic seizures were enrolled through the Initiative Recherche Urgence (IRU) network of the Société française de médecine d’urgence (SFMU).

The primary outcome was hospitalisation at ED discharge. Secondary outcomes included EEG performance, access to neurological consultation, post-discharge follow-up, and 30-day outcomes. Hospitalisation determinants were assessed by mixed logistic regression (ED as random intercept), adjusted for age, sex, seizure aetiology, risk factors, neuroimaging, and EEG results.

Among 350 included patients (61.8% male; median age 50 years [IQR: 33–68]), EEG was requested in 102 cases (29.1%) but performed in only 54 (15.4%). Neurological consultation was requested in 163 patients (46.6%) and obtained in 146 (41.7%). After ED care, 210 patients (60.2%) were discharged home, of whom 133 (66.5%) had no scheduled neurological follow-up. Hospitalisation occurred in 128 patients (36.6%). In multivariate analysis, abnormal neuroimaging was the strongest independent predictor (adjusted OR 8.70, P < 0.0001). Failure to perform a requested EEG was associated with hospitalisation in 81.2% of cases versus 46.3% when EEG was completed. Inter-centre variance accounted for 19.9% of total variance.

This study demonstrates that a substantial proportion of epilepsy-related ED admissions do not require hospitalisation. Improving access to EEG and neurological consultation, combined with standardised risk-stratification pathways for patients with known epilepsy, could meaningfully reduce avoidable admissions and enhance continuity of care.