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Institutional Pediatric Convulsive Status Epilepticus Protocol Decreases Time to First and Second Line Anti-Seizure
Steven P Trau1, Emily C Sterrett2, Lydia Feinstein3
1Department of Neurology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States.
Insights
Implementing a clinical pathway for convulsive status epilepticus (CSE) reduced time to anti-seizure medication (ASM) for patients arriving in the ED. However, appropriate benzodiazepine dosing for CSE remains a challenge.
Area of Science:
- Emergency Medicine
- Neurology
- Clinical Quality Improvement
Background:
- Convulsive status epilepticus (CSE) is a critical medical emergency with significant morbidity and mortality.
- Current guidelines advocate for prompt seizure treatment, but adherence remains suboptimal.
Purpose of the Study:
- To evaluate if a paper-based clinical pathway improves the timeliness and appropriate dosing of first- and second-line anti-seizure medications (ASMs) for CSE.
- To assess the impact of a quality improvement initiative on CSE management.
Main Methods:
- Retrospective analysis of 153 pediatric CSE cases (2012-2019) before and after a 2016 protocol implementation.
- Utilized descriptive statistics and Statistical Process Control (SPC) charts (XmR) to analyze time to ASM administration and dosing.
- Examined lorazepam (LZP) and fosphenytoin (FOS) as first- and second-line ASMs.
Main Results:
- Median time to first lorazepam (LZP) dose decreased from 15 to 11 minutes for ED arrivals (p=0.23).
- Median time to fosphenytoin (FOS) dose decreased from 40 to 25 minutes (p=0.04) for ED arrivals.
- While FOS dosing was appropriate, LZP dosing remained suboptimal, with only ~50% receiving recommended doses.
Conclusions:
- A paper-based CSE protocol reduced time to ASM administration, especially for second-line treatments, in ED arrivals.
- Further strategies are necessary to enhance appropriate benzodiazepine dosing in CSE management.
Purpose:
Convulsive status epilepticus (CSE) is a medical emergency associated with high rates of morbidity and mortality. Although guidelines for CSE management recommend rapid treatment of seizures, prior studies show that compliance with these guidelines is low. In this study, we assessed if implementation of a paper-based clinical pathway for the treatment of CSE improves the timeliness and appropriate dosing of first and second line anti-seizure medications (ASM).
Methods:
A non-digital CSE treatment protocol was implemented as part of a quality improvement initiative in 2016. A retrospective analysis was subsequently conducted on cases of CSE originating in the pediatric emergency department (ED) from 2012-2019. Standard descriptive statistics were used to assess patient demographics as well as the timing and dosing of the first and second line ASMs used in our protocol (lorazepam [LZP] and fosphenytoin [FOS]). Statistical process control charts (XmR charts) were used to assess the variation in time to drug administration before and after implementation of the protocol.
Results:
153 cases of CSE were identified (72 prior to and 81 after protocol implementation). Among patients who were actively having seizures on arrival to the ED (n = 44), the median time from arrival to ASM administration decreased from 15 to 11 minutes for the first LZP dose (p = 0.23), 23 to 10 minutes for the second LZP dose (p = 0.06), and 40 to 25 minutes for the PHE dose (p = 0.04). There was no improvement in time to LZP administration after seizure onset among those with seizure onset after hospital arrival (5 minutes before/after implementation for the first LZP dose and 15 to 14 minutes for second LZP dose); however, the time to FOS decreased from 42 to 22 minutes (p = 0.86). Statistical process control charts showed a universal decrease in variation for time to each drug administration after protocol implementation. Whereas FOS dosing was largely appropriate before and after protocol implementation, appropriate dosing of LZP did not improve, with only about half of patients receiving the recommended dose.
Conclusion:
The implementation of a paper-based treatment protocol for CSE was associated with a decreased time to ASM administration among patients who arrived to the ED, particularly for the second-line ASM. Approaches for improving appropriate benzodiazepine dosing are needed.
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