Interfacility Transfers for Seizure-Related Emergencies in the United States

Interfacility transfer protocols are important for seizure-related emergencies, the cause of approximately 1% of all emergency department (ED) visits in the United States, but data on current practices are lacking. We assessed the prevalence, temporal trends, and patterns of interfacility transfers following seizure-related ED visits.

We performed a retrospective longitudinal cross-sectional analysis of ED dispositions for seizure-related emergencies among adult and pediatric populations using the Nationwide Emergency Department Sample (NEDS). We used joinpoint regression to analyze annual trends in ED visits and transfer rates from 2007 to 2018. Logistic regression models using data from 2016 to 2018 explored the patient- and hospital-level factors associated with transfer vs admission. Sampling weights were applied to account for the complex survey design of the NEDS.

Using nationally representative data from 2007 to 2018, there were 7,372,065 weighted ED visits for seizure-related emergencies, including 419,368 (5.6%) visits for a primary diagnosis of status epilepticus. We found that 2.3%-5.6% of all these seizure-related ED visits resulted in an interfacility transfer and that the rate of transfer increased significantly over time. Among ED visits specifically for status epilepticus, interfacility transfers resulted from 19.8% to 23.24% of visits, which also increased over time. Multivariable logistic regression of adult and pediatric visits for status epilepticus revealed that transferring hospitals were more likely to be nonmetropolitan (adjusted odds ratio [aOR] 2.2, 95% CI 1.6-2.9) and less likely to have continuous electroencephalography (cEEG) capabilities (aOR 0.3, 98% CI 0.3-0.4). Transferred patients were more likely to be children (aOR 1.5, 95% CI 1.3-1.6 for those 1-4 years old; aOR 1.5 (95% CI 1.3-1.7) for ages 5-14 years), have acute cerebrovascular disease (aOR 1.4, 95% CI 1.1-1.8), and have received mechanical ventilation (aOR 1.5, 95% CI 1.4-1.7).

By 2018, approximately 1 in 19 seizure-related and 1 in 5 status epilepticus ED visits resulted in interfacility transfers. In order of strength of association, illness severity, ED seizure volume, comorbid meningitis and traumatic brain injury, nonrural location, cEEG capabilities, and pediatric age favored admission. Rural location, lack of cEEG capabilities, and comorbid stroke favored transfer. Thoughtful deployment of novel EEG technologies and teleneurology tools may help optimize triage and prevent unnecessary ED transfers.