Improving Standardization and Access to Care via Seizure Pathways in the Emergency Department

Seizures are one of the most common neurological presentations to an emergency department (ED), often as a first seizure of life or a breakthrough seizure. There is practice variation regarding the diagnostic workup and management for these patient populations. A standardized pathway for emergent evaluation of first seizure of life or breakthrough seizure currently does not exist, resulting in variability in evaluation and timing of outpatient care.

We created standardized pathways for evaluation and management of patients presenting to the ED with a first seizure of life or breakthrough seizure. These pathways, implemented at a large, quaternary-care hospital system, were utilized on 130 patients presenting with a seizure and compared with all patients with seizure on whom the pathway was not used, between May 2022-October 2023. Outcomes of interest included ED length of stay (LOS), proportion of patients admitted, time to outpatient follow-up, and difference in resource utilization. We compared categorical variables using chi-square test and continuous variables using the Wilcoxon rank-sum test. Equality of variance between the two cohorts was tested using the Levene test.

There was no statistically significant difference between the percentage of male and female patients evaluated via standard-of-care model (45.6% and 49.5%) and those on the pathway (56.9% and 43.1%). The average age of patients was similar between standard-of-care and pathway groups (41 and 39 years, respectively). Median ED LOS was 5.0 (Interquartile range [IQR] 2.9-9.4) hours for standard of care and 4.8 (IQR 3.1-7.0) hours for pathway (P = .34), with a significant difference in variability in time for pathway group (P < .001). Fewer patients were admitted or observed with pathway use (P < .02). Median time to outpatient follow-up was 41.0 days (IQR 17.0-93.0) with standard of care and 23.5 days (IQR 8.0-57.0) with pathway use (P < .001). More urinalyses (P < .001), drug screens (P < .001), alcohol levels (P < .001) and computed tomography for first seizures (P < .001) were ordered for the pathway group. Fewer magnetic resonance imaging studies were ordered for patients in the breakthrough seizures group using the pathway (P < .001).

Standardized pathways to approach seizure presentation in the ED can reduce variability in care, improve time to outpatient neurologic care, and standardize seizure-safety counseling.