Abstracts

Rationale: Status epilepticus (SE) is a life-threatening emergency. Delay in treatment may worsen seizure control and induce neuronal injury. Although studies have captured time to treatment and cessation of SE in the field, data in the hospital setting are limited. Our pilot practice improvement project demonstrated implementation of a treatment protocol through a standardized order set (SOS) available in the electronic medical record system and staff education led to shortened time to treatment and resolution of SE. The optional SOS included an algorithm which restricted immediate treatment to benzodiazepines coupled with either fosphenytoin or valproate, cEEG, labs, and neurology consultation. We hypothesized that while the SOS was available and teaching was performed, SOS was underutilized. This study was performed to determine utilization and correct use of the SOS in a larger patient cohort.Methods: Electronic medical records (EMR) were queried between 12/2012 through 9/2014, after the SOS became available. The EMR was searched for the ICD9-code for SE (345.3) and for use of the SOS. All patients identified were reviewed for verification of SE, defined as ≥5 minutes of continuous seizure or discrete seizures without return to consciousness. Patients treated at an outside facility or in the field were excluded. Abstracted data included patient age, gender, pre-existing epilepsy, etiology of SE, time and method of SE diagnosis. Outcome measures focused on comparison of patients documented with status to confirmed status by defined criteria and number of patients treated with the SOS as intended.Results: The EMR search yielded 150 admissions, 104 with assigned ICD9 diagnosis code (69%) and 69 with an SOS placed (46%). Only 25 admissions had both an SE diagnosis code and utilized the SOS. The following subgroups were excluded: pretreated at outside hospital (n=35); pretreated in the field (n=30; of these, 11 arrived in SE); diagnosis code applied incorrectly and/or the order set placed in absence of SE (n=35). Only 50 patients had SE in the hospital without prior treatment. Within this group, only 13 (26%) had the SOS applied as intended, 19 (38%) had the SOS placed but received different medications or altered sequence of drugs, and 18 (36%) received treatment without the SOS.Conclusions: Our study found that the SOS was utilized as designed in only 25% of eligible SE patients. A large number of patients were incorrectly assigned the SE code with presentations including single seizure with prior history of SE, seizure clusters not meeting criteria for SE, and coma. Treatment was often initiated before the SOS was placed or there were deviations from the suggested protocol. Barriers to proper utilization of the SOS included lack of knowledge about the SOS, administration of medications before EMR orders were formally placed, and concerns for respiratory suppression related to benzodiazepines. These observations explain some obstacles treating SE in a consistent fashion. Further education is needed to reinforce urgent recognition and adequate treatment of status epilepticus.