Abstracts

Rationale: Monitoring of practice parameter adherence and assessment on the effect on outcome in pediatric patients is limited. This study aims to assess adherence to American Academy of Neurology (AAN) practice parameters in children with first nonfebrile seizure at our center. Methods: We retrospectively reviewed charts of pediatric patients age 1 month - 21 years who presented to our Emergency Department for first time convulsive seizure between January 2010 and December 2011. Patients with ICD 9 codes 345.1, 345.9, and 780.39 were included. Patients who presented with a first time febrile seizure or had a known brain tumor were excluded. Using a standardized assessment tool, we reviewed adherence to the AAN practice parameters related to the recommended ordering of routine electrolytes, toxicology screen, EEG, lumbar puncture, urgent head CT, and brain MRI imaging. When a diagnostic study was ordered that did not adhere to guidelines, we determined if the test was abnormal and if the abnormality could explain the seizure or required urgent management. Results: One hundred ten patients met inclusion criteria. Chart review showed that physicians followed AAN guidelines on ordering of toxicology screens (88%; 95% C.I. 82-94%), EEG (96%; 95% C.I. 93-100%), lumbar puncture (96%; 95% C.I. 93-100%), and non-urgent brain MRI imaging (95%; 95% C.I. 95-99%) well. Although the majority of physicians followed the guidelines regarding routine electrolytes (79%; 95% C.I. 71-87%) and emergent head CT imaging (75%; 95% C.I. 67-84%), adherence to these parameters was lower. There was non-adherence to the parameter on ordering of routine electrolytes in 21% of the patients. Electrolyte results in these patients revealed mild abnormalities in 56% (95% C.I. 34-77%) including hyponatremia, hyperkalemia, and hyperglycemia. Electrolyte findings did not explain the etiology of the seizure or require intervention. There was non-adherence to the parameter on obtaining emergent head CT imaging in 25% of the patients. Of those, 77% had head CT imaging that was not indicated, while emergent imaging was not performed when indicated in 23% of the patients. 65% of the emergent head CTs performed when not indicated were ordered by outside emergency departments prior to transfer to our center. Of the patients who underwent unnecessary head CT imaging, 80% were normal and 20% (95% C.I. 6-44%) showed an abnormal result, which did not require urgent intervention (i.e. chronic changes, PVL). Conclusions: Child neurologists and pediatricians adhere to the majority of AAN practice parameters on children with first nonfebrile seizure. Occasional cases of non-adherence to guidelines including ordering of electrolytes or emergent head CTs within our and referring emergency departments did not alter urgent management supporting available guidelines. As a result of this review, we will implement a hospital wide standardized clinical management and assessment plan for first time nonfebrile seizure in children and continuously assess adherence. Additional efforts to include referring centers into this treatment plan are underway.