Abstracts

Rationale: Status epilepticus (SE) is a neurologic emergency associated with significant morbidity and mortality. Delayed or underdosed second-line anti-seizure medications (ASMs) may increase the risk of progression to refractory SE and permanent neuronal damage. We implemented a quality improvement initiative to study and minimize practice variability in the administration of second-line ASMs for suspected SE within our institution, with the goal of improving time to treatment and adequate dosing of second-line ASMs, in accordance with national treatment guidelines for SE. We hypothesized that improved early management may lead to improved clinical outcomes, including decreased hospital length of stay (LOS), likelihood of mechanical ventilation, and long-term morbidity.

Methods: We studied patients with a clinical or electrographic diagnosis of SE from August 2013 to March 2021. After identifying key drivers contributing to ASM delays and incorrect dosing, we performed Plan-Do-Study-Act (PDSA) cycles with the following tests of change: (1) dissemination of an institution-wide SE protocol and related education to guide appropriate dosing (PDSA cycle 1), and (2) creation of a standardized “Code Seizure” and electronic medical record (EMR) order set aimed at standardizing dosing for commonly used second-line ASMs (PDSA cycle 2).

Results: Baseline characteristics and clinical outcomes are depicted in Table 1. A total of 78 patients were included in this interim analysis, with 39 patients in the baseline group (08/2013-05/2018) and 39 patients in the post-intervention group (06/2019 to 03/2021). Within the post-intervention group, 15 patients were included in PDSA cycle 1 and 24 patients in PDSA cycle 2. Median time to the first second-line ASM administration (Figure 1) decreased significantly from the baseline to post-intervention cohorts (45.0 vs. 29.7 minutes, p = 0.028), with a significant decrease following creation of the EMR order set (PDSA 1 to PDSA 2, 42.0 vs. 23.1 minutes, p=0.011). Compared to baseline, more patients received a second-line ASM for suspected SE within the recommended 60-minute timeframe in the post-intervention period (61.5% vs. 84.6%, p=0.022). The median dose of levetiracetam administered increased significantly between the baseline and post-intervention groups (13.9 vs. 19.5 mg/kg, p=0.028), whereas the median dose of lacosamide did not differ significantly between cohorts; comparisons for other ASMs was not performed due to limited sample size. There were no statistically significant differences between baseline and post-intervention cohorts in the type of ASM used, hospital LOS, rates of mechanical ventilation and failed extubation, or discharge disposition.

Conclusions: Implementing an institution-wide SE protocol and standardized EMR order set significantly improved time to treatment of second-line ASMs at our center, with more patients receiving ASMs within the timeframe recommended by national treatment guidelines. Median dosing of the most commonly used ASM, levetiracetam, also increased significantly between baseline and post-intervention cohorts. Further study of SE management and the impact on in-hospital and long-term outcomes is warranted.

Funding: Please list any funding that was received in support of this abstract.: None.