Abstracts

Rationale: Management of psychogenic nonepileptic events (PNES) presents a number of challenges to neurologists and mental health professionals. Although families are informed that these symptoms do not require emergency response, families of youth with epilepsy struggle to accept this, and often present to the ED or call an ambulance when events occur, prompting unnecessary medical intervention.  When youth present for follow up medical or mental health appointments, PNES events may occur in the psychologist/physician office, prompting activation of facility-mandated emergency procedures (i.e., Code Blue).  This reinforces the idea that these events are a medical emergency and is confusing and frustrating to families.This quality improvement project examines the feasibility of an alternative code for PNES.  We outline the challenges associated with implementation of this procedure. We hypothesized that implementation of this procedure would decrease frequency of code blues while maintaining patient safety.   Methods: A team of professionals within a pediatric ambulatory neurology clinic worked to determine the feasibility of an alternative response plan for PNES that occur within the department. Youth with PNES are seen in this department for both medical management and CBT. The goal was to decrease frequency of unnecessary activation of code blue which reinforce use of unnecessary medical resources.  An additional goal included ensuring that patient safety was maintained. The team decided that for youth who’s PNES were confirmed by Video-EEG, that a code blue would not be called.  Instead a nurse would monitor safety and vital signs.  The youth would return to the medical or psychotherapy appointment once the event is over.  Results: The alternative response plan has been in place for one year.  Approximately five patients experienced a PNES during an outpatient therapy visit.  No patients required additional medical intervention or evaluation beyond the alternative response procedures. Families reported being pleased that they avoided an expensive and unnecessary trip to the ED.  There were no differences in the number of codes called within the ambulatory medical setting during the year that the alternative response was in place when compared to the year before.  However, there were no code blues initiated for PNES following implementation compared to one code blue called the year before.Barriers to implementation included ensuring that all team members were trained in the appropriate way to respond to events and developing a consistent way to inform response team that a patient with PNES is coming in for an appointment Conclusions: When examining the feasability of an alternative response code for PNES that occur in a pediatric ambulatory setting, the results are promising.  There were no code blues initiated for PNES in our setting over the past year.  Families were pleased and patient safety was maintained.  Although these results are preliminary and qualitative, this study is still important.  It is imperative for youth with PNES to receive follow up mental health and medical care.  It is inevitable that these events will occur in the settings they are receiving treatment.  There is nothing in the literature about the best way to respond to these events in an ambulatory medical setting.  In order for medical/mental health teams to care for these patients appropriately, it will be necessary for practice recommendations to be developed that provide justification for institutions to override their emergency response procedures and avoid calling a code blue for a seizure lasting >5 minutes.  Next steps include examining the impact of alternative code procedures on seizure frequency and follow through with recommended treatment.  Funding: None