Abstracts

Rationale: Expedient management of status epilepticus (SE) in children is critical to prevent further neurological and systemic sequalae, and thus health systems may develop protocols to standardize care and promote timely intervention. In May 2013, physicians at New York Presbyterian - Weill Cornell developed an evidence-based treatment protocol for pediatric status epilepticus. We examine the associated changes in patient outcomes since the publication of the protocol. We also examined which steps of the protocol had the highest rates of provider deviation.  Methods: We reviewed charts of children who arrived in the Weill Cornell Pediatric Emergency Department following implementation of the SE protocol meeting criteria for SE or seizure clusters (multiple seizures occurring at an increased rate from baseline the patient without returning to neurologic baseline between events) and who required an escalation in care, as marked by treatment beyond first-line therapy per  the SE protocol. We also reviewed the charts of subjects treated for SE or seizure clusters prior to protocol implementation. Patients with seizure clusters were included in this study as, in many cases, their management was clinically indistinguishable from those with overt SE. For these subjects, outcomes data   collected included escalation to burst suppression, intubation, and nosocomial infection. Additionally, for post protocol subjects, rates of  protocol medication, dosing, and timing deviations were recorded.  Results: We identified 48 children between 2012 and 2017 with SE, 9 before and 39 following protocol implementation. Of the 39 post-protocol patients, 46% were receiving treatment for a seizure disorder at the time of presentation. Three of 39 (8%) patients in the post-protocol cohort experienced escalation to burst suppression, 2 (5%) contracted a nosocomial infection, and 3 (39%) were treated with vasoactive infusions; of the 9 patients in the pre-protcol chohort, 3 (33%), 2 (22%), and 2 (22%) respectively had experienced those adverse events (p = .07; p = .15; p = .23). With regard to treatment progression, post-protocol patients had high rates of protocol deviations (1 -2 deviations for first, second, and third line management), with the highest rates of deviation being for dose and time deviations for second-line fosphenytoin (22 of 30 patients), and time deviations for third line phenobarbital (8 of 10 patients).Within the post protocol cohort, patients treated for seizure disorder demonstrated lower rates of protocol deviation when compared with those not on therapy for seizure disorder. Most notableare the 4 of 14 (29%) patients with a seizure disorder who had a second line medication deviation when compared with 1 of 16 (6%) patients without a seizure disorder ( p = .15) and the 3 of 6 (50%) patients with a seizure disorder who had a third line medication deviation when compared with 0 of 4 (0%) patients without a seizure disorder ( p = .2).  Conclusions: Despite a greater number of protocol deviations, adherence to SE protocol was associated with fewer adverse events post protocol when compared with pre-protocol subjects. Protocol deviations were fewer in subjects with a known seizure disorders, save for deviations of medication choice. Interim analysis of these data do not yet achieve statistical significance, however we continue to acrue subjects from the pre-protocol era. Lastly, we are attempting to explore reasons for protocol deviations,. We believe that these analyses will inform refinements of the protocol.  Funding: No funding