Abstracts

Rationale: A wide variation in care existed for uncomplicated seizure patients seen in the emergency department (ED) at Christiana Care Health System, the only Level I trauma center in Delaware. To reduce unnecessary variation, improve clinical outcomes, and ensure appropriate outpatient (OP) follow-up, the Neurosciences Service Line assembled a multidisciplinary team and designed the Uncomplicated Seizure Pathway. The initial implementation of the pathway was assessed. Methods: IRB approval was obtained. The first 40 consecutive patients were evaluated for pathway effectiveness. There were standardized orders and recommendations in the ED, customized patient education, automated reporting to the DMV for driving restrictions, and coordination for a follow-up care plan in the OP setting. An OP nurse coordinator contacts the patient after discharge from the ED and provides further education and scheduling for an OP neurology consult, EEG, and MRI as appropriate. Follow-up is available with a neurologist within 2 weeks if they did not have an inpatient neurology consult, and less than 8 weeks if they did. Results: The median age was 34.5 years old; they were 45% female, and 27.5% had inpatient neurology consult. 14% of patients who saw a neurologist had a final diagnosis other than a seizure (most common diagnosis was syncope). Despite best efforts, 10% of patients never saw a neurologist. These patients were more likely to have an active psychiatric illness (p-value=0.034). Critical adjustments were made to improve the evolving program. During pilot testing, the ED found that excluding drug-resistant epilepsy patients was too complicated, so this exclusion criterion was eliminated. In addition, since the patients were unable to drive, they found it difficult to return to the hospital for 3 separate EEG, MRI, and OP follow-up appointments. Thus, whenever possible, the MRI was temporarily deferred while the EEG and OP appointments were consolidated into 1 day. Also, when calling patients, the nurses identified that some were about to run out of seizure medication provided by the ED. The nurses helped obtain an adequate supply of medication until the patient was seen by neurology. We initially underestimated the demand of OP slots for pathway patients; however, the amount of available OP spaces has progressively increased. Conclusions: The Uncomplicated Seizure Pathway has been well-received by providers and adjustments are still ongoing. Unfortunately, some patients never saw a neurologist and were lost to follow-up (10%). Current psychiatric illness is likely a risk factor for being lost to follow-up. Our current plan is to implement social work consults to the pathway, especially for patients with psychiatric illness in an effort to ensure delivery of OP care. Funding: This abstract was supported by a grant from the National Institutes of Health – National Institute of General Medical Sciences Institutional Development Award (NIH-NIGMS: P20 GM103446).