Implementation of a Standardized Order Set for the Management of Status Epilepticus in the Electronic Medical Records System, a Quality Improvement Initiative
Abstract number :
3.128
Submission category :
13. Health Services (Delivery of Care, Access to Care, Health Care Models)
Year :
2024
Submission ID :
298
Source :
www.aesnet.org
Presentation date :
12/9/2024 12:00:00 AM
Published date :
Authors :
Presenting Author: Thiri Lin, MD, PhD – University of North Carolina Hospitals
Chhitij Tiwari, MD – University of North Carolina Hospitals
Casey Olm-Shipman, MD, MS – University of North Carolina Hospitals
Camille Liu, PhD – University of North Carolina Hospitals
Fei Zou, PhD – University of North Carolina Hospitals
Clio Rubinos, MD, MS – University of North Carolina Hospitals
Rationale:
Status epilepticus (SE) is a neurological emergency associated with high mortality and morbidities that require immediate treatment. Guidelines recommend rapid treatment of SE and the use of appropriate anti-seizure medications (ASMs) doses for SE management. Despite these recommendations, first-line and second-line ASMs are often delayed or underdosed, increasing the risk of SE progressing to more refractory stages, which have increased mortality and morbidity. We assessed if the implementation of a standardized order set (SOS) for the management of SE in the electronic medical records (EMR) system leads to shortened time to first and second-line ASM administration, improvement in appropriate dosing of ASMs and improved outcomes.
Methods:
We implemented a SE management SOS in the EMR system at the University of North Carolina in 2021. A retrospective analysis was done on all SE cases that were admitted at UNC between January 2019 and December 2022. A total of 104 cases were observed (44 pre-SOS and 60 post-SOS). Critical illness severity score and in-hospital mortality risk were measured by calculating the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Status Epilepticus Severity Scores (STESS) respectively. Favorable discharge outcomes were defined as disposition to home, skilled nursing facility, or acute inpatient rehabilitation, while unfavorable outcomes were defined as in-hospital mortality or discharge to hospice.
Results:
After SOS implementation, there was a trend in decreased median time from arrival to lorazepam administration and time to first non-benzo ASM administration, 15.5 min (post-SOS) from 27 min (pre-SOS) (p= 0.37) and 75 min (pre-SOS) vs. 56 min (post-SOS) (p = 0.13) respectively. There was an increase in appropriate dosing of lorazepam from 20% (pre-SOS) to 30% (post-SOS). Interestingly, the implementation of the SOS significantly increased the use of levetiracetam as the first non-benzodiazepine ASM, 77.3% (pre-SOS) vs. 91.7% (post-SOS), (p = 0.04). There was no difference in hospital length of stay among patients pre- and post-SOS. However, there was a trend in increase in favorable dispositions post-SOS implementation from 52.3% (pre-SOS) to 65% (post-SOS) and a decrease of unfavorable disposition from 43.2% (pre-SOS) to 21.7% (post-SOS) after correcting for critically illness severity and mortality risk.
Conclusions:
Implementing a standardized order set for managing SE in the EMR system leads to shortened time for first and second-line ASM administration and improved favorable disposition at discharge. Future PDSA (Plan-Do-Study-Act) cycles are planned to increase the use of the standardized order set and improve education in SE management. The goal is to ensure appropriate dosing, rapid ASM delivery, and optimization of management for patients with SE.
Funding: None.
Health Services (Delivery of Care, Access to Care, Health Care Models)