Improving Time to EEG in Pediatric Status Epilepticus Patients
Abstract number :
3.392
Submission category :
13. Health Services (Delivery of Care, Access to Care, Health Care Models)
Year :
2022
Submission ID :
2205039
Source :
www.aesnet.org
Presentation date :
12/5/2022 12:00:00 PM
Published date :
Nov 22, 2022, 05:27 AM
Authors :
Brittany Sprigg, MD – University of California, San Diego; Nicholas Allar, R.EEG.T – Seattle Children's Hospital; Dwight Barry, PhD – Seattle Children's Hospital; Javier Carregha, BS – Seattle Children's Hospital; Leslie Dervan, MD MS – Seattle Children's Hospital; Jennifer Hrachovec, PharmD MPH – Seattle Children's Hospital; Lindsey Morgan, MD – Seattle Children's Hospital; Edward Novotny, MD – Seattle Children's Hospital
Rationale: Status epilepticus (SE) is a life-threatening neurologic emergency. As patients receive pharmacologic treatment, the associated clinical signs of a seizure may become subtle, be masked by pharmacologic paralysis, or cease entirely (non-convulsive seizures). National guidelines recommend electroencephalogram (EEG) monitoring within 60 minutes of seizure onset for prompt recognition of ongoing seizures, but time from EEG request to conventional EEG initiation is often delayed, in some reports up to 4 hours. We aimed to evaluate and improve the time to EEG initiation for pediatric patients with SE.
Methods: A retrospective cohort study was conducted including all STAT EEG orders on patients from 5/4/2016-10/31/2021, which included a year of baseline data and 5 plan-do-study-act (PDSA) cycles (Table 1). We measured time from EEG order (via the electronic health record (EHR)) to interpretable EEG (via manual review of EEG recording in the neurodiagnostic database). EEG reports were reviewed for presence of seizures. Time of benzodiazepine administration was identified in the EHR. Comparisons were made using run charts and generalized linear models.
Results: There were 475 identified patients: baseline: 5/2016 (n= 179), PDSA cycle 1: 5/2017 (n=35), PDSA cycle 2: 8/2017 (n=29), PDSA cycle 3: 10/2017 (n=128), PDSA cycle 4: 8/2018 (n=57), PDSA cycle 5: 10/2020-10/2021 (n=39). A run chart (Figure 1) demonstrates that over these cycles, we improved time from EEG order to acquisition of interpretable EEG data from a baseline median of 84 minutes to a median of 37 minutes during PDSA cycle 4. This improvement was sustained over 2 years. The median time then increased to 70 minutes with PDSA cycle 5, when our hospital adopted a new EHR system. The proportion of EEGs capturing seizures increased during PDSA cycle 4 and 5 compared to baseline (18% to 34% and 39%, p=0.025 and 0.011, respectively), even though time to interpretable EEG increased in PDSA 5. This trend may suggest that STAT EEGs are being ordered more appropriately, on higher-risk populations, over time. Earlier time to EEG was associated with receipt of fewer interval doses of benzodiazepine (median 85 minutes to EEG for patients receiving additional benzodiazepines vs. 54 minutes for those who did not receive additional benzodiazepines; OR=1.02, 95% CI 1.00 to 1.05, p=0.033).
Conclusions: Our interventions resulted in a clinically significant decrease in time to interpretable EEG, to less than 60 minutes. Seizures were identified more often with earlier time to EEG, and earlier time to EEG may have decreased additional benzodiazepine doses. Unfortunately, the systems we created were not sustained following a major EHR transition. Subsequent process review to identify and resolve new barriers to timely EEG will be needed to re-establish optimal EEG access for patients with SE.
Funding: Seattle Children's Hospital Clinical Effectiveness Research Fund
Health Services (Delivery of Care, Access to Care, Health Care Models)