Abstracts

Rationale: Prolonged seizures are correlated with poor short- and long-term neurological outcomes and early treatment provides better response to treatment. Despite the development of multiple guidelines for the treatment of status epilepticus, the timing of administration of anti-seizure medications is often delayed (Sᮣhez Fernᮤez et al., Neurology 2015;84(23):2304-2311). We report baseline data from Nationwide Children's Hospital and the subsequent improvement in the percentage of patients with prolonged seizures receiving timely administration of benzodiazepines and fosphenytoin following implementation of Institute for Healthcare Improvement (IHI) methodologies. Methods: Pilot data for inpatients on the neurology and physical medicine and rehabilitations services at Nationwide Children's Hospital during 2015 were obtained from retrospective chart review. Patients with a single prolonged seizure or seizure cluster without return to baseline on these services who received a benzodiazepine or fosphenytoin per the institutional status epilepticus protocol were identified and timing of administration recorded. Patients in the Epilepsy Monitoring Unit were excluded. A multidisciplinary QI team was developed and consisted of attending physicians, resident physicians, floor nurses, pharmacists and a QI process specialist. A process map, key driver diagram and Pareto chart were developed to focus interventions. Plan-Do-Study-Act (PDSA) cycles were utilized with adjustments when necessary. Interventions implemented included: nurse and clinician education, simulations, revising the process of medication administration, relocation of medication administration items, creating an electronic medical record (EMR) order set, refining medication and route of administration and standardizing documentation. Data were tracked utilizing I-charts and p-charts and trends identified employing accepted principles. We report our work utilizing SQUIRE guidelines. Institutional Review Board approval was waived, as this work was performed for QI purposes. Results: Baseline time to administration was a median of 8 minutes for first benzodiazepine and 76 minutes for fosphenytoin. The baseline percentage of patients receiving a first dose of benzodiazepine within 10 minutes was 33% and first dose of fosphenytoin within 20 minutes of 0%. Trends in the desired direction have developed for both the administration of benzodiazepines and fosphenytoin. Furthermore, a baseline shift in the desired direction developed following several PDSA cycles for benzodiazepine administration. Fewer patients have required administration of fosphenytoin after several PDSA cycles. A balancing measure of number of children receiving treatment for seizures in less than 2 minutes was 0. Data continue to accrue, with updated analysis for presentation at the annual AES meeting in December, 2016. Conclusions: Applying IHI QI methodology improved the timeliness of administration of first line medications for prolonged seizures in the inpatient setting. A trend toward improvement emerged for second-line treatment. Many of the interventions may be applicable in similar institutions. Further education- and EMR- based interventions are planned to further improve upon and maintain initial successes. Funding: None