Abstracts

Rationale: Epilepsy surgery (ES) has been shown to improve seizure outcome and reduce patient mortality. However, analyses have shown that the number of ES falls short of the estimated demand, given that approximately 1/3 of patients have refractory epilepsy. ES volume at our center was low compared to projected numbers for the size of our catchment area. As quality improvement project, we introduced process changes aimed at facilitating the work-up and increasing ES numbers (including invasive monitoring without resection; excluding VNS). Evaluation time (ET) from non-invasive video-EEG monitoring (P1) to ES, and number of ES, were determined for patients at baseline (B-group) and after implementation of process changes (C-group). Results were compared to assess the impact of these measures. Methods: The University of Colorado Hospital patient database was searched for all epilepsy surgeries from January 2009 - May 2016. Time from P1 to Wada testing, patient care conference (PCC: panel of epileptologists, radiologists, neuropsychologists, neurosurgeons) and ES was determined. Measures to improve access to surgery, included: 1) increased PCC frequency from once monthly to weekly; 2) faster scheduling for Wada test by allocation of reserved appointments; 3) adding a dedicated epilepsy surgery clinic for review of results, education, test planning, and referral to neurosurgery; and 4) hiring a nurse navigator to coordinate the process. ES volume and ET, including the break down of time from P1 to Wada, PCC and ES were determined for: 1) B-group (patients with P1 between January 2009 and March 2013), and 2) C-group (P1 after March 2013). Each group was further subdivided into "typical' patients (TP) who completed the work-up without apparent hold up, and "atypical" patients (AP), with personal reasons for delaying testing or ES. Kruskal Wallis/Wilcoxon and ANOVA/T-tests were used to compare the means between groups. Poisson and Piecewise models were assumed for ES rates. Results: Total number of surgeries was 61 for B-group and 61 for C-group, increasing the annual rate after 3 years from 13.3 to 37.8 (p=0.0004), with a yearly increase of 42%, after process changes (Figure 1). Interventions aimed at expediting the process to epilepsy surgery in appropriate candidates significantly lowered average ET by 96 days (p= < 0.0001), time from P1 to Wada by 37 days (p=0.0061), and time to PCC by 58 days (p=0.0009) for TP (Table 1). For AP, times Wada and ES were not significantly different. Conclusions: Implementing more frequent PCCs, quicker access to testing, a dedicated clinic and coordinating nurse navigator significantly decreased the time from P1 to resective ES and increased ES volume, except when patient preference slowed the process. Similar strategies could be adopted by other centers building surgical programs or attempting to increase surgical volume, by decreasing wait time and increasing access to ES. Additionally, such QI measures stand to improve patient safety by lowering seizure-related mortality through expediting evaluation and effective treatment. Ongoing investigations are aimed at identifying patient reasons for delaying surgery. Funding: N/A