Abstracts

Rationale: Prevention of unnecessary 30-day readmissions is important in terms of quality of care and cost reduction. Epilepsy patients are vulnerable to readmission given behavioral health comorbidities and the complexity of medication regimens and discharge instructions. A recent retrospective review at our institution identified breakthrough seizures, non-epileptic seizures (NES), and psychiatric symptoms as common reasons for 30-day readmissions and emergency department (ED) visits in patients discharged from the Dartmouth-Hitchcock Epilepsy Center inpatient epilepsy monitoring unit (EMU). Our objective was to assess the effect of two interventions to reduce 30-day re-encounters (defined as epilepsy-related readmissions and ED visits) among adult patients admitted for video electroencephalogram (VEEG) monitoring. Methods: A retrospective examination of 876 consecutive admissions to the inpatient neurology service for elective VEEG monitoring from January 2010 to June 2013 identified demographics, length of stay (LOS), seizure type(s), number of 30-day urgent re-encounters, and reason(s) for readmissions. We excluded encounters unrelated to epilepsy or its comorbidities. In March 2013 we revised the discharge document templates for epilepsy and NES. In July 2013, two interventions were implemented: (1) a post-EMU discharge nurse phone call to answer questions, coordinate care, and provide support; (2) a co-located psychiatrist within the outpatient clinic (0.1 FTE) to provide psychopharmacologic management and time-limited structural psychotherapeutic interventions for patients with severe psychiatric symptoms or refractory NES. Rates of 30-day re-encounters were monitored over 3-month intervals through March 2014 using statistical process control charts. Results: Baseline rate of 30-day re-encounters was 5.7% (49 patients accounting for 73 encounters among 876 EMU admissions), with the most common reasons including breakthrough seizures (23% of encounters), recurrent or new onset NES (19%), and active psychiatric symptoms (34%, consisting of depression, psychosis, or suicidal ideation). Following the implementation of the interventions, 60% of the 186 EMU discharges over the subsequent 9 months received a nurse follow-up phone call and 4% were referred to the co-located psychiatrist for severe psychiatric symptoms warranting urgent evaluation. While a non-significant trend towards an overall increase in 30-day re-encounters occurred with a post-intervention rate of 7.1% (14 patients with 18 encounters among 188 EMU admissions), the reasons for 30-day re-encounters dramatically shifted: Breakthrough seizures represented 67% of encounters, while active psychiatric symptoms and NES combined comprised only 10% of encounters after July 2013. Conclusions: Interventions specifically addressing psychiatric comorbidities and NES may help prevent unnecessary readmissions and urgent hospital re-encounters. Increased attention to outpatient management of breakthrough seizures in patients with intractable epilepsy may further decrease unnecessary health care utilization.