Authors :
Presenting Author: Sonali Sen, MD – Texas Children's Hospital
Thara Bala, MD – Texas Children's Hospital; Jon Cokley, PharmD – Texas Children's Hospital; Jennifer Erklauer, MD – Texas Children's Hospital; Neida Juarez, R.EEG/EP T – Texas Children's Hospital; Adrienne Kocher, RN – Texas Children's Hospital; Leigh Ligas, R.EEG/EP T, CLTM – Texas Children's Hospital; Stacy Pedigo, BBA, R.EEG/EP T, CLTM – Texas Childrens' Hospital; Lisa Rhodes, R.EEG/EP T – Texas Children's Hospital; James Riviello, MD – Texas Children's Hospital; Frances Sumulong, RN – Texas Children's Hospital; Chelsey Ortman, MD – Texas Children's Hospital
Rationale:
First-line seizure rescue medication should be given within five minutes of seizure onset
1 due to worse neurological outcomes for patients in status epilepticus.
2 The median time to treatment for patients on continuous EEG (cEEG) who met rescue treatment (RT) criteria in the Texas Children’s Hospital Pediatric Intensive Care Unit (PICU) is 59 minutes which is over ten times the recommended guidelines.
A multi-disciplinary team determined causes of delayed response time and developed interventions to reduce the timeline to first line anti-seizure medication (ASM). The global aim of this project was to reduce potential adverse neurological sequelae associated with status epilepticus, with a specific aim to reduce median time to first line (ASM) for patients meeting RT criteria in the PICU by at least 25% within one year.
1 Brophy GM et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012 Aug;17(1):3-23.
2 Lalgudi GS, Hahn CD. Electrographic seizure burden and outcomes following pediatric status epilepticus. Epilepsy Behav. 2019 Dec;101(Pt B):106409.
Methods:
Quality Improvement (QI) methodology was used to create a key-driver diagram to identify primary and secondary drivers of delayed administration of ASM (Figure 1). A process map highlighted opportunities to streamline our cEEG workflow and RT protocol. Plan-Do-Study-Act (PDSA) cycles were used to implement interventions and assess improvement. PDSA cycle 1 focused on staff education and optimizing communication between EEG technologists and bedside nurses once a patient met RT criteria. PDSA cycle 2 centered on standardizing and ordering first line ASM for all patients monitored on cEEG. An ongoing third
PDSA cycle reinforces workflow protocols and ascribes ownership of the 1st-line ASM orders to members of the critical care team.Results:
After PDSA #1, there was a 14% reduction (58 minutes to 50 minutes) in median time to first-line ASM. This reduction was not sustained during PDSA #2 with a return to the previous baseline of 58 minutes. Notably, compliance with new workflows between EEG technologists and bedside nurses decreased from 78% during PDSA #1 to 64% during PDSA #2. Preliminary results from PDSA #3 show improved compliance (95%) to workflows and an associated 38% reduction in treatment time, down to 36 minutes (Figure 2). Notably, patients in status epilepticus had a similar baseline, but with a sustained reduction in treatment time down to 28 minutes over the past year.
Conclusions:
Staff education and improved communication between EEG technicians and nursing was associated with improved RT times. Barriers to implementation included inconsistency adhering to protocols, notification fatigue, variable nursing phone numbers, and competing nursing demands. Ownership of first-line ASM orders was identified as an additional measure to reduce RT times. Future interventions include implementing a continuous EEG with RT order set, re-educating staff on new protocols, and shortening pharmacy RT delivery times.
Funding: None