Authors :
Author: Ritika Shetty, MBBS – Terna Medical College
Presenting Author: Muhammad Zafar, MD, FACNS – Duke University Hospital
Rishi Chilappa, N/A – Duke University
Lauren Chamberlain Morris, DO – Johns Hopkins Hospital
Emily Greenwald, MD – Duke University Hospital
Rationale:
Pediatric status epilepticus (SE) is a medical emergency requiring prompt initiation of treatment. While existing literature has primarily focused on identifying and addressing delays in the administration of first-line benzodiazepines, there remains a critical need to optimize the interval between the administration of first and second-line medications in the management of SE. Specifically, the transition from benzodiazepine therapy to second-line agents, such as fosphenytoin, levetiracetam or valproate represents a crucial juncture where delays can occur, potentially prolonging seizure activity. This quality improvement project seeks to enhance the efficiency of medication administration protocols for status epilepticus in the emergency room setting.
Methods:
A Plan-Do-Study-Act (PDSA) quality improvement methodology was employed. The project engaged a collaborative team comprising pediatric neurologists, epileptologists, emergency room physicians, pharmacists, nurses, emergency room fellows, and pediatric neurology fellows at Duke University Hospital (DUH). Interventions included the development of a simplified status algorithm, adding levetiracetam as a preferred second-line option, creation of an electronic health record (EPIC) order set, making medication dosing easily accessible and providing extensive training and education to emergency care providers. Data collection for this quality improvement project comprised of process measures, outcome measures, and balancing measures. Process measures included tracking the use of levetiracetam as a second-line medication and utilization of the order set. Outcome measures were the time from the initial order of medication to the time of administration, and safety events, such as ICU admissions and patient intubations. Balancing measures focused on the frequency of pediatric neurology consultations and hospital admissions. Data was collected from January 2021 to June 2024 for patients under the age of 21 presenting in status epilepticus to the DUH Pediatric Emergency Room who received first and second-line antiseizure medications. The data was plotted on X-charts and mR-charts using Microsoft Excel’s QI Macros.
Results:
Analysis of the data revealed a reduction in the median medication administration time from 38 minutes pre-intervention to 10 minutes post-intervention. Furthermore, the implementation of interventions led to a decrease in variability in medication administration times, as evidenced by X-charts. The balancing measures remained stable throughout the study period.
Conclusions:
The results of this quality improvement project reflect significant improvements in medication administration times for pediatric patients presenting in status epilepticus to the emergency room after switching the preferred second-line medication to levetiracetam. This demonstrates the importance of standardized protocols and continuous quality improvement efforts in optimizing patient care.
Funding: None