Abstracts

Rationale: Anti-seizure medications are associated with a risk for fetal malformations. The use of folic acid prior to and throughout pregnancy may help mitigate certain risks. One of the AAN Epilepsy Quality Measures includes a recommendation to discuss folic acid supplementation with females of childbearing potential who are taking anti-seizure medications. Prior studies have reported less than 40% of women are appropriately counseled. We utilized quality improvement methodology to design a project aimed at increasing the percentage of female patients with epilepsy greater than age of 12 seen at the Nationwide Children's Hospital outpatient epilepsy center who are counseled about folic acid supplementation. Methods: We included girls 12 years and older with epilepsy who were taking an anti-seizure medication. Baseline data regarding folic acid supplementation and counseling were collected over a 12 month period. An aim statement was formed. Key drivers were developed using a process map. Interventions were formed. The first intervention was a nursing-based counseling intervention, which included written educational information distributed by the nurses during triage. Data was collected following the intervention utilizing a plan, do, study, act cycle (PDSA) and the key driver diagram was modified as a result. The second intervention involved modifying the electronic medical record to use a Best Practice Alert (BPA), to identify appropriate patients and flag providers. Data was collected following the intervention. Results: Two hundred and sixty-five female patients who were evaluated over a 12 month period prior to the interventions were included. Of those, 190 (72%) were appropriately counseled or were taking folic acid supplementation. Following the nursing intervention, 121 female patients were included over a 7 month assessment period. Seventy-two patients (59%) were appropriately counseled or had folic acid on their medication list. Finally, following the initiation of the BPA, a 3-month time period was evaluated, and 39 female patients were included. Of those, 32 (79%) were appropriately counseled or were taking a folic acid supplement. Conclusions: One AAN Epilepsy Quality Measure recommends discussing folic acid supplementation with females of childbearing potential. This study demonstrates an example of utilizing quality improvement methodology to improve compliance with that quality measure, and the barriers we encountered. These techniques are generalizable to other clinical settings. A nursing-based intervention was unsuccessful and resulted in a decline in our overall compliance from 72% (baseline) to 59% (post-intervention). One possible reason for this decline is clinician reliance of the nursing intervention without reassessment. A second intervention in the form of a best practice alert, showed some improvement, from 72% (baseline) to 79% (post-intervention). Further interventions are planned to continue improving our baseline. Funding: None