Impact of an ICU EEG monitoring pathway on timeliness of therapeutic intervention and electrographic seizure termination

Abstract

Summary Objectives We aimed to determine whether implementation of a structured multi-disciplinary EEG monitoring pathway improved the timeliness of anti-seizure medication administration in response to electrographic seizures in encephalopathic critically ill children. Methods A multidisciplinary team developed a pathway to standardize EEG monitoring and seizure management in encephalopathic critically ill children, aiming to decrease the time from electrographic seizure onset to anti-seizure medication administration. Data was collected to inform the team of improvement opportunities which were then provided by an institutional pathway, staff education, and streamlined communication. Measurements were obtained prior to and after pathway implementation to assess for improvement. Results We collected data on 41 patients before and 21 after pathway implementation. There were no differences between the baseline and pathway groups in demographic characteristics, acute encephalopathy etiologies, or anti-seizure medications utilized. The median duration from seizure onset to anti-seizure medication administration was shorter for patients treated with the pathway (64 minutes [50, 101]) compared to patients treated prior to pathway implementation (139 minutes [71, 189]) (p=0.0006). The interval from seizure onset to anti-seizure medication order was shorter for the pathway group (31 minutes [20, 49]) than the baseline group (71 minutes [33, 131]) (p=0.003). The interval from anti-seizure medication order to administration was shorter for the pathway group (30 minutes [19, 40]) than the baseline group (40 minutes [17, 68]) (p=0.047). Seizure termination was more likely to occur following initial anti-seizure medication administration in the pathway than baseline group (67% vs. 27%, p=0.002). Significance Implementation of the pathway resulted in a significant reduction in the duration between electrographic seizure onset and anti-seizure medication administration, and a significant increase in the rate of electrographic seizure termination following an initial anti-seizure medication. Further study is needed to determine whether these changes are associated with improved outcomes.

Time to electroencephalography is independently associated with outcome in critically ill neonates and children

“…The mortality was 36% when patients were evaluated by EEG and diagnosed with nonconvulsive seizures within 30 min of onset, 39% when this occurred 1–24 h after onset, and 75% in those with diagnosis later than 24 h . In a study on the impact of a standardized EEG monitoring pathway in critically ill children, 41 patients admitted before pathway implementation were compared with 21 similar patients after the implementation of the pathway . The median (p 25 –p 75 ) interval from seizure onset to administration of antiepileptic drugs was shorter in patients treated after the implementation of the pathway (64 [50–101] vs. 139 [71–189] min) .…”

“…In a study on the impact of a standardized EEG monitoring pathway in critically ill children, 41 patients admitted before pathway implementation were compared with 21 similar patients after the implementation of the pathway . The median (p 25 –p 75 ) interval from seizure onset to administration of antiepileptic drugs was shorter in patients treated after the implementation of the pathway (64 [50–101] vs. 139 [71–189] min) . Furthermore, the interval from seizure onset to antiepileptic drug order was also shorter in the patients on the pathway (31 [20–49] vs. 71 [33–131] min) .…”

“…The time to detection and treatment of seizure may be important. A recent series showed that early seizure detection and treatment is associated with a higher likelihood of seizure termination . Surprisingly, there are no other series evaluating time to cEEG as a potential predictor of outcome.…”

Extended EEG and non-convulsive status epilepticus: Benefit over routine EEG?

“…24,25 Continuous EEG monitoring is increasingly used especially in intensive care units in patients with disorders of consciousness of unclear origin, and has represents an invaluable tool in patients with refractory SE treated with therapeutic coma, as it allows a direct follow-up of treatment. 28 This contrasts with the situation using routine EEGs, where the next assessment could take place only 12-24 hours later, and it remains to be demonstrated that this different policy has an impact on clinical outcome in this particular clinical setting. A more accurate follow-up of the epileptic activity could have been expected led to a better, tailored therapy, potentially decreasing the risk of overor undertreatment.…”

Implementation strategies in pediatric neurocritical care

“…For status epilepticus, seizure burden has been associated with short term outcome in critically ill children (13). While further study is needed to determine the impact on patient outcomes, initiation of electroencephalography monitoring and administration of antiepileptic therapy through a standardized protocol can reduce time to treatment by 50% and increased the rate of electrographic seizure termination (14, 15). …”