Quality assurance evaluation of a simple linear protocol for the treatment of impending status epilepticus in a pediatric emergency department 2 years postimplementation

Abstract

Objective: To evaluate the efficacy and safety of a simple linear midazolam-based protocol for the management of impending status epilepticus in children up to 18 years of age. Methods: This is a descriptive, quality assessment, retrospective chart review of children presenting with the chief complaint of seizure disorder in the emergency department (ED) of a tertiary care pediatric hospital and a triage category of resuscitation or urgent from April 1, 2009, to August 31, 2011 In children with at least one seizure episode in the ED treated according to the linear protocol, three main outcomes were assessed: compliance, effectiveness, and complications. Results: Of the 128 children meeting the above study criteria, 68 had at least one seizure episode in the ED, and treatment was required to terminate at least one seizure episode in 46 of 68 patients (67.6%). Fifty-five seizure episodes were treated in the 46 patients: 51 of 55 seizure episodes were treated with midazolam (92.7%) and 4 of 55 with lorazepam or diazepam (7.3%). Of those treated with midazolam, 86.3% (44 of 51) were successfully treated with one or two doses of midazolam. The median seizure duration for all treated patients was 6 minutes. Of the 42 patients treated with midazolam, 7 required either continuous positive airway pressure or intubation, and two patients were treated for hypotension. One patient died of pneumococcal meningitis. Conclusion: This simple linear protocol is an effective and safe regimen for the treatment of impending status epilepticus in children. RÉ SUMÉObjectif: L'é tude visait à é valuer l'efficacité et l'innocuité d'un simple protocole liné aire, fondé sur le midazolam, pour le traitement d'un é tat de mal é pileptique imminent, chez des enfants â gé s de 18 ans et moins.

Timing is everything: Where status epilepticus treatment fails

“…The first phase of each QI initiative consisted of multidisciplinary engagement and careful surveillance of current practice at individual institutions. Observed causes of variation and delays included failure to correctly identify time of seizure onset, inconsistent physician orders, delayed decision making regarding when to administer drugs, lack of standing orders for medication as needed, varying experience of staff and personnel, knowledge gaps, inefficient communication, and issues with availability of antiepileptic medication …”

“…All three studies chose to standardize treatment by creating or modifying a treatment protocol. Following employment of a linear, single‐agent protocol for pediatric patients presenting with impending status epilepticus, 93% (51 of 55) of seizures were appropriately treated with first‐line midazolam and 86% (6 of 7) were appropriately treated with phenytoin as second‐line therapy (no comparison group available) . In another study that used an automatically activated electronic order set for any pediatric patient with a diagnosis of seizure, the mean time from impending status recognition to first‐line therapy improved (3.74 vs 7.72 minutes; p < 0.0001) as did delay to second‐line therapy (25 vs 49.5 minutes; p < 0.0001) .…”

“…Observed causes of variation and delays included failure to correctly identify time of seizure onset, inconsistent physician orders, delayed decision making regarding when to administer drugs, lack of standing orders for medication as needed, varying experience of staff and personnel, knowledge gaps, inefficient communication, and issues with availability of antiepileptic medication. [38][39][40] All three studies chose to standardize treatment by creating or modifying a treatment protocol. Following employment of a linear, single-agent protocol for pediatric patients presenting with impending status epilepticus, 93% (51 of 55) of seizures were appropriately treated with first-line midazolam and 86% (6 of 7) were appropriately treated with phenytoin as second-line therapy (no comparison group available).…”

Automated identification and quality measurement for pediatric convulsive status epilepticus

“…Automated calculation of the quality measure and time to treatment should facilitate future quality improvement efforts. For pediatric CSE, protocol‐driven initiatives are effective at decreasing time to treatment 18‐22 . One author suggested that hospitals should organize rapid response teams that respond to seizures with similar urgency and coordination to “code teams” for cardiorespiratory arrest 23 .…”

Feasibility of Automatic Extraction of Electronic Health Data to Evaluate a Status Epilepticus Clinical Protocol

“…The evidence is unclear on the effectiveness of protocol adherence. A retrospective chart review of children presenting with seizures to the emergency department found that adherence to a protocol successfully treated 55 episodes in 46 patients, 5 although there was no comparison group in the study. Conversely, a prospective study of 54 adults with status epilepticus found that patient outcomes at an academic hospital, which followed a status epilepticus protocol closely, were not different from outcomes at regional hospitals, which often deviated from the status epilepticus protocol.…”