Standardized Treatment of Neonatal Status Epilepticus Improves Outcome

Abstract

We aimed to decrease practice variation in treatment of neonatal status epilepticus by implementing a standardized protocol. Our primary goal was to achieve 80% adherence to the algorithm within 12 months. Secondary outcome measures included serum phenobarbital concentrations, number of patients progressing from seizures to status epilepticus, and length of hospital stay. Data collection occurred for 6 months prior and 12 months following protocol implementation. Adherence of 80% within 12 months was partially achieved in patients diagnosed in our hospital; in pretreated patients, adherence was not achieved. Maximum phenobarbital concentrations were decreased (56.8 vs 41.0 µg/mL), fewer patients progressed from seizures to status epilepticus (46% vs 36%), and hospital length of stay decreased by 9.7 days in survivors. In conclusion, standardized, protocol-driven treatment of neonatal status epilepticus improves consistency and short-term outcome.

Timing is everything: Where status epilepticus treatment fails

“…Additionally, there was a reduction in mean maximum serum phenobarbital concentration (41.0 vs 56.8ug/ml) as intended and a 10% reduction in seizures progressing to status epilepticus. 40 …”

“…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).…”

Development of a NeuroNICU with a Broader Focus on All Newborns at Risk of Brain Injury: The First 2 Years

“…However, there is evidence that NeuroNICUs have changed practices and improved care in ways that are likely to impact neurodevelopmental outcomes and may positively impact families by reducing exposure to sedating medications and by reducing length of hospital stay. [30][31][32][33] Bashir et al describe a significant improvement in electrographic seizure detection, lower phenobarbital burden, and less anticonvulsant therapy at discharge associated with a clinical protocol in their neurocritical care program that used cEEG for 72 hours in all babies with HIE. 30 Similar findings were seen in an earlier study by Wietstock et al who reported that implementation of a neonatal neurocritical care service was associated with a reduction in cumulative phenobarbital dose, shorter duration of maintenance dosing, less medication use at discharge, and a shorter length of stay.…”

Implementation strategies in pediatric neurocritical care

“…Haris’ group also used strategies focused on planning and educating, but did not rely as heavily on restructuring healthcare delivery at their institution. With the development of a protocol for management of neonatal status epilepticus, they were able to significantly decrease the progression of seizures from 46% to 36% of patients, serum phenobarbital concentration from 56.8 micrograms/mL to 41micrograms/mL, and length of stay by 9.7 days in survivors (23). …”