(85) Quality Improvement Initiative to Reduce Fosphenytoin Administration Time for Status Epilepticus in the Emergency Department

This abstract has been invited to present during the Better Patient Outcomes through Diversity Platform poster session
This abstract is recognized by Partners Against Mortality in Epilepsy for its contribution to improving the understanding of epilepsy-related mortality

Rationale: Status epilepticus (SE) is a common neurologic emergency¹ associated with significant morbidity and mortality² if not treated quickly and effectively. Benzodiazepines are typically first-line treatment, however during continuous SE, the potency of benzodiazepines may decrease 20-fold over 30 minutes if untreated. Therefore, a second-line abortive medication is often needed.

The American Epilepsy Society (AES) SE guideline³ holds that second-line abortive medications be given between 1-20 minutes after first-line medications. Yet, there is a high degree of variability in hospital protocols for the treatment of SE. New studies have shown a considerable time delay in administration of first, second, and third anticonvulsants for SE. The authors of a prospective observational study reported that the median time for administration of the first dose of a non-benzodiazepine drug was 69 minutes (range 40-120).⁴

We aimed to utilize Quality Improvement (QI) methodology to decrease the time to administration of second-line treatment for ongoing generalized convulsive status epilepticus (GCSE).

Methods: A multidisciplinary QI team including neurologists and emergency department (ED) personnel was established. The team conducted an analysis of baseline data concerning patients with GCSE who received fosphenytoin (FPHT) after receiving first line benzodiazepine treatment at the Nationwide Children's Hospital (NCH) ED. Our preexisting institutional protocol sought for a time window of 15 minutes or less in between administration of first-line benzodiazepine and FPHT.

Using the institute for Health Care improvement methodology and a process map, the QI team identified areas of focus for improvement opportunities and developed a specific project aim and key driver affinity diagram (Figure 1). Interventions where then developed for each key driver and sequentially implemented in "Plan-Do-Study-Act cycles" for over two years. Progressed was monitored monthly

Results: Preliminary baseline data from January to December 2013 showed an average delay of 30 minutes in administering FPHT. From January 2014 to December 2019 the average in administration of FPHT decreased to 11.4 minutes (62% reduction) and this improvement was sustained (Figure 2). This was achieved by the implementation of six main interventions over the course of 15 months.

Conclusions: SE is a neurologic emergency and timely administration of anticonvulsants is important to reduce morbidity and mortality. We show here that QI methodology can be successfully applied to decrease administration time of second-line anticonvulsants for SE.



References:
1. Betjemann JP. Trends in Status Epilepticus-Related Hospitalizations and Mortality: Redefined in US Practice Over Time. JAMA Neurol. 2015 Jun;72(6):650-5.
2. Alford, E. L., et al. (2015). "Treatment of Generalized Convulsive Status Epilepticus in Pediatric Patients." J Pediatr Pharmacol Ther 20(4): 260-289.
3. Vasquez, A., et al. (2018). "Hospital Emergency Treatment of Convulsive Status Epilepticus: Comparison of Pathways From Ten Pediatric Research Centers." Pediatr Neurol 86: 33-41.
4. Sanchez Fernandez, I., et al. (2015). "Time from convulsive status epilepticus onset to anticonvulsant administration in children." Neurology 84(23): 2304-2311.

Funding: Please list any funding that was received in support of this abstract.: None