Original Article
Emergency Department Management of Pediatric Unprovoked Seizures and Status Epilepticus in the State of Illinois
Journal of Child Neurology 1-14 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0883073814566626 jcn.sagepub.com
Connie Taylor, MD1, Juan Piantino, MD1, Joseph Hageman, MD1,2, Evelyn Lyons, RN, MPH3, Kathryn Janies, BA4, Daniel Leonard, MS4, Kent Kelley, MD2, and Susan Fuchs, MD5
Abstract The purpose of this survey and record review was to characterize emergency department management of unprovoked seizures and status epilepticus in children in Illinois. The survey was sent to 119 participating emergency departments in the Emergency Medical Services for Children program; responses were received from 103 (88% response rate). Only 44% of the emergency departments had a documented protocol for seizure management. Only 12% of emergency departments had child neurology consultation available at all times. Record review showed that 58% of patients were discharged home, 26% were transferred to another institution, and 10% were admitted to a non-intensive care unit setting. Ninety percent of patients were treated with anticonvulsants. Seizure education was provided by the primary emergency department nurse (97%) and the treating physician (79%). This project demonstrated strengths and weaknesses in the current management of pediatric seizure patients in Illinois emergency departments. Keywords unprovoked seizure, status epilepticus, seizure protocol Received February 01, 2014. Accepted for publication November 24, 2014.
Children account for more emergency department visits for seizures than any other age group. In the United States, almost 10% of pediatric ambulance calls and 1.5% of pediatric visits to the emergency department are for chief complaints related to seizure.1-3 Annually, as many as 40 000 pediatric patients experience their first nonfebrile seizure. In addition, status epilepticus is an important neurologic emergency encountered in pediatric emergency departments. The status epilepticus incidence in the pediatric population is 17 to 23 per 100 000 children. The number may be as high as 51 per 100 000 in younger children.4 Although guidelines exist for the assessment and management of childhood seizures, information is not routinely gathered from emergency departments regarding their practices. The American Academy of Neurology has published practice parameters for the evaluation of first nonfebrile seizures5 and status epilepticus.6 The American Academy of Neurology uses the term nonfebrile seizure to encompass all seizures in a child aged 1 to 21 years that cannot be explained by another provoking factor such as trauma, fever, or infection. In this study, we use a similar definition, but use the umbrella term unprovoked seizure. However, in our study, status epilepticus was defined as a condition in which epileptic activity persists (with prolonged or repeated seizures without intervals of
consciousness). This definition is similar to that used by the International League Against Epilepsy which does not include seizure duration.7,8 The guidelines for unprovoked seizure and status epilepticus are similar (Table 1). In practice, initial evaluation and treatment of unprovoked seizure and status epilepticus in the emergency department does not consistently follow American Academy of Neurology guidelines. One study found that many emergency departments routinely order CT scans on all patients with new-onset unprovoked seizure.9 Several other studies document that emergency departments frequently order unnecessary laboratory studies 1
Pediatrics, University of Chicago, Chicago, IL, USA Pediatrics, North Shore University Health System, Evanston, IL, USA 3 Illinois Department of Public Health, Chicago, IL, USA 4 Illinois Emergency Medical Services for Children, Loyola University Chicago, Maywood, IL, USA 5 Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA 2
Corresponding Author: Connie Taylor, MD, Pediatrics, University of Chicago, 5841 S. Maryland Avenue MC 3055, Chicago, IL 60637, USA. Email: [email protected]
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Table 1. American Academy of Neurology Practice Parameter Guidelines for First Unprovoked Seizure and Status Epilepticus. First unprovoked seizure Purpose of initial evaluation Lumbar puncture Routine lab studies
Decision to image
Determine if a seizure actually occurred and the etiology of the event (provoked, cryptogenic, remote symptomatic or idiopathic) Based on individual history of physical examination findings Has not been shown to be a sufficient reason for children presenting with first unprovoked seizure who have returned to baseline in the ED Based on history and physical examination
Status epilepticus
Recommendations for lumbar punctures and blood cultures were similar to nonfebrile seizure For status epilepticus, the AAN guideline acknowledges that most EDs will routinely order basic chemistry panels and complete blood counts, so recommendations were not made regarding this practice. For children taking anticonvulsant medication, the guidelines recommend checking the levels (as indicated) Insufficient data for the AAN to recommend routine neuroimaging; however, in situations where it is clinically warranted, it should be performed after the patient is stabilized
Abbreviation: AAN, American Academy of Neurology; ED, emergency department.
for patients presenting with unprovoked seizure.10 The purpose of this study was to investigate the current diagnostic and therapeutic practices for children who present with first unprovoked seizure and status epilepticus to emergency departments participating in the Illinois Emergency Medical Services Quality Improvement program.
Survey The 17-question survey, created by a multidisciplinary team, was distributed to the 119 hospitals in the Illinois Emergency Medical Services for Children Quality Improvement program. The hospitals were asked to respond to the survey regarding their management of pediatric seizures (Appendix A).
Record Review
Methods Illinois Emergency Medical Services for Children is a collaborative program between the Illinois Department of Public Health and Loyola University Chicago aimed at improving pediatric emergency care throughout the state of Illinois. Since 1994, the Illinois Emergency Medical Services for Children Advisory Board and several committees, organizations, and individuals within EMS and pediatric communities have worked to enhance and integrate pediatric education, practice standards, injury prevention, and data initiatives. In 2010 and 2011, there were approximately 190 hospitals with emergency departments of which 119 emergency departments actively participated in the Illinois Emergency Medical Services for Children Quality Improvement program. The Illinois Department of Public Health categorizes hospitals by size and location; by this scheme 12 hospitals were in Chicago, 17 were in suburban Cook County, 19 were in ‘‘collar’’ counties surrounding Cook County, 23 were in urban counties throughout Illinois, and 32 were in rural counties in the remainder of Illinois. Overall, 49% of the hospitals were in the Chicago area and 51% of the hospitals had more than 6000 visits a year. Participating hospitals submitted surveys and medical record reviews regarding patients (age 1 month to 15 years) admitted to the emergency department for first unprovoked seizure or status epilepticus. The survey and record review were completed primarily (51%) by pediatric quality coordinators who are nurses who have at least 2 years of experience in pediatric critical care or emergency medicine. Other individuals who completed the survey included emergency department staff nurse (34%), emergency department educator (18%), emergency department medical director (12%), emergency department physician (9%), hospital quality improvement management (2%), chief of staff (1%), or other (17%). The project was approved by the institutional review board for human subjects at Loyola University Chicago.
The emergency departments were also asked to conduct a retrospective medical record review of up to 10 patients (there was no minimum required number of cases so as to not exclude smaller hospitals) presenting with first unprovoked seizure or status epilepticus. Hospitals were asked to abstract medical records for emergency department visits from January 2010 through April 2011. A data dictionary was provided as was a standard case review form (Appendix B).
Data Analysis For analysis, data were aggregated by size and location of facility. Hospitals were either designated as large facilities (having more than 6000 pediatric emergency department visits per year) or small facilities (having up to 6000 pediatric ED visits per year). Hospitals were also characterized by location into 2 groups. One group consisted of hospitals located in the Chicago metropolitan area, and the second group consisted of those located outside this area. Pearson w2 and Fisher exact tests were used to evaluate differences between these groups for the 105 surveys (P < .05) and 707 record reviews (P < .01). All analyses were performed using IBM SPSS software version 17 (IBM Corporation, Somers, NY).
Results Survey Results For the survey, 105 total responses were received from 119 candidate facilities, for a total response rate of 88%. Assessment. For the initial assessment of patients presenting with status epilepticus, most hospitals required assessment and documentation of neurologic status (96%), medication history (94%), respiratory status (96%), and previous seizure activity
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(92%). Most facilities (84%) noted that they routinely perform an emergent head CT for first unprovoked seizure. Fewer hospitals (71%) routinely performed head CTs in status epilepticus. For status epilepticus, laboratory studies were routinely performed, with the most common being complete blood count with differential (89%), electrolytes (88%), blood glucose (86%), antiepileptic drug level, as indicated (83%), urinalysis (72%), blood urea nitrogen and creatinine (72%), and urine drug screen (61%). Management. In addition to the actual management, the survey assessed the availability of protocols and pediatric neurologists to aid in the management of pediatric seizures. Less than half of responding facilities had a protocol that addressed the clinical management of seizures overall (44%) or clinical management of status epilepticus in particular (19%). Facilities in Chicago metropolitan area were more likely to have status epilepticus protocols (28% compared to 10% in regions in the rest of Illinois, P < .05). These protocols were also more prevalent in larger facilities (26% vs 11%, P < .05). Some protocols were general and were used for both adults and pediatric patients. In the facilities with seizure protocols, 71% of protocols were specifically written for pediatric patients; in protocols that addressed status epilepticus, only 50% were written for pediatric patients (Figure 1). In-house pediatric neurologic services were limited, with 12% of facilities reporting that a pediatric neurologist was available around the clock and 10% reporting that a pediatric neurologist was available, in-house, for limited coverage. Differences were found for emergency departments located in the Chicago area relative to the rest of the state. For Chicago area emergency departments, 20% reported full-time in-house availability, and 18% reported limited availability. For the rest of the state, only 4% reported full-time in-house availability, and 2% reported limited availability (P < .05 for both comparisons). Separately, when comparing by emergency department size, 23% of large emergency departments reported full-time availability compared to none of the small emergency departments (P < .01). There was also more full-time pediatric neurology coverage in the Chicago area (P < .01) Furthermore, 28% of facilities reported no in-house neurology services available (adult or pediatric) with a much higher percentage in this category reported by small facilities (P < .01) and facilities outside of the Chicago area (P < .01) (Table 2). A further analysis of clinical management practices was performed by comparing in-house availability of neurology specialists with the presence of protocols for seizure management. We found that all of the facilities lacking in-house neurologic services also lacked a protocol for the management of status epilepticus. By contrast, for all other facilities with at least some neurologic services in-house, 26% had a protocol for status epilepticus (P < .01). Education. The survey asked both about education of patients and of emergency department staff. Seizure-related patient or parent education was provided by the treating physician
Figure 1. Emergency departments with protocols (including pediatric-specific protocols) for seizures and status epilepticus.
Table 2. Neurology Consultation Services in the Pediatric Emergency Departments.a Coverage Pediatric neurologist Adult neurologist with pediatric privileges Adult neurologist None Other
Percentage of EDs 22 7 51 28 6
Abbreviation: ED, emergency department. a Consultations are divided into pediatric neurologist (either full-time or limited coverage), adult neurologist with privileges in a pediatric hospital (either fulltime or limited coverages), adult neurology (with no or minimal pediatric consultation services), no coverage or other coverage.
(79%) or patient’s primary nurse (99%) prior to discharge. In 13% of facilities, emergency department staff received pediatric seizure-related education in the previous year.
Medical Record Review For the medical record review component, 707 first unprovoked seizure or status epilepticus cases (ages 1 month through 15 years) were submitted by 92 hospitals. Assessment. In the initial emergency department assessment, neurologic status was assessed and documented in 99% of cases, the medical and seizure history was documented in 98% of the cases, and there was a description of the seizure in 91% of the cases. Laboratory studies were ordered specific to the presenting history in 86% of cases. Most patients (86%) were reassessed before disposition. Management. The emergent management of these patients included airway control and administration of an anticonvulsant,
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if necessary. The medical record review indicated that 12% of patients were having a seizure upon arrival to the emergency department. Of these records, 95% documented that the child’s airway was controlled appropriately., and 90% documented that the patient received an anticonvulsant (82% within 15 minutes of arrival). After the initial assessment and control of seizure activity, a magnetic resonance imaging (MRI) or computed tomography (CT) was performed in 46% of the cases. Disposition. After care in the emergency department was completed, 58% of patients were discharged home, 26% were transferred to another hospital, 10% were admitted to the general pediatric or neurology floor, and 6% were admitted to another service (eg, pediatric intensive care unit, intermediate care, observation unit). Thirty-four percent of patients in small emergency departments were transferred compared to 21% of patients in large facilities (P < .01). Of the children discharged home, 6% were prescribed rectal diazepam and 23% were prescribed oral anticonvulsants. Oral anticonvulsants were more likely to be prescribed in large facilities (27%) than in small facilities (15%) (P < .05). In addition, rectal diazepam was also prescribed more in large facilities (8%) compared to small facilities (1%) (P < .01). For follow-up care, 90% of patients were instructed to see their primary pediatricians, and 56% were instructed to follow-up with a pediatric neurologist. Patients treated in large facilities (63%) were more likely to receive instructions to follow up with neurology than those in small facilities (45%) (P < .01). In addition, patients in the Chicago area were more likely to be referred for follow-up with neurology (64% compared to 46%, P < .01). Education. The record review showed that of the patients discharged home, pediatric seizure patient education was documented as being initiated in the emergency department in 84% of the cases.
Discussion The primary purpose of this project was to assess what practices emergency departments use to assess and treat first unprovoked seizure and status epilepticus. The project was divided into a survey (which evaluated routine practices in these situations) and a medical record review (to evaluate if survey responses correlated with clinical practice). We compared the practices to the existing guidelines; however, we did not evaluate the efficacy of these practices. We found that access to pediatric neurologic consultation services or standardized pediatric seizure protocols were not ubiquitous in the
emergency departments we evaluated. There were several important findings:
Less than half of the responding facilities have a protocol that addressed the clinical management of seizures, and even less had protocols that addressed status epilepticus. In-house pediatric neurologic services were limited. Follow-up care after discharge was predominantly with a primary care physician.
In the context of the low availability of child neurology specialists in the emergency department, these are concerning findings. Decisions about the care of children with unprovoked seizure and status epilepticus made without standardized protocols or consultations may have potentially negative effects on patient outcomes. The strengths of this study were the high response rate (88%) and the large number of cases reviewed (707). We were able to investigate the management practice in a large number of emergency departments across the state of Illinois. Study limitations included the failure to discriminate between severity and length of seizures. Both unprovoked seizures and status epilepticus were combined in the survey and medical record review. However, the American Academy of Neurology practice parameters differ very little between the 2 types of seizures. The largest discrepancy in practice is likely to be patient disposition. In addition, the study did not ask about consultation beyond the emergency department or outcome of patients. These patients may have had delayed neurologic consultations that impacted care. The management of seizures by non-neurologists, such as emergency department physicians and primary care physicians, is common. From our data, we see that many emergency departments, especially smaller hospitals further from the Chicago area, treat seizures without the benefit of seizure protocols or in-house consultations. In addition, many of these patients are advised to follow up with pediatricians, rather than neurologists. The lack of available consultation services illustrates the importance of educating nonspecialists on the management of these conditions. In addition, standardized protocols and phone consultations are important resources for nonneurologists. Future studies may seek to develop or evaluate the effectiveness of these protocols for the clinical management of seizures in the emergency department. Another possible area for future studies is the evaluation of the effectiveness of seizure educational programs for emergency department and primary care pediatricians. Illinois Emergency Medical Services for Children has developed such a module to educate interested physicians on the initial treatment of pediatric seizures.11
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Appendix A Illinois EMSC Pediatric Seizure Emergency Department (ED) Survey Job Title of Survey Respondent(s) Check all that apply
Definitions
Pediatric Quality Coordinator ED Medical Director ED Nurse Manager ED Staff Nurse ED Physician ED Educator Hospital QI/QA Manager Seizure/Neuro Educator Pediatric Neurologist Chief/staff Department of Neurology Chief of Staff Other______________________
Seizure: abnormal paroxysmal neuronal discharge associated with motor, sensory, autonomic, or behavioral alterations. Simple Febrile: seizure accompanied by fever (before, during or after) without CNS infection (i.e., meningitis, encephalitis); duration less than 15 minutes, and without recurrence within the next 24 hours. Unprovoked: seizure that does not require an immediate precipitating event; occurrence suggests possible underlying neurologic disorder that may predispose a child to recurrent seizures. Status Epilepticus: condition in which epileptic activity persists (with prolonged or repeated seizures without intervals of consciousness) causing a wide spectrum of clinical symptoms, and with a highly variable pathophysiological, anatomical, and aetiological basis.
1. How does your emergency department define the pediatric population? Check one answer only 0 through 12 years old
0 through 18 years old
0 through 13 years old
0 through 19 years old
0 through 14 years old
0 through 20 years old
0 through 15 years old
0 through 21 years old
0 through 16 years old
Not defined specifically
0 through 17 years old
Other
2. What is the average volume of pediatric (defined as 0 through 15 years old) ED visits per year in your facility? Check one answer only 0 – 2,000/year
7,001 – 9,000/year
2,001 – 3,000/year
9,001 – 11,000/year
3,001 – 5,000/year
11,001 – 13,000/year
5,001 – 6,000/year
13,001 – 15,000/year
6,001 – 7,000/year
15,001þ/year
3. What is the average volume of ALL patient (adult and pediatric) ED visits per year in your facility? Check one answer only 0 – 4,000/year
40,001 – 50,000/year
4,001 – 10,000/year
50,001 – 60,000/year
10,001 – 20, 000/year
60,001 – 70,000/year
20,001 – 30,000/year
70,001 – 80,000/year
30,001 – 40,000/year
80,001þ/year
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Journal of Child Neurology 4. Does your ED have a documented protocol/policy/guideline/clinical pathway that addresses the clinical management of seizures (e.g., Seizure, Altered Level of Consciousness, Fever)? Yes (answer Q.4a) No (go to Q.5) 4a. Does your ED’s protocol/policy/guideline/clinical pathway specifically address pediatrics? Yes No 5. Does your ED have a documented Status Epilepticus protocol/policy/guideline/clinical pathway? Yes (answer Q.5a) No (go to Q.6) 5a. Does your ED’s Status Epilepticus protocol/policy/guideline/clinical pathway specifically address pediatrics? Yes No 6. What laboratory and radiologic measure(s) does your ED routinely require for the management of Simple Febrile Seizures (SFS)? Check all that apply Laboratory Evaluation
SFS
a. CBC with differential
0
b. Blood cultures
0
c. Blood glucose
0
d. Urinalysis
0
e. Urine culture
0
f. Electrolytes (Ca, Mg, Phos)
0
g. Strep/RSV swab
0
h. BUN and Creatinine
0
i. Lumbar puncture
0
j. Chest x-ray
0
k. Head CT
0
l. EEG
0
m. MRI/MRA
0
n. EKG
0
o. None
0
Other ___________________
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7. What documentation does your ED routinely require for the management of Simple Febrile Seizures? Check all that apply Documentation
SFS
a. Respiratory status
0
b. Cardiovascular status
0
c. Neurologic status
0
d. Signs of infection (OM, UTI, URI, GI, etc.)
0
e. Description of presenting seizure
0
f. Immunization history/status
0
g. Previous seizure activity
0
h. Medication history (include antibiotics)
0
i. Medical/surgical history
0
j. Exposure or ingestion history
0
k. Familial history of seizure
0
l. None
0
Other ___________________
8. For Simple Febrile Seizure patients, what are your ED’s criteria for doing an LP? Check all that apply Based on child’s age (e.g., every child under 12 months) Based on clinical presentation (signs/symptoms of meningitis/bacteremia; child looks ‘‘toxic’’) Based on child’s immunization status (unknown or deficient in H. influenzae and S. pneumoniae immunizations) Based on if child has/has been previously/recently treated with antibiotics Per physician decision (no set criteria) LPs are not done on patients presenting with simple febrile seizures I don’t know Other_______________________ 9. For patients presenting with First Unprovoked/Non-febrile Seizures, what tests are routinely conducted in the ED? Check all that apply Head CT EEG MRI/MRA EKG None Other____________________
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Journal of Child Neurology 10. What laboratory and radiologic measure(s) does your ED routinely require for the management of Status Epilepticus? Check all that apply Laboratory Evaluation
Status Epilepticus
a. CBC with differential
0
b. Blood cultures
0
c. Blood gases
0
d. Blood glucose
0
e. Urinalysis
0
f. Electrolytes (Ca, Mg, Phos)
0
g. Urine drug/tox screen
0
h. BUN and Creatinine
0
i. Antiepileptic drug level (as indicated)
0
j. Urine HCG (age-appropriate)
0
k. Lumbar puncture
0
l. Head CT
0
m. EEG
0
n. MRI/MRA
0
o. EKG
0
p. None
0
Other ___________________
11. What documentation does your ED routinely require for the management of Status Epilepticus? Check all that apply Documentation
Status Epilepticus
a. Respiratory status
0
b. Cardiovascular status
0
c. Neurologic status
0
d. Description of presenting seizure
0
e. Immunization history/status
0
f. Previous seizure activity
0
g. Medication history (include anti-epileptic drug)
0
h. Medical/surgical history
0
i. Exposure or ingestion history
0
j. Familial history of seizure
0
k. Seizure precautions
0
l. None
0
Other ___________________
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12. How frequently is an antiepileptic drug prescribed for a pediatric ED patient presenting in Status Epilepticus (exclude refilling previously ordered medications)? Check all that apply For every patient Less then 50% of the time Less than 25% of the time Per ED Physician decision Per Neurologist decision I don’t know Never Other_____________________ 13. What neurology services does your hospital provide on site? Check all that apply Pediatric Neurologist – at all times (24/7) Pediatric Neurologist – limited coverage Adult Neurologist with pediatric privileges – at all times (24/7) Adult Neurologist with pediatric privileges – limited coverage Adult Neurologist (provides no/minimal pediatric consultation services) – at all times (24/7) Adult Neurologist (provides no/minimal pediatric consultation services) – limited coverage None Other_________________ 14. Typically, who provides the seizure-related patient/parent education prior to discharge from the ED? Check all that apply Treating physician Primary nurse Nurse educator Neurologist Hospitalist No hospital staff Other______________________ 15. What component(s) are included on your ED’s seizure discharge instructions/patient education Simple Febrile Seizure? Check all that apply Education
Simple Febrile
a. Explanation of febrile seizure
0
b. What to do if another seizure occurs
0
c. When to return to ED/call 911
0
d. Provide reassurance (benign nature, doesn’t lead to neuro problems, etc.)
0
e. Fever management
0
f. Review risk of reoccurrence
0
g. Conduct medication reconciliation
0
h. Review seizure precautions
0
i. Primary Care Physician referral
0
j. Neurology referral
0
k. None
0
Other ___________________
16. In the past year, has your ED staff received education related to pediatric seizure disorders? Yes No
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Journal of Child Neurology 17. Does your hospital conduct chart reviews of patients with any type of Seizure diagnoses for QI purposes? Yes (go to Q.17a-b) No 17a. What QI indicators are included in the Seizure chart reviews? Check all that apply QI Indicators a. Prehospital evaluation
0
b. Documentation of laboratory evaluation
0
c. Seizure precautions taken
0
d. Vital signs assessment
0
e. Neurologic status assessment
0
f. Blood glucose assessement
0
g. Supplemental oxygen provided
0
h. History of seizure activity
0
i. History of antiepileptic drug non-compliance
0
j. Neurologic status reassessment
0
k. Blood glucose reassessment
0
l. Neurology consultation (while in ED)
0
m. EEG assessment (while in ED)
0
n. Neurology referral
0
o. EEG outpatient referral
0
p. Patient disposition
0
q. Patient/caregiver discharge instructions/education
0
Other ___________________
0
17b. Is this information reviewed at some type of formal QI committee/process within your organization? Yes No THANK YOU FOR COMPLETING THE SURVEY!
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Appendix B Illinois EMSC Pediatric Unprovoked Seizure/Status Epilepticus in the ED Medical Record Review – Data Dictionary Confidential – for QI purposes only AIM Statement To provide safe and effective care for pediatric patients (1 month 15 years) presenting to the Emergency Department with seizure activity (unprovoked/nonfebrile or status epilepticus) as evidenced by: – Appropriate Assessment – Appropriate Management – Appropriate Disposition & Education REVIEW THE PATIENT’S ENTIRE ED MEDICAL RECORD TO COLLECT THE NECESSARY DATA (i.e., BOTH MD AND RN NOTES) Record Sampling – Review a maximum of 10 patients that meet the inclusion criteria Can include same patient with multiple visits – Timeframe: January 2010 – present. Inclusion Criteria Each patient must meet the following inclusion criteria: 1. Age: 1 month 15 years 2. Presenting Complaint – any child that presents with seizure activity that fits either of the following definitions: Status Epilepticus: condition in which epileptic activity persists (with prolonged or repeated seizures without intervals of consciousness) causing a wide spectrum of clinical symptoms, and with a highly variable pathophysiological, anatomical, and aetiological basis. Unprovoked: seizure that does not require an immediate precipitating event; occurrence suggests possible underlying neurologic disorder that may predispose a child to recurrent seizures. Exclude: Neonatal Seizure, Infantile Spasms, Simple Febrile Seizure **Suggested ICD-9 Codes: & & & & & &
345 to 345.5 – Epilepsy 345.9 – Epilepsy unspecified 780.0 – Alteration of consciousness 780.3 – Convulsions 780.39 – Other convulsions 780.97 – Altered mental status
**Ask your Medical Record and/or Quality Departments for help in identifying appropriate patients** Answer the questions using the following acronyms (unless otherwise directed) Y ¼ Yes N/D ¼ Not Documented/Unknown N ¼ No N/A ¼ Not Applicable Status & Arrival 1. Was the seizure related to a traumatic event? 2. What was the patient’s mode of arrival? Prehospital (P) ¼ transported by EMS from the scene (go to Q.3) Transfer (T) ¼ transported from one acute care facility to another acute care facility (skip to Q.5) Walk- in (W) ¼ brought in by family/caregiver; as a referral from an urgent care center, doctor’s office, etc. (skip to Q.5) 3. Was the child actively seizing at scene upon EMS arrival?
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Journal of Child Neurology 4. What level of prehospital service was used? Choose N/A if child was Transferred or was a Walk-in. BLS (answer Q.4a-e) ALS/ILS (answer Q.4a-f) 4a. All levels: Was the child’s airway controlled appropriately? 4b. All levels: Was the child’s neurologic status assessed? 4c. All levels: Was the child’s blood glucose level checked? 4d. All levels: Was the child and/or family’s seizure history documented (for example: child/family seizure hx, previously treated with anticonvulsant, etc.)? Choose N/A if child had no previous history of seizures 4e. All levels: Was a description of the seizure documented (for example: who witnessed seizure, what did the seizure look like, how long did it last, how was the child acting right before seizure, how was the child acting the day before, etc.)? 4f. ALS/ILS: If child was actively seizing, was an anticonvulsant administered by prehospital provider? Choose N/A if child was not actively seizing OR if parent/caregiver administered anticonvulsant prior to EMS arrival.
Initial ED Assessment 5. Age of child (in months or years) 6. Was the child actively seizing upon arrival to the ED? 7. Was the neurologic status assessed? 8. Was full medical and seizure history documented (for example: child/family seizure hx, antibiotic/antiepileptic medication hx, medications given prior to arrival, immunization status, hx of incontinence, recent hx of trauma, last feeding/meal, underlying health problems, surgical hx, recent ingestion, recent exposure, patient’s baseline status, age-related assessments, bruising, bites, etc.)? 9. Was a description of the seizure documented (for example: who witnessed the seizure, what did the seizure look like, how long did it last, how was the child acting right before seizure, how was the child acting the day before, etc.)? 10. Was a full physical examination performed (for example: vital signs; head to toe; look for bruises, bites, exposure, etc.)? 11. Were labs ordered specific to the presenting history (per hospital guideline such as: CBC, electrolytes, accucheck, blood gases, urine tox screen, antiepileptic drug level, etc.)?
ED Management 12. Was the child’s airway controlled appropriately? 13. Was an IV/IO started? 14. Was a head CT and/or MRI performed while child was in the ED?
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15. If child was actively seizing, was an anticonvulsant administered? Choose N/A if child was not actively seizing 15a. If yes, was it administered within 15 minutes of child’s arrival? 16. Were seizure precautions taken (per policy)? Choose N/A if not required per policy.
Disposition/Discharge 17. Was the child’s neurologic status reassessed before disposition? 18. What was the child’s disposition from the ED? Transferred (T) ¼ transferred to a higher level of care (answer Q.18a) PICU Admission (P) ¼ admitted to PICU/ICU (in same hospital) Intermediate Care Admission (I) ¼ admitted to an intermediate care bed (in same hospital) General Admission (F) ¼ admitted to a general care floor (in same hospital) Observed (O) ¼ admitted to an observation unit/general floor and/or observed in the ED for 23 hours (in same hospital) Home (H) ¼ discharged home after a brief period of observation ( 6 hours) (answer Q.19 - 23) Expired (E) ¼ expired in the ED 18a. If transferred, what level/type of patient transport service was used? Speciality/Transport Team (S) ALS/ILS (A) ALS/ILS (with nurse) (A/n) BLS (B) BLS (with nurse) (B/n) Private vehicle (PV) 19. Was rectal diazepam prescribed in the ED for home use? Choose N/A if already prescribed or if the child was transferred. 20. Was an oral antiepileptic drug (for example: phenobarbital, phenytoin, valproate, etc.) prescribed in the ED for home use? Choose N/A if already prescribed or if the child was transferred. 21. Was pediatric seizure patient education initiated in the ED? Choose N/A if child was transferred. 22. Was the child/family instructed to follow up with a Primary Care Physician? Choose N/A if child was transferred. 23. Was the child/family instructed to follow up with a Neurologist? Choose N/A if child was transferred.
Acknowledgements
Ethical Approval
The authors would like to acknowledge the staff and patients at the facilities participating in the Illinois Emergency Medical Services for Children Quality Improvement program. These data were presented at the Pediatric Academic Society Meeting, Boston, MA, May 1, 2012.
The project was approved by the institutional review board for human subjects at Loyola University Chicago. The IRB Number is 109638080607.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Author Contributions KK, JH, and SF were responsible for the planning of the project and, along with CT and JP, were involved with data analysis. KJ and DL were responsible for the planning of the project and took part in the collection and analysis of the data. EL, program manager of Illinois Emergency Medical Services for Children, was involved with planning of the project. All authors prepared and revised the manuscript.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by EMSC Targeted Issue Grant H34 MC08516,
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Maternal and Child Health Bureau, Health Resources and Services Administration.
References 1. Terndrup T. Clinical issues in the acute childhood seizure management in the emergency department. J Child Neurol. 1998; 13(suppl 1):S7-S10. 2. Lerner EB, Dayan PS, Brown K, Fuchs S, Leonard J. Characteristics of the pediatric patients treated by the pediatric emergency care applied research network’s affiliated EMS agencies. Prehosp Emerg Care. 2014;18:52-59. 3. Pallin D, Goldstein J, Moussally J, Pelletier A, Camargo C. Seizure visits in US emergency departments: epidemiology and potential disparities in care. Int J Emerg Med. 2008;1:97-105. 4. Goldstein J. Status epilepticus in the pediatric emergency department. Clin Pediatr Emerg Med. 2008;9:96-100. 5. Hirtz D, Ashwal S, Berg A, et al. Practice parameter: evaluating a first nonfebrile seizure in children. Report of the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society. Neurology. 2000;55:616-623.
6. Riviello J Jr, Ashwal S, Hirtz D, et al. Practice parameter: diagnostic assessment of the child with status epilepticus (an evidencebased review). Report of the quality standards subcommittee of the American Academy of Neurology and the practice committee of the Child Neurology Society. Neurology. 2006;67:1542-1550. 7. Engel J. Report of the ILAE Classification Core Group. Epilepsia. 2006;47:1558-1568. 8. Blume W, Luders M, Mizrahi E, Tassinari C, Van Emde Boas W, Engel J. Glossary of descriptive terminology for ictal semiology: report of the ILAE task force on classification and terminology. Epilepsia. 2001;42:1212-1218. 9. Maytal J, Krauss J, Novak G, Nagelberg J, Patel M. The role of brain computed tomography in evaluating children with new onset of seizures in the emergency department. Epilepsia. 2000; 41:950-954. 10. Nypaver M, Reynolds S, Tanz R, Davis T. Emergency department laboratory evaluation of children with seizures; Dogma or dilemma? Pediatr Emerg Care. 1992;8:13-16. 11. Illinois Emergency Medical Services for Children. Pediatric Seizures, Second Edition. 2013. Available at: http://www.luhs.org/ depts/emsc/pedseizure_main_web.htm. Accessed August 20, 2014.
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Emergency Department Management of Pediatric Unprovoked Seizures and Status Epilepticus in the State of Illinois
Journal of Child Neurology 1-14 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0883073814566626 jcn.sagepub.com
Connie Taylor, MD1, Juan Piantino, MD1, Joseph Hageman, MD1,2, Evelyn Lyons, RN, MPH3, Kathryn Janies, BA4, Daniel Leonard, MS4, Kent Kelley, MD2, and Susan Fuchs, MD5
Abstract The purpose of this survey and record review was to characterize emergency department management of unprovoked seizures and status epilepticus in children in Illinois. The survey was sent to 119 participating emergency departments in the Emergency Medical Services for Children program; responses were received from 103 (88% response rate). Only 44% of the emergency departments had a documented protocol for seizure management. Only 12% of emergency departments had child neurology consultation available at all times. Record review showed that 58% of patients were discharged home, 26% were transferred to another institution, and 10% were admitted to a non-intensive care unit setting. Ninety percent of patients were treated with anticonvulsants. Seizure education was provided by the primary emergency department nurse (97%) and the treating physician (79%). This project demonstrated strengths and weaknesses in the current management of pediatric seizure patients in Illinois emergency departments. Keywords unprovoked seizure, status epilepticus, seizure protocol Received February 01, 2014. Accepted for publication November 24, 2014.
Children account for more emergency department visits for seizures than any other age group. In the United States, almost 10% of pediatric ambulance calls and 1.5% of pediatric visits to the emergency department are for chief complaints related to seizure.1-3 Annually, as many as 40 000 pediatric patients experience their first nonfebrile seizure. In addition, status epilepticus is an important neurologic emergency encountered in pediatric emergency departments. The status epilepticus incidence in the pediatric population is 17 to 23 per 100 000 children. The number may be as high as 51 per 100 000 in younger children.4 Although guidelines exist for the assessment and management of childhood seizures, information is not routinely gathered from emergency departments regarding their practices. The American Academy of Neurology has published practice parameters for the evaluation of first nonfebrile seizures5 and status epilepticus.6 The American Academy of Neurology uses the term nonfebrile seizure to encompass all seizures in a child aged 1 to 21 years that cannot be explained by another provoking factor such as trauma, fever, or infection. In this study, we use a similar definition, but use the umbrella term unprovoked seizure. However, in our study, status epilepticus was defined as a condition in which epileptic activity persists (with prolonged or repeated seizures without intervals of
consciousness). This definition is similar to that used by the International League Against Epilepsy which does not include seizure duration.7,8 The guidelines for unprovoked seizure and status epilepticus are similar (Table 1). In practice, initial evaluation and treatment of unprovoked seizure and status epilepticus in the emergency department does not consistently follow American Academy of Neurology guidelines. One study found that many emergency departments routinely order CT scans on all patients with new-onset unprovoked seizure.9 Several other studies document that emergency departments frequently order unnecessary laboratory studies 1
Pediatrics, University of Chicago, Chicago, IL, USA Pediatrics, North Shore University Health System, Evanston, IL, USA 3 Illinois Department of Public Health, Chicago, IL, USA 4 Illinois Emergency Medical Services for Children, Loyola University Chicago, Maywood, IL, USA 5 Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA 2
Corresponding Author: Connie Taylor, MD, Pediatrics, University of Chicago, 5841 S. Maryland Avenue MC 3055, Chicago, IL 60637, USA. Email: [email protected]
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Table 1. American Academy of Neurology Practice Parameter Guidelines for First Unprovoked Seizure and Status Epilepticus. First unprovoked seizure Purpose of initial evaluation Lumbar puncture Routine lab studies
Decision to image
Determine if a seizure actually occurred and the etiology of the event (provoked, cryptogenic, remote symptomatic or idiopathic) Based on individual history of physical examination findings Has not been shown to be a sufficient reason for children presenting with first unprovoked seizure who have returned to baseline in the ED Based on history and physical examination
Status epilepticus
Recommendations for lumbar punctures and blood cultures were similar to nonfebrile seizure For status epilepticus, the AAN guideline acknowledges that most EDs will routinely order basic chemistry panels and complete blood counts, so recommendations were not made regarding this practice. For children taking anticonvulsant medication, the guidelines recommend checking the levels (as indicated) Insufficient data for the AAN to recommend routine neuroimaging; however, in situations where it is clinically warranted, it should be performed after the patient is stabilized
Abbreviation: AAN, American Academy of Neurology; ED, emergency department.
for patients presenting with unprovoked seizure.10 The purpose of this study was to investigate the current diagnostic and therapeutic practices for children who present with first unprovoked seizure and status epilepticus to emergency departments participating in the Illinois Emergency Medical Services Quality Improvement program.
Survey The 17-question survey, created by a multidisciplinary team, was distributed to the 119 hospitals in the Illinois Emergency Medical Services for Children Quality Improvement program. The hospitals were asked to respond to the survey regarding their management of pediatric seizures (Appendix A).
Record Review
Methods Illinois Emergency Medical Services for Children is a collaborative program between the Illinois Department of Public Health and Loyola University Chicago aimed at improving pediatric emergency care throughout the state of Illinois. Since 1994, the Illinois Emergency Medical Services for Children Advisory Board and several committees, organizations, and individuals within EMS and pediatric communities have worked to enhance and integrate pediatric education, practice standards, injury prevention, and data initiatives. In 2010 and 2011, there were approximately 190 hospitals with emergency departments of which 119 emergency departments actively participated in the Illinois Emergency Medical Services for Children Quality Improvement program. The Illinois Department of Public Health categorizes hospitals by size and location; by this scheme 12 hospitals were in Chicago, 17 were in suburban Cook County, 19 were in ‘‘collar’’ counties surrounding Cook County, 23 were in urban counties throughout Illinois, and 32 were in rural counties in the remainder of Illinois. Overall, 49% of the hospitals were in the Chicago area and 51% of the hospitals had more than 6000 visits a year. Participating hospitals submitted surveys and medical record reviews regarding patients (age 1 month to 15 years) admitted to the emergency department for first unprovoked seizure or status epilepticus. The survey and record review were completed primarily (51%) by pediatric quality coordinators who are nurses who have at least 2 years of experience in pediatric critical care or emergency medicine. Other individuals who completed the survey included emergency department staff nurse (34%), emergency department educator (18%), emergency department medical director (12%), emergency department physician (9%), hospital quality improvement management (2%), chief of staff (1%), or other (17%). The project was approved by the institutional review board for human subjects at Loyola University Chicago.
The emergency departments were also asked to conduct a retrospective medical record review of up to 10 patients (there was no minimum required number of cases so as to not exclude smaller hospitals) presenting with first unprovoked seizure or status epilepticus. Hospitals were asked to abstract medical records for emergency department visits from January 2010 through April 2011. A data dictionary was provided as was a standard case review form (Appendix B).
Data Analysis For analysis, data were aggregated by size and location of facility. Hospitals were either designated as large facilities (having more than 6000 pediatric emergency department visits per year) or small facilities (having up to 6000 pediatric ED visits per year). Hospitals were also characterized by location into 2 groups. One group consisted of hospitals located in the Chicago metropolitan area, and the second group consisted of those located outside this area. Pearson w2 and Fisher exact tests were used to evaluate differences between these groups for the 105 surveys (P < .05) and 707 record reviews (P < .01). All analyses were performed using IBM SPSS software version 17 (IBM Corporation, Somers, NY).
Results Survey Results For the survey, 105 total responses were received from 119 candidate facilities, for a total response rate of 88%. Assessment. For the initial assessment of patients presenting with status epilepticus, most hospitals required assessment and documentation of neurologic status (96%), medication history (94%), respiratory status (96%), and previous seizure activity
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(92%). Most facilities (84%) noted that they routinely perform an emergent head CT for first unprovoked seizure. Fewer hospitals (71%) routinely performed head CTs in status epilepticus. For status epilepticus, laboratory studies were routinely performed, with the most common being complete blood count with differential (89%), electrolytes (88%), blood glucose (86%), antiepileptic drug level, as indicated (83%), urinalysis (72%), blood urea nitrogen and creatinine (72%), and urine drug screen (61%). Management. In addition to the actual management, the survey assessed the availability of protocols and pediatric neurologists to aid in the management of pediatric seizures. Less than half of responding facilities had a protocol that addressed the clinical management of seizures overall (44%) or clinical management of status epilepticus in particular (19%). Facilities in Chicago metropolitan area were more likely to have status epilepticus protocols (28% compared to 10% in regions in the rest of Illinois, P < .05). These protocols were also more prevalent in larger facilities (26% vs 11%, P < .05). Some protocols were general and were used for both adults and pediatric patients. In the facilities with seizure protocols, 71% of protocols were specifically written for pediatric patients; in protocols that addressed status epilepticus, only 50% were written for pediatric patients (Figure 1). In-house pediatric neurologic services were limited, with 12% of facilities reporting that a pediatric neurologist was available around the clock and 10% reporting that a pediatric neurologist was available, in-house, for limited coverage. Differences were found for emergency departments located in the Chicago area relative to the rest of the state. For Chicago area emergency departments, 20% reported full-time in-house availability, and 18% reported limited availability. For the rest of the state, only 4% reported full-time in-house availability, and 2% reported limited availability (P < .05 for both comparisons). Separately, when comparing by emergency department size, 23% of large emergency departments reported full-time availability compared to none of the small emergency departments (P < .01). There was also more full-time pediatric neurology coverage in the Chicago area (P < .01) Furthermore, 28% of facilities reported no in-house neurology services available (adult or pediatric) with a much higher percentage in this category reported by small facilities (P < .01) and facilities outside of the Chicago area (P < .01) (Table 2). A further analysis of clinical management practices was performed by comparing in-house availability of neurology specialists with the presence of protocols for seizure management. We found that all of the facilities lacking in-house neurologic services also lacked a protocol for the management of status epilepticus. By contrast, for all other facilities with at least some neurologic services in-house, 26% had a protocol for status epilepticus (P < .01). Education. The survey asked both about education of patients and of emergency department staff. Seizure-related patient or parent education was provided by the treating physician
Figure 1. Emergency departments with protocols (including pediatric-specific protocols) for seizures and status epilepticus.
Table 2. Neurology Consultation Services in the Pediatric Emergency Departments.a Coverage Pediatric neurologist Adult neurologist with pediatric privileges Adult neurologist None Other
Percentage of EDs 22 7 51 28 6
Abbreviation: ED, emergency department. a Consultations are divided into pediatric neurologist (either full-time or limited coverage), adult neurologist with privileges in a pediatric hospital (either fulltime or limited coverages), adult neurology (with no or minimal pediatric consultation services), no coverage or other coverage.
(79%) or patient’s primary nurse (99%) prior to discharge. In 13% of facilities, emergency department staff received pediatric seizure-related education in the previous year.
Medical Record Review For the medical record review component, 707 first unprovoked seizure or status epilepticus cases (ages 1 month through 15 years) were submitted by 92 hospitals. Assessment. In the initial emergency department assessment, neurologic status was assessed and documented in 99% of cases, the medical and seizure history was documented in 98% of the cases, and there was a description of the seizure in 91% of the cases. Laboratory studies were ordered specific to the presenting history in 86% of cases. Most patients (86%) were reassessed before disposition. Management. The emergent management of these patients included airway control and administration of an anticonvulsant,
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if necessary. The medical record review indicated that 12% of patients were having a seizure upon arrival to the emergency department. Of these records, 95% documented that the child’s airway was controlled appropriately., and 90% documented that the patient received an anticonvulsant (82% within 15 minutes of arrival). After the initial assessment and control of seizure activity, a magnetic resonance imaging (MRI) or computed tomography (CT) was performed in 46% of the cases. Disposition. After care in the emergency department was completed, 58% of patients were discharged home, 26% were transferred to another hospital, 10% were admitted to the general pediatric or neurology floor, and 6% were admitted to another service (eg, pediatric intensive care unit, intermediate care, observation unit). Thirty-four percent of patients in small emergency departments were transferred compared to 21% of patients in large facilities (P < .01). Of the children discharged home, 6% were prescribed rectal diazepam and 23% were prescribed oral anticonvulsants. Oral anticonvulsants were more likely to be prescribed in large facilities (27%) than in small facilities (15%) (P < .05). In addition, rectal diazepam was also prescribed more in large facilities (8%) compared to small facilities (1%) (P < .01). For follow-up care, 90% of patients were instructed to see their primary pediatricians, and 56% were instructed to follow-up with a pediatric neurologist. Patients treated in large facilities (63%) were more likely to receive instructions to follow up with neurology than those in small facilities (45%) (P < .01). In addition, patients in the Chicago area were more likely to be referred for follow-up with neurology (64% compared to 46%, P < .01). Education. The record review showed that of the patients discharged home, pediatric seizure patient education was documented as being initiated in the emergency department in 84% of the cases.
Discussion The primary purpose of this project was to assess what practices emergency departments use to assess and treat first unprovoked seizure and status epilepticus. The project was divided into a survey (which evaluated routine practices in these situations) and a medical record review (to evaluate if survey responses correlated with clinical practice). We compared the practices to the existing guidelines; however, we did not evaluate the efficacy of these practices. We found that access to pediatric neurologic consultation services or standardized pediatric seizure protocols were not ubiquitous in the
emergency departments we evaluated. There were several important findings:
Less than half of the responding facilities have a protocol that addressed the clinical management of seizures, and even less had protocols that addressed status epilepticus. In-house pediatric neurologic services were limited. Follow-up care after discharge was predominantly with a primary care physician.
In the context of the low availability of child neurology specialists in the emergency department, these are concerning findings. Decisions about the care of children with unprovoked seizure and status epilepticus made without standardized protocols or consultations may have potentially negative effects on patient outcomes. The strengths of this study were the high response rate (88%) and the large number of cases reviewed (707). We were able to investigate the management practice in a large number of emergency departments across the state of Illinois. Study limitations included the failure to discriminate between severity and length of seizures. Both unprovoked seizures and status epilepticus were combined in the survey and medical record review. However, the American Academy of Neurology practice parameters differ very little between the 2 types of seizures. The largest discrepancy in practice is likely to be patient disposition. In addition, the study did not ask about consultation beyond the emergency department or outcome of patients. These patients may have had delayed neurologic consultations that impacted care. The management of seizures by non-neurologists, such as emergency department physicians and primary care physicians, is common. From our data, we see that many emergency departments, especially smaller hospitals further from the Chicago area, treat seizures without the benefit of seizure protocols or in-house consultations. In addition, many of these patients are advised to follow up with pediatricians, rather than neurologists. The lack of available consultation services illustrates the importance of educating nonspecialists on the management of these conditions. In addition, standardized protocols and phone consultations are important resources for nonneurologists. Future studies may seek to develop or evaluate the effectiveness of these protocols for the clinical management of seizures in the emergency department. Another possible area for future studies is the evaluation of the effectiveness of seizure educational programs for emergency department and primary care pediatricians. Illinois Emergency Medical Services for Children has developed such a module to educate interested physicians on the initial treatment of pediatric seizures.11
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Appendix A Illinois EMSC Pediatric Seizure Emergency Department (ED) Survey Job Title of Survey Respondent(s) Check all that apply
Definitions
Pediatric Quality Coordinator ED Medical Director ED Nurse Manager ED Staff Nurse ED Physician ED Educator Hospital QI/QA Manager Seizure/Neuro Educator Pediatric Neurologist Chief/staff Department of Neurology Chief of Staff Other______________________
Seizure: abnormal paroxysmal neuronal discharge associated with motor, sensory, autonomic, or behavioral alterations. Simple Febrile: seizure accompanied by fever (before, during or after) without CNS infection (i.e., meningitis, encephalitis); duration less than 15 minutes, and without recurrence within the next 24 hours. Unprovoked: seizure that does not require an immediate precipitating event; occurrence suggests possible underlying neurologic disorder that may predispose a child to recurrent seizures. Status Epilepticus: condition in which epileptic activity persists (with prolonged or repeated seizures without intervals of consciousness) causing a wide spectrum of clinical symptoms, and with a highly variable pathophysiological, anatomical, and aetiological basis.
1. How does your emergency department define the pediatric population? Check one answer only 0 through 12 years old
0 through 18 years old
0 through 13 years old
0 through 19 years old
0 through 14 years old
0 through 20 years old
0 through 15 years old
0 through 21 years old
0 through 16 years old
Not defined specifically
0 through 17 years old
Other
2. What is the average volume of pediatric (defined as 0 through 15 years old) ED visits per year in your facility? Check one answer only 0 – 2,000/year
7,001 – 9,000/year
2,001 – 3,000/year
9,001 – 11,000/year
3,001 – 5,000/year
11,001 – 13,000/year
5,001 – 6,000/year
13,001 – 15,000/year
6,001 – 7,000/year
15,001þ/year
3. What is the average volume of ALL patient (adult and pediatric) ED visits per year in your facility? Check one answer only 0 – 4,000/year
40,001 – 50,000/year
4,001 – 10,000/year
50,001 – 60,000/year
10,001 – 20, 000/year
60,001 – 70,000/year
20,001 – 30,000/year
70,001 – 80,000/year
30,001 – 40,000/year
80,001þ/year
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Journal of Child Neurology 4. Does your ED have a documented protocol/policy/guideline/clinical pathway that addresses the clinical management of seizures (e.g., Seizure, Altered Level of Consciousness, Fever)? Yes (answer Q.4a) No (go to Q.5) 4a. Does your ED’s protocol/policy/guideline/clinical pathway specifically address pediatrics? Yes No 5. Does your ED have a documented Status Epilepticus protocol/policy/guideline/clinical pathway? Yes (answer Q.5a) No (go to Q.6) 5a. Does your ED’s Status Epilepticus protocol/policy/guideline/clinical pathway specifically address pediatrics? Yes No 6. What laboratory and radiologic measure(s) does your ED routinely require for the management of Simple Febrile Seizures (SFS)? Check all that apply Laboratory Evaluation
SFS
a. CBC with differential
0
b. Blood cultures
0
c. Blood glucose
0
d. Urinalysis
0
e. Urine culture
0
f. Electrolytes (Ca, Mg, Phos)
0
g. Strep/RSV swab
0
h. BUN and Creatinine
0
i. Lumbar puncture
0
j. Chest x-ray
0
k. Head CT
0
l. EEG
0
m. MRI/MRA
0
n. EKG
0
o. None
0
Other ___________________
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7. What documentation does your ED routinely require for the management of Simple Febrile Seizures? Check all that apply Documentation
SFS
a. Respiratory status
0
b. Cardiovascular status
0
c. Neurologic status
0
d. Signs of infection (OM, UTI, URI, GI, etc.)
0
e. Description of presenting seizure
0
f. Immunization history/status
0
g. Previous seizure activity
0
h. Medication history (include antibiotics)
0
i. Medical/surgical history
0
j. Exposure or ingestion history
0
k. Familial history of seizure
0
l. None
0
Other ___________________
8. For Simple Febrile Seizure patients, what are your ED’s criteria for doing an LP? Check all that apply Based on child’s age (e.g., every child under 12 months) Based on clinical presentation (signs/symptoms of meningitis/bacteremia; child looks ‘‘toxic’’) Based on child’s immunization status (unknown or deficient in H. influenzae and S. pneumoniae immunizations) Based on if child has/has been previously/recently treated with antibiotics Per physician decision (no set criteria) LPs are not done on patients presenting with simple febrile seizures I don’t know Other_______________________ 9. For patients presenting with First Unprovoked/Non-febrile Seizures, what tests are routinely conducted in the ED? Check all that apply Head CT EEG MRI/MRA EKG None Other____________________
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Journal of Child Neurology 10. What laboratory and radiologic measure(s) does your ED routinely require for the management of Status Epilepticus? Check all that apply Laboratory Evaluation
Status Epilepticus
a. CBC with differential
0
b. Blood cultures
0
c. Blood gases
0
d. Blood glucose
0
e. Urinalysis
0
f. Electrolytes (Ca, Mg, Phos)
0
g. Urine drug/tox screen
0
h. BUN and Creatinine
0
i. Antiepileptic drug level (as indicated)
0
j. Urine HCG (age-appropriate)
0
k. Lumbar puncture
0
l. Head CT
0
m. EEG
0
n. MRI/MRA
0
o. EKG
0
p. None
0
Other ___________________
11. What documentation does your ED routinely require for the management of Status Epilepticus? Check all that apply Documentation
Status Epilepticus
a. Respiratory status
0
b. Cardiovascular status
0
c. Neurologic status
0
d. Description of presenting seizure
0
e. Immunization history/status
0
f. Previous seizure activity
0
g. Medication history (include anti-epileptic drug)
0
h. Medical/surgical history
0
i. Exposure or ingestion history
0
j. Familial history of seizure
0
k. Seizure precautions
0
l. None
0
Other ___________________
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12. How frequently is an antiepileptic drug prescribed for a pediatric ED patient presenting in Status Epilepticus (exclude refilling previously ordered medications)? Check all that apply For every patient Less then 50% of the time Less than 25% of the time Per ED Physician decision Per Neurologist decision I don’t know Never Other_____________________ 13. What neurology services does your hospital provide on site? Check all that apply Pediatric Neurologist – at all times (24/7) Pediatric Neurologist – limited coverage Adult Neurologist with pediatric privileges – at all times (24/7) Adult Neurologist with pediatric privileges – limited coverage Adult Neurologist (provides no/minimal pediatric consultation services) – at all times (24/7) Adult Neurologist (provides no/minimal pediatric consultation services) – limited coverage None Other_________________ 14. Typically, who provides the seizure-related patient/parent education prior to discharge from the ED? Check all that apply Treating physician Primary nurse Nurse educator Neurologist Hospitalist No hospital staff Other______________________ 15. What component(s) are included on your ED’s seizure discharge instructions/patient education Simple Febrile Seizure? Check all that apply Education
Simple Febrile
a. Explanation of febrile seizure
0
b. What to do if another seizure occurs
0
c. When to return to ED/call 911
0
d. Provide reassurance (benign nature, doesn’t lead to neuro problems, etc.)
0
e. Fever management
0
f. Review risk of reoccurrence
0
g. Conduct medication reconciliation
0
h. Review seizure precautions
0
i. Primary Care Physician referral
0
j. Neurology referral
0
k. None
0
Other ___________________
16. In the past year, has your ED staff received education related to pediatric seizure disorders? Yes No
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Journal of Child Neurology 17. Does your hospital conduct chart reviews of patients with any type of Seizure diagnoses for QI purposes? Yes (go to Q.17a-b) No 17a. What QI indicators are included in the Seizure chart reviews? Check all that apply QI Indicators a. Prehospital evaluation
0
b. Documentation of laboratory evaluation
0
c. Seizure precautions taken
0
d. Vital signs assessment
0
e. Neurologic status assessment
0
f. Blood glucose assessement
0
g. Supplemental oxygen provided
0
h. History of seizure activity
0
i. History of antiepileptic drug non-compliance
0
j. Neurologic status reassessment
0
k. Blood glucose reassessment
0
l. Neurology consultation (while in ED)
0
m. EEG assessment (while in ED)
0
n. Neurology referral
0
o. EEG outpatient referral
0
p. Patient disposition
0
q. Patient/caregiver discharge instructions/education
0
Other ___________________
0
17b. Is this information reviewed at some type of formal QI committee/process within your organization? Yes No THANK YOU FOR COMPLETING THE SURVEY!
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Appendix B Illinois EMSC Pediatric Unprovoked Seizure/Status Epilepticus in the ED Medical Record Review – Data Dictionary Confidential – for QI purposes only AIM Statement To provide safe and effective care for pediatric patients (1 month 15 years) presenting to the Emergency Department with seizure activity (unprovoked/nonfebrile or status epilepticus) as evidenced by: – Appropriate Assessment – Appropriate Management – Appropriate Disposition & Education REVIEW THE PATIENT’S ENTIRE ED MEDICAL RECORD TO COLLECT THE NECESSARY DATA (i.e., BOTH MD AND RN NOTES) Record Sampling – Review a maximum of 10 patients that meet the inclusion criteria Can include same patient with multiple visits – Timeframe: January 2010 – present. Inclusion Criteria Each patient must meet the following inclusion criteria: 1. Age: 1 month 15 years 2. Presenting Complaint – any child that presents with seizure activity that fits either of the following definitions: Status Epilepticus: condition in which epileptic activity persists (with prolonged or repeated seizures without intervals of consciousness) causing a wide spectrum of clinical symptoms, and with a highly variable pathophysiological, anatomical, and aetiological basis. Unprovoked: seizure that does not require an immediate precipitating event; occurrence suggests possible underlying neurologic disorder that may predispose a child to recurrent seizures. Exclude: Neonatal Seizure, Infantile Spasms, Simple Febrile Seizure **Suggested ICD-9 Codes: & & & & & &
345 to 345.5 – Epilepsy 345.9 – Epilepsy unspecified 780.0 – Alteration of consciousness 780.3 – Convulsions 780.39 – Other convulsions 780.97 – Altered mental status
**Ask your Medical Record and/or Quality Departments for help in identifying appropriate patients** Answer the questions using the following acronyms (unless otherwise directed) Y ¼ Yes N/D ¼ Not Documented/Unknown N ¼ No N/A ¼ Not Applicable Status & Arrival 1. Was the seizure related to a traumatic event? 2. What was the patient’s mode of arrival? Prehospital (P) ¼ transported by EMS from the scene (go to Q.3) Transfer (T) ¼ transported from one acute care facility to another acute care facility (skip to Q.5) Walk- in (W) ¼ brought in by family/caregiver; as a referral from an urgent care center, doctor’s office, etc. (skip to Q.5) 3. Was the child actively seizing at scene upon EMS arrival?
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Journal of Child Neurology 4. What level of prehospital service was used? Choose N/A if child was Transferred or was a Walk-in. BLS (answer Q.4a-e) ALS/ILS (answer Q.4a-f) 4a. All levels: Was the child’s airway controlled appropriately? 4b. All levels: Was the child’s neurologic status assessed? 4c. All levels: Was the child’s blood glucose level checked? 4d. All levels: Was the child and/or family’s seizure history documented (for example: child/family seizure hx, previously treated with anticonvulsant, etc.)? Choose N/A if child had no previous history of seizures 4e. All levels: Was a description of the seizure documented (for example: who witnessed seizure, what did the seizure look like, how long did it last, how was the child acting right before seizure, how was the child acting the day before, etc.)? 4f. ALS/ILS: If child was actively seizing, was an anticonvulsant administered by prehospital provider? Choose N/A if child was not actively seizing OR if parent/caregiver administered anticonvulsant prior to EMS arrival.
Initial ED Assessment 5. Age of child (in months or years) 6. Was the child actively seizing upon arrival to the ED? 7. Was the neurologic status assessed? 8. Was full medical and seizure history documented (for example: child/family seizure hx, antibiotic/antiepileptic medication hx, medications given prior to arrival, immunization status, hx of incontinence, recent hx of trauma, last feeding/meal, underlying health problems, surgical hx, recent ingestion, recent exposure, patient’s baseline status, age-related assessments, bruising, bites, etc.)? 9. Was a description of the seizure documented (for example: who witnessed the seizure, what did the seizure look like, how long did it last, how was the child acting right before seizure, how was the child acting the day before, etc.)? 10. Was a full physical examination performed (for example: vital signs; head to toe; look for bruises, bites, exposure, etc.)? 11. Were labs ordered specific to the presenting history (per hospital guideline such as: CBC, electrolytes, accucheck, blood gases, urine tox screen, antiepileptic drug level, etc.)?
ED Management 12. Was the child’s airway controlled appropriately? 13. Was an IV/IO started? 14. Was a head CT and/or MRI performed while child was in the ED?
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15. If child was actively seizing, was an anticonvulsant administered? Choose N/A if child was not actively seizing 15a. If yes, was it administered within 15 minutes of child’s arrival? 16. Were seizure precautions taken (per policy)? Choose N/A if not required per policy.
Disposition/Discharge 17. Was the child’s neurologic status reassessed before disposition? 18. What was the child’s disposition from the ED? Transferred (T) ¼ transferred to a higher level of care (answer Q.18a) PICU Admission (P) ¼ admitted to PICU/ICU (in same hospital) Intermediate Care Admission (I) ¼ admitted to an intermediate care bed (in same hospital) General Admission (F) ¼ admitted to a general care floor (in same hospital) Observed (O) ¼ admitted to an observation unit/general floor and/or observed in the ED for 23 hours (in same hospital) Home (H) ¼ discharged home after a brief period of observation ( 6 hours) (answer Q.19 - 23) Expired (E) ¼ expired in the ED 18a. If transferred, what level/type of patient transport service was used? Speciality/Transport Team (S) ALS/ILS (A) ALS/ILS (with nurse) (A/n) BLS (B) BLS (with nurse) (B/n) Private vehicle (PV) 19. Was rectal diazepam prescribed in the ED for home use? Choose N/A if already prescribed or if the child was transferred. 20. Was an oral antiepileptic drug (for example: phenobarbital, phenytoin, valproate, etc.) prescribed in the ED for home use? Choose N/A if already prescribed or if the child was transferred. 21. Was pediatric seizure patient education initiated in the ED? Choose N/A if child was transferred. 22. Was the child/family instructed to follow up with a Primary Care Physician? Choose N/A if child was transferred. 23. Was the child/family instructed to follow up with a Neurologist? Choose N/A if child was transferred.
Acknowledgements
Ethical Approval
The authors would like to acknowledge the staff and patients at the facilities participating in the Illinois Emergency Medical Services for Children Quality Improvement program. These data were presented at the Pediatric Academic Society Meeting, Boston, MA, May 1, 2012.
The project was approved by the institutional review board for human subjects at Loyola University Chicago. The IRB Number is 109638080607.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Author Contributions KK, JH, and SF were responsible for the planning of the project and, along with CT and JP, were involved with data analysis. KJ and DL were responsible for the planning of the project and took part in the collection and analysis of the data. EL, program manager of Illinois Emergency Medical Services for Children, was involved with planning of the project. All authors prepared and revised the manuscript.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by EMSC Targeted Issue Grant H34 MC08516,
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Journal of Child Neurology
Maternal and Child Health Bureau, Health Resources and Services Administration.
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6. Riviello J Jr, Ashwal S, Hirtz D, et al. Practice parameter: diagnostic assessment of the child with status epilepticus (an evidencebased review). Report of the quality standards subcommittee of the American Academy of Neurology and the practice committee of the Child Neurology Society. Neurology. 2006;67:1542-1550. 7. Engel J. Report of the ILAE Classification Core Group. Epilepsia. 2006;47:1558-1568. 8. Blume W, Luders M, Mizrahi E, Tassinari C, Van Emde Boas W, Engel J. Glossary of descriptive terminology for ictal semiology: report of the ILAE task force on classification and terminology. Epilepsia. 2001;42:1212-1218. 9. Maytal J, Krauss J, Novak G, Nagelberg J, Patel M. The role of brain computed tomography in evaluating children with new onset of seizures in the emergency department. Epilepsia. 2000; 41:950-954. 10. Nypaver M, Reynolds S, Tanz R, Davis T. Emergency department laboratory evaluation of children with seizures; Dogma or dilemma? Pediatr Emerg Care. 1992;8:13-16. 11. Illinois Emergency Medical Services for Children. Pediatric Seizures, Second Edition. 2013. Available at: http://www.luhs.org/ depts/emsc/pedseizure_main_web.htm. Accessed August 20, 2014.
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