Authors :
Presenting Author: Gabrielle Brown-Mitchell, MS – Division of Neurology, Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH
Tobias Loddenkemper, MD – Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA
Lindsey Morgan, MD – Seattle Childrens Hospital
Brian Appavu, MD – Barrow Neurological Institute at Phoenix Children's Hospital
Raquel Farias-Moeller, MD – Medical College Wisconsin
Dana Harrar, MD, PhD – Center for Neuroscience and Behavioral Health, Children's National Hospital, George Washington University
Craig Press, MD, PhD, FCNS – Children's Hospital of Philadelphia
Nicholas Abend, MD – Children's Hospital of Philadelphia and University of Pennsylvania
William Gaillard, MD – Children's National Hospital
Shasha Bai, PhD – Emory University School of Medicine
Mariah Eisner, MS – Biostatistics Resource at Nationwide Children’s Hospital, Columbus, OH
Lauren McHenry, MHA – Nationwide Children's Hospital and The Ohio State University
Emily Kroshus, ScD, MPH – Department of Pediatrics, University of Washington
Kathryn Vannatta, PhD – Nationwide Children's Hospital and The Ohio State University
Howard Goodkin, MD, PhD – University of Virginia
Adam Ostendorf, MD – Division of Neurology, Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University College of Medicine, Columbus, OH
Rationale:
Treatment for status epilepticus (SE), or life-threatening prolonged seizures, is more effective when benzodiazepines (BZD) are given rapidly. The QuiTT-SE multicenter, randomized, stepped-wedge clinical trial is an ongoing effectiveness-implementation hybrid study aimed at improving time to SE treatment with BZD1. Here, we describe the characteristics of the QuiTT-SE baseline cohort and test the hypothesis that SE episodes treated more rapidly will have different characteristics compared to those treated late. Methods:
Data from 371 episodes of SE treated with a BZD in the inpatient, non-ICU setting were included from 207 individual patients across 8 centers in this continuous cohort study per the QuiTT-SE protocol.1 Patient and SE episode features were summarized with frequency (percentage) for categorical variables and median (interquartile range [IQR]) for continuous variables. To test our hypothesis, we utilized a multivariable negative binomial mixed effects model with random intercepts to estimate the incidence rate ratios for variables of interest for time to BZD treatment. Results:
The median patient age was 7 years (3-12), with nearly half of patients having an admission PCPC score of 4. The median length of stay was 9 days (5-21). Non-elective ICU transfers occurred with 26% of SE episodes, including 13% within 6 hours of the SE episode. Floor nurses made the initial decision to treat in 49% of SE episodes. The route of BZD was IV (63%), IN (29%) or other (e.g. oral, rectal, etc.; 7.5%), and 47% were treated with lorazepam (LZP) while 43% received midazolam (MDZ).
The median time from seizure to BZD treatment was 6 minutes (4-10). On multivariable testing, time to BZD was faster when the floor nurse decided to treat, the patient had received rescue medication within the last 24 hours, or with certain types of elective admissions (Table 1). Seizures were shorter when time to BZD was faster (Figure 1). Seizures were shorter when treated with IN MDZ (median 8 min, 6-15) compared to IV LZP (10 min (7-17) (p=0.04). Patients were less likely to be transferred to the ICU if they received IN midazolam (OR 0.3, p=0.007).
Conclusions:
Time to BZD was delayed in one quarter of all SE episodes treated across 8 centers during the baseline period, and nearly one eighth resulted in transfer to the ICU within 6 hours. Time to BZD was faster when t the front-line nurse made the decision to treat or if the patient had previously received rescue BZD. SE treated with IN MDZ was less likely to result in transfer to ICU care compared to IV LZP. These baseline data suggest drivers of delayed SE treatment may be addressed using the QuiTT-SE bundle, the study of which is currently ongoing. Funding:
This study was funded by NINDS (R01NS133037-01).