Authors :
Presenting Author: Brian Emmert, MD – Perelman School of Medicine at the University of Pennsylvania
Cody Nathan, MD – Northwestern Memorial Hospital
James Gugger, MD, PharmD – Perelman School of Medicine at the University of Pennsylvania
Kathryn Davis, MD – University of Pennsylvania
Laura Stein, MD, MSEd – Perelman School of Medicine at the University of Pennsylvania
Keith Hemmert, MD – Perelman School of Medicine at the University of Pennsylvania
Rationale: Seizures are one of the most common neurological symptoms in patients presenting to an Emergency Department (ED), accounting for nearly 1% of all adult patient visits [Martindale JL, et al. Emerg Med Clin North AM. 2011]. Patients may present with a first seizure of life or a breakthrough seizure in the setting of a known seizure disorder.
There is large practice variation regarding diagnostic workup and management for patients with either first seizure of life or breakthrough seizure presenting to the ED. The American Academy of Neurology guidelines focus on counseling of risk of subsequent seizures in patients with a first seizure of life. Assessment of risk can depend on certain ancillary testing such as head imaging and EEG, although the timing and availability of these studies varies across institutions.
We propose that instituting standardized pathways for the evaluation and management of these patient populations can result in reduced ED length of stay, reduced resource utilization, and expedited outpatient neurologic evaluation.
Methods: We created a pathway for evaluation and management of patients presenting to the ED with a first seizure of life or breakthrough seizure in the setting of a known seizure disorder (Figure 1, 2). The pathways were implemented at a large quaternary care hospital system in Philadelphia, Pennsylvania. Variables of interest included total time in ED, variance of time in ED, proportion of patients admitted, time to outpatient follow up, and difference in resource utilization. Categorical variables were compared using Chi square test and continuous variables were compared using Wilcoxon. Equality of variance between the two cohorts was tested using a Levene test of variance.
Results: Mean time in ED for no pathway was 9.8 hours and with pathway was 6.7 hours. Median time was 5.0 (IQR 2.9-9.4) hours for no pathway and 4.8 (IQR 3.1-7.0) hours for pathway (p=0.34). The difference in mean and median was driven outliers for the no pathway group. Namely, the 90
th percentile for no pathway was 24.4 hours and 11.7 hours with pathway use (p< 0.001).
Significantly fewer patients were admitted or observed compared to discharged with pathway use (p=0.02). Median time to outpatient follow-up decreased from 41 (IQR 17-93) days to 23.5 (IQR 8-57) days. Median time to follow up for first time seizure was 24 (IQR 9-62) days, and breakthrough seizure 16 (IQR 7-57) days (p=0.1). Significantly more urinalyses (p< 0.0001), urine drug screens (p< 0.0001), alcohol levels (p< 0.0001) and CT scans for first seizures (p< 0.0001) were ordered. Significantly fewer MRIs were ordered for patients with breakthrough seizures utilizing the pathway (< 0.0001). There was no significant difference between readmission rates with pathway use, but readmission rates were overall low
Conclusions: Standardized pathways to approach first seizure of life and breakthrough seizures in the ED can improve efficiency, reduce variability in care, reduce ED length of stay and admissions/observations, improve access and time to outpatient neurologic care, improve appropriate utilization of testing, and, by extension, reduce healthcare costs associated with seizure care.
Funding: None