Authors :
Presenting Author: Rae Leonor Gumayan, MD, MPH – Children's National Medical Center
Nancy Auer, FNP – Department of Pediatrics, Division of Neurology – Nationwide Children’s Hospital; Shawn Aylward, MD – Department of Pediatrics, Division of Neurology – Nationwide Children’s Hospital; William Parker, MHA, CPHQ – The Center for Clinical Excellence – Nationwide Children’s Hospital; Dara Albert, DO, Med – Department of Pediatrics, Division of Neurology – Nationwide Children’s Hospital; Anup Patel, MD – Department of Pediatrics, Division of Neurology – Nationwide Children’s Hospital
Rationale:
Pediatric epilepsy requires a multifaceted approach involving medical management, caregiver education, and navigation of complex healthcare systems. The disease also involves intermittent exacerbations that require acute interventions. Written seizure action plans (SAPs) have been used as an educational tool to empower caregivers regarding their child’s diagnosis and plan during a seizure emergency. The importance of SAPs for families have become more ubiquitous as advocated by expert opinions on developing a standardized format.
A quality improvement (QI) team implemented an SAP within a pediatric Epilepsy Center with the aim to increase implementation of a seizure action plan in patients with epilepsy, initially amongst epilepsy providers and then expanded to all neurology providers.
Methods:
A multidisciplinary team assessed barriers to improve the uptake of the institution’s standard SAP. This project had two primary aims: (1) increase the percentage of Epilepsy Center patients with seizures who are prescribed with rescue medications and receive an SAP from a baseline of 39% (taken on January-June 2016) to 85% by December 2019 and with follow-up analysis to sustain goal for six months, (2) increase the percent of patients with seizures, who are prescribed with seizure rescue medications and receive an SAP from a general neurology provider from a baseline of 43% (taken from January through June 2018) to 85% by December 2020 and with follow-up analysis to sustain the goal for six months.
Key drivers were developed after identifying the system opportunities from a current state process map. Interventions for each key driver were carried out in iterative Plan-Do-Study-Act (PDSA) cycles over a four year period (2017 through 2020) with monthly meetings to address hurdles as well as progress updates using control charts. The team focused on tracking patients who received SAPs and identified opportunities including multiple levels of redundancy, optimizing reminders within the electronic medical record, standardizing clinic processes, and enhancing the SAP based on user feedback. We surveyed emergency room (ER) utilization of patients with epilepsy during the same time frame of these interventions.
Results:
The SAP utilization rate amongst epilepsy providers increased from a baseline of 39% to 78% by December 2019 and reached the goal of 85% by June 2020, with further increase and maintained at 92% (p < 0.001) by December 2022. The SAP utilization rate amongst general neurology providers increased from 43% in 2018 to 85% by July 2020 (p < 0.001), and further increased to 93% (p < 0.001) and maintained by December 2022. Inversely, ER visits of established patients with epilepsy decreased from a baseline of 12 per 1000 to 7.5 per 1000.