Association Between Treatment Guidelines Adherence Pre-transfer and Patient Disposition in Children Transported for Status Epilepticus

Purpose/Objectives: Seizures accounted for more than 69,000 pediatric hospital admissions in 2012, with status epilepticus (SE) being the most common neurologic emergency. Previous work has found that adherence to first-line antiepileptic medications was suboptimal. The American Epilepsy Society (AES) released guidelines for management of status epilepticus in 2016. We sought to determine whether adherence to treatment guidelines pre-transfer was associated with decreased hospitalizations and lower rates of ICU admission among children transported for SE to a tertiary care pediatric center.

Design/Methods: We conducted a retrospective chart review of patients 1 month through 18 years of age transferred to the Johns Hopkins Children’s Center for management of SE between 2017-2019. We reviewed order and route of administration of antiepileptic medications, calculated whether doses were appropriately weight-based, and recorded total number of doses of benzodiazepines. We assessed whether patients with SE were treated according to AES 2016 guidelines pre-transfer and calculated descriptive statistics. We tested for statistical significance using the chi-square test for categorical variables and the Mann-Whitney test for continuous variables.

Results: Of 312 patients transferred from 44 different institutions, 69 (22.1%) were guideline compliant, 217 (69.6%) were non-guideline compliant, and 26 (8.3%) had insufficient data to determine guideline compliance. Most patients received antiepileptic therapy (280/312, 89.7%), with the most common medications administered being benzodiazepines; followed by levetiracetam and fosphenytoin. Non-compliance was mostly due to receiving incorrect doses of antiepileptics (319/587, 54.3%) or receiving more than two doses of benzodiazepines (82/274, 29.9%). More than half of benzodiazepines with available dosing information (227/422, 53.8%), nearly three-fourths of levetiracetam doses (71/95, 74.7%), and over a quarter of fosphenytoin doses (17/61, 27.9%) were underdosed. Patient demographics and medical histories were not different between compliant vs. non-compliant groups.

Compared to the compliant group, patients in the non-compliant group were significantly more likely to require ICU admission (47.9% vs. 29%), and less likely to be discharged home from the ED (16.6% vs. 31.9%; chi-square p=0.03). Patients in the non-compliant group had longer overall median length of stays (32.2 hours [19.5-60.2] vs. 21.7 hours [6.6-56.1]), though shorter ICU admissions (32.5 hours [19.5-60.2] vs. 38.1 hours [28.5-66.9]) in comparison to the guideline compliant group (p=0.01 for both). Rates of intubation were not significantly different between groups (55/217, 25.3% in the non-compliant group vs. 11/69, 15.9% in the compliant group; p=0.25).

Conclusion/Discussion: Most children with SE transported from referring institutions to our tertiary center were not treated according to guidelines pre-transfer. Non-compliance with guidelines was associated with longer hospitalizations and increased ICU admissions. Children treated according to guidelines were more likely to be discharged home from our ED. Our future efforts will focus on development, implementation, and testing of quality improvement interventions to increase adherence to SE treatment guidelines at front-line community hospitals.