Sudden Neurologic Deterioration - Improving Recognition of Neurologic Emergencies

Purpose/Objectives: Pediatric patients rarely present to the Emergency Department with signs and symptoms of neurologic compromise. The differential diagnosis broadly includes stroke, inflammatory processes, and intracranial mass or hemorrhage which are time sensitive and may be devastating without efficient intervention. Early recognition and treatment of neurological emergencies improves outcomes. Stroke is the most common cause in adults, thus adult hospital systems utilize “stroke alerts” to facilitate early intervention. However, stroke is less common in children, and their acute neurologic comprise often results from other sources. We aimed to decrease the time to diagnosis of sudden neurologic deterioration (SND) to facilitate prompt evaluation, consultation, and treatment in the pediatric emergency department.

Design/Methods: Using a multidisciplinary team, we implemented sequential plan-do-study-act cycles in the Emergency Department (ED) at our quaternary children’s hospital to reduce the time from patient arrival to completed neuroimaging. We defined SND as any patient presenting with acute neurologic signs and symptoms without a known cause. Exclusion criteria included trauma, diabetic ketoacidosis and known ingestion or neurologic process. Neuroimaging completed was defined as results available in the electronic health record. Interventions included a nurse and physician education program, a triage nurse neurologic assessment, a “Neuro Huddle” for provider assessment, a two-tiered alert system with order-sets, and a note template.

Results: During our baseline period, time from patient arrival to neuroimaging finalized was on average 211 minutes. We decreased this time interval, our outcome measure, to 149 minutes resulting in a center line shift. Our process measure was time from ED arrival to MRI order placement. We also noticed a center line shift in this time interval with a decrease from a baseline of 124 minutes to 94 minutes. For a balancing measure, we monitored for any changes in the outcome measure for patients triggering for sepsis evaluation – who have a similar alert system. The time from arrival to initiation of antibiotics in this patient population improved during the implementation of our SND project.

Conclusion/Discussion: The SND quality improvement project successfully decreased the time from arrival to the ED to completed imaging for patients presenting with new neurologic symptoms. This is the first step leading to treatment of the underlying illness. A cohesive team, a two-tiered alert system and leveraging our electronic health record system contributed most to our improvement. The interventions implemented at our facility are feasible to be adopted by other institutions. Our next step is to transition this work to inpatient units.