PC1010: Decreasing Unnecessary Resource Utilization for Emergency Department Patients with First Time Unprovoked Seizure

Purpose/Objectives: Seizures commonly present to pediatric emergency departments (PED) and account for 1% of visits. Providers must treat life threatening causes while avoiding unnecessary testing for patients with a low likelihood of emergent pathology. While the American Academy of Neurology recommends an electroencephalogram (EEG) as part of the neurodiagnostic evaluation for a first-time seizure, EEG findings in the first 48 hours may be misleading due to post-ictal or medication effects. Therefore, prompt outpatient EEGs provide beneficial diagnostic information while decreasing the use of limited ED resources. The primary aim of this quality improvement (QI) initiative was to decrease the proportion of patients with a first time, unprovoked, afebrile seizure receiving an ED (EEG) by 50% over a 9 month period.

Design/Methods: A multi-disciplinary team of stakeholders including pediatric ED and neurology physicians, nurses, nurse practitioners, and a process engineer created a clinical pathway for children over 6 months old presenting with new onset unprovoked generalized seizures. A process was created to allow scheduling of outpatient EEGs from the ED. Pathway education commenced in 2021. Learnings from multiple PDSA cycles led to the creation of a provider order set and automated in basket message to ensure EEG scheduling for those not scheduled from the ED. The primary outcome measure was the number of patients in between ED EEGs. Secondary outcomes included time from rooming to disposition and patients in between CBC obtainment and in-person neurology consultation. The process measure was the percentage of patients who had an EEG scheduled from the ED. The balancing measures was 30-day ED bounce back rates. Due to the low volume of patients included, outcomes were analyzed via Statistical Process Control G charts for attribute data and X-bar chart for continuous data. Special cause was determined via application of standard rules. Significance for the balancing measure was determined using chi-squared test.

Results: There were 35 patients in the pre-intervention (January 2020-April 2021) and 41 in the post-intervention cohorts (April 2021-February 2022). The average number of patients in between EEGs, CBCs, and in-person neurology consultation has increased from 0.5 to 40 (Figure 1), 0.5 to 2, and 1 to 33, respectively. Room to disposition time decreased from 308 to 203 minutes (Figure 2). 20% of patients had an EEG ordered from the ED. 30 Day ED bounce back rates increased from 0 to 7% (p <.001).

Conclusion/Discussion: By decreasing unnecessary ED resource utilization, ED throughput improved by 105 minutes. While there was a modest increase in 30 day ED bounce back rates, none of the patients returned in status epilepticus or had long lasting neurologic compromise. Future plans include improving the mechanism to schedule outpatient EEGs from the ED and performing a cost analysis of the findings.