A Quality Improvement Initiative to Reduce Underdosing of Rectal Diazepam as Home Seizure Rescue Medication After Hospitalization

Seizure rescue medications are commonly prescribed to patients with epilepsy to treat and prevent clusters of seizures or status epilepticus. Underdosing of rescue medications decreases their efficacy, which may lead to status epilepticus and potentially avoidable emergency department (ED) visits or hospitalizations. In this quality improvement initiative, we aimed to reduce the rate of underdosed rectal diazepam prescriptions for children discharged from the inpatient neurology service at our institution from a baseline of 6% to 3% by July 2023. The primary intervention was an order panel in the electronic health record that automated selection of correct dosing for age-based and weight-based seizure rescue medications including rectal diazepam, intranasal diazepam, and intranasal midazolam. A statistical process control p-chart was used to analyze our primary outcome measure, the monthly rate of underdosed rectal diazepam prescriptions for patients discharged from the inpatient neurology service. The process measure was use of the new order panel. Balancing measures included the dispense rate, cost for seizure rescue medications, and provider satisfaction. During the baseline period, July 2020-August 2022, rectal diazepam was underdosed for 6% of patients discharged from the neurology service. After intervention, we achieved and sustained 0% underdosing of rectal diazepam. We observed no concerning changes in the dispense rate for the medications, the average copay cost remained low, and surveys of ordering providers showed overall high rates of satisfaction. By spreading the intervention, we reduced underdosing from 21% to 0.6% in the ED and from 12% to 4% across the health care system. An order panel that automated selection of correct dosing effectively and sustainably reduced underdosing of seizure rescue medications and is transferrable across care settings. We expect that proper dosing of seizure rescue medications should reduce the occurrence of status epilepticus and associated complications.