Reducing Time to Seizure Treatment in a Pediatric Intensive Care Unit Through Quality Improvement Methodology

BACKGROUND AND OBJECTIVES: Delays in administration of antiseizure medications (ASMs) are common and may be associated with increased morbidity and mortality, as well as adverse long-term neurologic outcomes. There are multiple barriers to adequate and timely dosing of ASMs. Quality improvement methodology was used to determine key drivers of delayed administration of rescue medication in the pediatric intensive care unit (PICU) at Texas Children's Hospital. Targeted interventions were implemented with the goal of reducing the median time to first-line ASM administration for patients meeting rescue treatment (RT) criteria in the PICU by at least 25% within 1 year. METHODS: Time from seizure onset to initial ASM was tracked for patients on continuous EEG (cEEG) who met RT criteria in the Texas Children's Hospital PICU. Baseline data were collected from 23 patients, which demonstrated a median treatment time of 57 minutes. For patients in status epilepticus (SE), the baseline median treatment time was 55 minutes. A key driver diagram was used to determine contributors to delayed ASM administration, including but not limited to challenges with seizure identification, weaknesses in communication, anticipatory RT plans, and staff education, among others. Four Plan-Do-Study-Act (PDSA) cycles were executed with the goal of streamlining our cEEG workflow as well as optimizing medication administration. RESULTS: After our first PDSA cycle, the median time to rescue ASM decreased by 26.3%, meeting our primary aim. At the end of the fourth PDSA cycle, we observed a 40.4% reduction in median treatment time, down to 34 minutes. For patients in SE, treatment time was reduced by 45.5%, down to 30 minutes. Furthermore, the percentage of patients meeting criteria for SE decreased from a baseline of 47.8% down to 35%. DISCUSSION: Reduction in median time to treatment was seen after a change to our cEEG workflow and implementation of an order set mandating ASM orders on initiation of cEEG. A decrease in the percentage of patients meeting criteria for SE suggests that these interventions had a clinically meaningful outcome. Given the ubiquitous nature of this issue, adopting similar changes at other institutions may allow more timely delivery of ASM to critically ill patients.