Optimizing the timeliness of treatment for patients with status epilepticus – almost ready for protocol implementation

Mauricio F. Villamar, MD

Fellow in Epilepsy at BWH

PGY 5 

March 20, 2019

Shortly after starting my epilepsy fellowship at Brigham and Women’s Hospital, I was privileged to receive a grant from the Partners Center of Expertise in Medical Education. Thanks to their valuable support, we are working to implement a protocol that aims to optimize the inpatient management of status epilepticus.

Status epilepticus is a neurological emergency. Studies have found that delays in the treatment of status epilepticus are associated with increased in-hospital mortality and morbidity. This includes longer duration of convulsive seizures, increased need for continuous infusions, delayed return of consciousness, and poorer functional outcomes. More rapid seizure control has the potential of decreasing these adverse outcomes.

Despite the importance of timely management of status epilepticus, treatment delays occur commonly in clinical practice due to several factors that may vary between institutions. During my neurology residency at the University of Kentucky, we tried to address some of these delays by implementing an alert protocol for inpatient management of status epilepticus. Briefly, this is an alert system that resembles the one used for patients with acute stroke, and it involves the collaborative work of the neurology, pharmacy, and rapid response teams. Its use led to earlier administration of antiseizure medications compared to usual care. When I came to BWH, my goal was to refine the protocol and to adapt it to the specific needs of our hospital.

Being a newcomer, I think that the biggest challenge so far was to understand the practical and logistical differences between BWH and my previous hospital, and to identify BWH’s specific needs when implementing a system of this kind. The support that I have received from Dr. Jong Woo Lee, Director of the Critical Care EEG Monitoring Program at BWH, has been essential in this regard. Jack Donleavy, Neurology Operations Coordinator, is also leading the project and has provided critical logistical and administrative advice. Numerous other physicians, nurses, and pharmacists have shown their interest in the project and provided valuable feedback to optimize the protocol.

After several meetings with members of the BWH Epilepsy and Neurocritical Care Divisions, with the Neurology Quality Assurance Committee, and with Pharmacy Services, we have developed a protocol that we think fits our specific needs. It shares some similarities with the acute stroke protocol that is already being used at BWH. In the coming days we will present the status epilepticus alert protocol to the Patient Safety and Risk Management team, after which it will be ready for implementation.

Finally, we are developing methods to facilitate collection of pertinent clinical data from our electronic medical record to objectively measure the impact of the status epilepticus alert system. We have identified Research Patient Data Registry (RPDR) as a tool to obtain historical data and to assess the variables that need to be collected. We explored the Enterprise Data Warehouse (EDW) system but were unsuccessful in engaging the necessary resources. 

After working to implement protocols of this kind at two different institutions, I have learned that the most important factors determining their success are how well they adapt to the local needs, and the team’s ability to establish an interdisciplinary collaboration. I am grateful for the support I have received from the Partners Center of Expertise in Medical Education and look forward to implementing the protocol soon.