Abstracts

Rationale: Status epilepticus (SE) is a life-threatening condition. There is limited treatment data in children, gathered from small studies or extrapolation from adult data. Seattle Children’s Hospital (SCH) has used Clinical Standard Work (CSW) to create pathways outlining management and treatment of specific populations or diagnoses.  The primary goal was to use CSW to develop a standardized pathway for management of pediatric status epilepticus in pediatric intensive care units, based on best-available data, which could be disseminated to multiple acute care settings, in order to reduce the duration of SE and the incidence of refractory SE. Methods: A multidisciplinary team led by an epileptologist and an intensivist was established. The team identified four primary objectives impacting time in SE: timely medication choice and delivery, timely recognition of subclinical seizures, improvement in communication and provider confidence, and reliable data for quality improvement metrics (Figure 1).  A literature search was performed, and the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) methodology was applied to link available evidence to clinical recommendations. 294 unique references were identified; 56 were included in pathway development.  Expert opinion of the multidisciplinary team was utilized when the GRADE methodology was insufficient to support necessary clinical recommendations. Results: The CSW for management of pediatric SE was completed and disseminated in May 2017 (Figure 2). Literature review provided support for the use of second line agents outside the current institutional standard (fosphenytoin and phenobarbital). Requesting medications earlier, increasing intravenous pump delivery rates, and adjusting drug concentrations to reduce volume were the interventions identified to reduce medication administration time. EEG monitoring was integrated after administration of the second line medication. Standardization of 2nd and 3rd line medication doses and titration schedules were defined to improve communication and provider confidence.  To evaluate CSW use and associated outcomes, monitored metrics will include time to anti-epileptic administration, time to EEG, adverse events (respiratory and pressor support), length of stay, and readmission rate. Conclusions: Variable practice in our institution led to gaps in optimal treatment of SE and RSE, providing the foundation for the development of this pathway. In addition to implementation at our institution, the standardized protocol was published online for use by regional facilities, to support referring regional pediatric and non-pediatric institutional providers in managing this life-threatening condition. A provider questionnaire assessing practices prior to, and after, implementation of this CSW is underway, and patient outcome data will be assessed once the pathway has been active for 1 year. Funding: None