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Hosp Pediatr. 2021 Apr; 11(4): 389–395.
PMCID: PMC8006203
PMID: 33685859
Sara Pavitt, MD,
Alison Carley, BSN, RN-BC, Brenda Porter, MD, PhD, and Juliet K. Knowles, MD, PhD
Author information Copyright and License information PMC Disclaimer
Abstract
BACKGROUND:
Studies of seizure management in the pediatric inpatient setting are needed. Seizures recorded by video EEG provide an opportunity to quantitatively evaluate acute management. We observed variation in delivery of standardized seizure safety measures (seizure first aid) during epilepsy monitoring unit admissions at our hospital. Our goals were to increase consistency and speed of seizure first aid and neurologic assessment in acutely seizing patients.
METHODS:
Using a root cause analysis, we identified major factors contributing to variation in seizure management and key drivers for improvement. Targeted interventions, centered around a protocol for acute seizure management, were implemented through quality improvement methodology. The primary outcome was correct performance of standardized seizure first aid and neurologic assessment. Secondary outcomes were time intervals to each assessment. Run charts were used to analyze primary outcomes, and statistical control charts were used for secondary outcomes. Nursing confidence in seizure management was determined through pre- and postsurveys and analyzed with the χ2 test.
RESULTS:
Thirteen seizures were evaluated in the preintervention phase and 10 in the postintervention phase. Completed components of seizure first aid increased from a median of 3 of 4 to 4 of 4; completed components of neurologic assessment increased from a median of 2 of 4 to 4 of 4. Responses to acute seizures were faster, and nursing confidence increased.
CONCLUSIONS:
A collaborative quality improvement effort between physicians and nurses led to prompt and correct delivery of seizure first aid by first responders. These relatively simple interventions could be adapted broadly to improve acute seizure management in the pediatric inpatient setting.
Seizures are a frequent cause of pediatric hospitalization.1–4 In such cases, patient safety relies on prompt management, including standardized and widely accepted maneuvers collectively referred to here as “seizure first aid.”5,6 This includes turning the patient to the lateral supine position, and in the inpatient setting, obtaining vital signs and providing support measures such as supplemental oxygen. In addition to seizure first aid, a brief neurologic examination can aid in clinical evaluation and, when relevant, seizure localization. A critical factor in patient safety is therefore the ability of first responders, particularly bedside nursing staff, to manage acute seizures. The importance of acute seizure management protocols for patient safety is underscored by their requirement in epilepsy specialty centers; previous work indicates that training of nursing staff may improve acute seizure management.7,8
Phase 1 epilepsy studies, commonly performed at pediatric medical centers with epilepsy surgery programs, provide a unique opportunity to quantitatively assess inpatient management of acute seizures and the impact of targeted interventions. These involve admitting a pediatric epilepsy patient to an inpatient epilepsy monitoring unit (EMU) for long-term video EEG (vEEG) monitoring for surgical planning.9,10 The goal of phase 1 admissions is to capture seizures on EEG and video simultaneously to determine the location of seizure onset. During such admissions, it is typical for multiple provoking measures to be employed, including cessation of antiseizure medications. Serious adverse events can occur, with status epilepticus occurring in as many as 79% of EMUs,11 and rarely even deaths occur.12 Therefore, it is imperative that patients experiencing a seizure during phase 1 admissions receive prompt bedside care with adequate safety measures. Moreover, interventions that improve seizure management in the EMU may be applicable to the wider pediatric inpatient setting.
We observed variation in practice of bedside nursing providers in acute seizure management, which could negatively impact patient safety. We conducted a quality improvement project to improve acute seizure management. Our SMART (specific, measurable, attainable, relevant, and time-bound) aim was to increase completed components of seizure first aid from a median of 3 to 4 (of 4 total components) and neurologic assessment from a median of 2 to 3 (of 4 total components) in patients admitted to the EMU for phase 1 monitoring within 6 months. Our secondary aims were faster administration of both seizure first aid and focused neurologic assessment.
Methods
Context
We conducted this study at a large (364-bed) West Coast quaternary care children’s hospital with an active epilepsy program consisting of 9 pediatric epileptologists, a nurse practitioner, and a pediatric epilepsy fellow. Within our institution, there is a dedicated EMU that admitted ∼40 phase 1 studies in 2018. Patients are cared for by our inpatient neurology team, nursing staff, and EEG technologists. On admission, vEEG is initiated by EEG technologists. A family member is required to stay at the bedside to monitor for seizure activity and is instructed to push a nursing notification button when a seizure occurs. This prompts nursing staff to assess the patient at the bedside.
Planning Interventions
The improvement team was composed of a pediatric neurology resident, 2 epileptologists, and the neuroscience nursing team, consisting of nurses who are responsible for care of patients with neurologic conditions at our institution. We engaged key stakeholders including neuroscience nursing leadership, the pediatric epilepsy physician team, EEG technologists, and pediatric neurology attending physicians and residents.
Lean methodology was used to perform this quality improvement project.13 An A3 report (a living, collaborative document outlining the problem, current state, root cause analysis, aims, plan with identified countermeasures, and results) was created to design and track the project.14 The current state analysis of bedside care for actively seizing patients was determined through manual review of phase 1 vEEG recordings as well as Gemba discussions and process observations15 with nursing staff, patients, and families. This revealed large variation in bedside seizure care (see Results section). Incorporating information from video review and Gemba, an Ishikawa diagram was developed to identify factors contributing to this variation (Supplemental Fig 5),16 Nearly all contributory factors fell into 2 categories: factors resulting from lack of knowledge or adherence to a protocol or incomplete communication between physicians and nursing staff. The Ishikawa diagram and a 5 whys exercise subsequently informed a key driver diagram to identify the specific areas for targeted improvement (Fig 1).16
FIGURE 1
Key driver diagram identifying primary drivers to achieve the specific, measurable, attainable, relevant, and time-bound (SMART) aim and interventions to test (secondary drivers). MD, medical doctor; RN, registered nurse.
Specifically, our key driver diagram led us to theorize that a protocol standardizing bedside care for actively seizing EMU patients would improve seizure management. Our current state analysis determined that seizure first aid was not consistently delivered because (1) an existing seizure management protocol at our hospital was not routinely used by nursing staff, (2) nursing staff were unaware of the protocol and its location, and (3) they received no specific training on delivering this protocol effectively at the bedside. Therefore, we updated our previous protocol to create a new standardized protocol (Fig 2) for acute bedside seizure management, which included seizure first aid measures and neurologic assessment. The updated protocol was based on current guidelines from the National Association of Epilepsy Centers17,18 and iterative input from pediatric epileptologists and neuroscience nursing.
FIGURE 2
Standardized acute seizure management protocol that was implemented during this quality improvement study. BP, blood pressure; EMR, electronic medical record; MD, medical doctor; o2, oxygen; Spo2, pulse oxygen saturation.
To address the identified gaps in team communication, individualized seizure action plans were created jointly by physicians and nurses for each patient on admission to the EMU. This included seizure semiology, frequency of seizures, planned medication weans, and rescue medications along with contact information for the physician caring for the patient.
Improvement Activities
Our interventions were completed as a bundle from August to October 2018. To familiarize staff with the standardized protocol, in late August 2018, we delivered a 30-minute didactic session reviewing the standardized acute seizure management protocol, which was delivered to all nursing staff who work in the EMU and made available online for later viewing. In September 2018, a multimedia campaign included fliers, newsletters, and e-mails to allow for widespread dissemination to all providers caring for patients in the EMU. A hard copy of the protocol was placed in a centralized location in the EMU with other unit guidelines and attached to each EEG machine, so it would be in the hospital room of all phase 1 study patients. After admission, the nurse assigned to the patient would meet with the admitting provider to fill out the patient’s individualized seizure action plan.
After broad dissemination and teaching of the acute seizure management protocol and seizure action plan template, these were incorporated into standard work by review on daily nursing huddle in October 2018.
Study of Interventions
Measures
Outcome Measures
We defined our primary outcome measures as the number of completed components (of 4 total) of seizure first aid and number of completed components (of 4 total) of a brief neurologic examination. The 4 scored components of seizure first aid were (1) turning patient to the lateral supine position and complete assessment of vital signs: (2) heart rate, (3) oxygen saturation, and (4) blood pressure. The 4 scored components of the neurologic examination were defined as assessing (1) level of consciousness; (2) mental status (state name, follow simple command, name object); (3) brief cranial nerve assessment with eye movement evaluation; and (4) motor function.
Our secondary outcomes were the time to seizure first aid and neurologic examination, defined as the interval between nursing notification button activation and the start of the first component of seizure first aid and neurologic assessment by the nurse. Seizures in which first aid or neurologic examination were not clearly performed by the nurse after entering the room were excluded from the secondary analysis.
Data were collected through manual review of vEEG data obtained during the EMU admission. We quantified seizures during phase 1 admissions that lasted >1 minute and in which a family member notified nursing staff of the seizure by pressing the call button. These events would enable performance of seizure first aid and neurologic assessment during the ictal period. Patients who did not have seizures were excluded.
Balancing Measure
Our balancing measure was nursing-perceived effectiveness of seizure care in patients admitted to the EMU. This was assessed through pre- and postintervention survey data, which were conducted in May 2018 and May 2019.
Statistical Analysis
Run charts were used to assess completed components of seizure first aid and neurologic assessment. I-charts were used to evaluate time to assessments.19,20 The use of run charts and I-charts allowed continuous measurement of outcomes. Signal of change19 and special cause variation was determined by using established rules.20,21 QI Macros 2020 was used for statistical analyses of run charts and I-charts. The χ2 test was used to analyze differences in nursing survey data, performed with Prism by GraphPad software.
Ethical Considerations
This study was reviewed and deemed exempt from the institutional review board.
Results
In our preintervention phase, November 2017 to July 2018, all vEEGs from patients admitted for phase 1 studies (24 patients in total) were examined. Nursing was notified in 13 seizures. Postintervention, all vEEGs were again analyzed from August 2018 to February 2019, which included a total of 23 patients; nursing was notified in 10 seizures. Throughout the entire study period (pre-, during, and postintervention), 3 patients required rescue medications for prolonged seizures (1 in preintervention and 2 postintervention) and 1 patient (postintervention; seizure number 14) required transfer to the ICU. EEG video and chart review determined that the patient requiring ICU transfer had complete seizure safety and neurologic assessment and received appropriate rescue medications. Forty members of the nursing team responded to the preintervention survey and 42 responded to the postintervention survey.
In the preintervention phase, the median was 3 of 4 completed components of seizure first aid; this increased to 4 of 4 in the postintervention phase (Fig 3A). Preintervention, the median was 2 of 4 completed components of the neurologic assessment, which increased to 4 of 4 after interventions (Fig 3B). Shifts in the median were noted beginning at seizure 14 in both seizure first aid and neurologic assessment.
FIGURE 3
Primary outcome measures. A, Run chart of the number of completed seizure first aid components per seizure. B, Run chart of the number of completed neurologic assessment components per seizure.
Seizure first aid was performed in 19 seizures, and neurologic assessment was conducted in 20 seizures, enabling measurement of the secondary outcomes. Four seizures (2 in which seizure first aid was not conducted and 2 in which the timing of seizure first aid was ambiguous) were excluded from the secondary analysis. Three seizures in which neurologic assessment was not conducted were also excluded from analysis. Notably, all of these occurred in the preintervention phase. The mean time to initiate seizure first aid was 3.0 and 3.3 minutes to begin neurologic assessment in the preintervention phase, which significantly decreased to 1.2 minutes to begin seizure first aid and 1.3 minutes to begin neurologic assessment in the postintervention phase (Fig 4A and B). Special cause variation occurred beginning at seizure 10 for seizure first aid and seizure 13 for neurologic assessment. There was also decreased variation with narrowing of control limits.
FIGURE 4
Secondary outcome measures. A, I-chart revealing the time to begin seizure first aid. Special cause variation was noted beginning at seizure 10. B, I-chart revealing the time to begin neurologic assessment. Special cause variation was noted beginning at seizure 13. LCL, lower control limit; UCL, upper control limit.
Perceived effectiveness of seizure care was measured on a 5-point Likert scale. Before our intervention, 29% of nursing felt they were good or great at managing acute seizures. After the intervention phase, this increased to 51% of nurses (P = .04; χ2 test).
Discussion
Given the frequency of pediatric hospital admissions for seizure and the risk of seizure-associated serious adverse events,1,2,12 the study and systematic implementation of safety measures are critical. In previous work, researchers have quantified adverse events in EMUs, such as falls, status epilepticus, and patient deaths, as well as impediments and tools, to aid in diagnostic yield.22–24 This body of work revealed that, despite the obvious need for inpatient safety measures during seizures and the relative simplicity of basic seizure first aid, bedside care for patients varies considerably, at times with lack of standardized protocols.25,26 Similarly, we found inconsistent seizure first aid practice in our EMU, which led to incomplete and delayed patient care. Seizures are considered a medical emergency that require prompt vital sign assessment and support; there is consensus that seizure first aid is critical to patient safety.5,18,27 Our interventions to increase consistency of bedside seizure care were also associated with faster delivery of care. This increased efficiency may have been due to improved nursing knowledge and confidence. It is also conceivable, although yet to be studied, that faster, more coordinated seizure management achieved through these methods improves patient and family satisfaction and decreases adverse outcomes (see Future Directions section).
We believe this quality improvement effort was effective because it was used to target key areas contributing to variation of practice in our local environment, primarily, lack of knowledge and/or adherence to standard seizure management and inadequate communication between physicians and nurses. Our findings are consistent with other studies that reveal the effectiveness of standardized protocols in the management of medical emergencies7,28,29 and the importance of adequate communication among medical team members.30,31 In line with the importance of team communication, engagement of all key stakeholders who play a role in seizure management (neuroscience nursing, the pediatric epilepsy physician team, EEG technologists, and pediatric neurology attending physicians and residents) was critical. Each of these groups contributed specific input that informed the planning and ultimate execution of the work. It was advantageous to work with a specialized group of nurses with coordinated leadership (neuroscience nursing group); however, similar methods could likely be adapted in nursing groups without neuroscience expertise, provided adequate communication with group members.
Limitations
One limitation to our study is generalizability, given it was conducted at an EMU within a single institution. However, our quality improvement efforts and the protocol used were relatively simple and did not require major financial or technical resources yet were highly effective. Therefore, similar measures might easily be applied to improve acute seizure management in multiple settings within pediatric hospitals. Data collection over 15 months yielded a modest sample size of phase 1 patients; future efforts will involve a longer-term study with larger groups of patients. Finally, in this study, we addressed short-term sustainability of our interventions by incorporating the protocol into standard workflow. However, long-term sustainability of these improvements will be important to assess. We implemented practices that may contribute to sustained improvement in acute seizure management, including incorporating the protocol into standard work with discussion on daily nursing huddle and as part of standard neuroscience nursing group training.
Future Directions
A critical next question, which will require a longer-term study with larger groups of patients, is whether standardized first responder management of acute seizures decreases the rate of patient-centered adverse outcomes, such as status epilepticus, prolonged length of stay, appropriately timed and administered rescue medication, and ICU transfer. It will also be important to evaluate how these interventions impact patient and family satisfaction. In addition, future work will target improved patient and family reporting of seizures to nursing staff, the continued gap in self-reported nursing confidence, and long-term sustainability of the newly developed measures. Finally, standardized seizure management protocols can be tested in broader pediatric hospital settings, including the emergency department and ICUs, and can involve additional first responders such as housestaff.
Conclusions
We conducted a quality improvement project in which a standardized seizure management protocol increased the correct and timely delivery of seizure first aid and neurologic assessment. Furthermore, there was a significant increase in nursing confidence. Taken together, our data indicate that these interventions improved care for patients with acute seizures.
Acknowledgments
We thank all the Brain and Behavior Nursing Group, neuroscience nursing group, and EEG technicians at Lucile Packard Children’s Hospital for their essential contributions to the implementation of this work. We thank Dr Carl Gold of Stanford Neurology for advising us on the design of this project.
Footnotes
Dr Pavitt’s current affiliation is Department of Neurology, University of California, San Francisco, San Francisco, CA.
Contributed by
Dr Pavitt conceptualized and designed the study, collected and analyzed the data, conducted initial analysis, and drafted the initial manuscript; Ms Carley conceptualized and designed the study, collected data, and reviewed the final manuscript; Dr Porter conceptualized and designed the study and reviewed and revised the manuscript; Dr Knowles conceptualized and designed the study, conducted data analysis, and critically reviewed all manuscript drafts; and all authors approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Dr. Knowles is supported by a National Institutes of Health/National Institute of Neurological Disorders and Stroke K12NS098482-02 award, a Taking Flight Award from the CURE Foundation, and the Stanford Maternal and Child Health Research Institute. This study was also supported by the Stanford Department of Neurology. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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