Table 1
Acute Seizure Care Pathway Care Gaps and Interventions. Summary of twenty-nine care gaps along the acute seizure care pathway, evidence-based interventions to bridge these gaps, and the care setting location for the implementation of the interventions.
| GAP | INTERVENTION | IMPLEMENTATION LOCATION | |
|---|---|---|---|
| 1 | Seizure onset not recognized by another individual | Emergency Department Inpatient Outpatient Post-Hospitalization | |
| 2 | SAP not available |
| |
| 3 | SAP not implemented | ||
| 4 | RM not available | ||
| 5 | RM not administered | ||
| 6 | Drug not administered through proper route and dosage | ||
| 7 | EMS does not administer RM |
| Pre-Hospitalization |
| 8 | EMS does not administer the correct dosage of rescue medication | ||
| 9 | Staff delay | Emergency Department Inpatient | |
| 10 | Pharmacy delay | ||
| 11 | ASM delay | ||
| 12 | ASM unavailable | ||
| 13 | Deviation from the treatment protocol |
| |
| 14 | Route of administration difficulties | ||
| 15 | Delay in obtaining EEG results if the diagnosis is unclear |
| |
| 16 | Patient does not bring a personal seizure diary and medication log |
| Inpatient Outpatient Post-Hospitalization |
| 17 | Patient not given seizure diary and medication log | ||
| 18 | SAP not prescribed or SAP updated |
| |
| 19 | Caregiver not trained on SAP | ||
| 20 | RM not prescribed for patient | ||
| 21 | Caregiver not trained on RM administration | ||
| 22 | Caregiver does not schedule appointment | ||
| 23 | Patient does not attend appointment | ||
| 24 | Caregiver does not fill RM prescription | ||
| 25 | Caregiver does not give RM to outside institutions | ||
| 26 | Outside institution cannot legally administer RM | ||
| 27 | Outside institution not trained on RM administration | ||
| 28 | Caregiver does not provide SAP to outside institutions | ||
| 29 | Outside institution not trained on SAP | ||
[i] EMR: Electronic Medical Record, PCP: Primary Care Provider, SAP: Seizure Action Plan, RM: Rescue Medication, SE: Status Epilepticus, EMS: Emergency Medical Services, ASM: Anti-Seizure Medication, ED: Emergency Department.
Table 2
Acute Seizure Care Pathway Interventions and Implementation Care Group. Summary of twenty-five proposed interventions delineated by the key clinical and patient family care stakeholders.
| INTERVENTION | IMPLEMENTATION CARE GROUP | |
|---|---|---|
| A | Implement patient seizure monitoring system to [43, 48, 52, 53]:
| Hospital, Emergency Physician, Neurologist, Epileptologist, Patient Family, Insurance |
| B | Physician prescribes SAP and RM | Emergency Physician, Neurologist, Epileptologist, Clinic Staff |
| C | Implement RM administration methods that are preferred by users [72, 73] | |
| D | Hospital and clinic staff train caregivers on SAP and RM administration through “hands-on” seizure simulation modules and mannequins [24, 26] | |
| E | Provide caregivers with physical reminders of SAP and RM instructions, such as refrigerator magnets and cards [28, 36] | |
| F | Implement inpatient seizure action code to alert [37, 38]:
| |
| G | Standardize SE and seizure algorithms with weight-based doses [30, 35] | |
| H | Standardize SE and seizure algorithms in pre- and in-hospital care settings to assure algorithm adherence and continuation of care [33, 34, 35, 36, 37] | |
| I | Integrate SE algorithm and SAP in the electronic physician order set [36, 37, 38] | |
| J | Standardization of clinic notes, detailing seizure history and events [37] | |
| K | Train ED and inpatient staff on SE and seizure algorithms through “hands-on” seizure simulation modules and mannequins [34] | |
| L | Require all clinicians to watch an audiovisual seizure treatment training module before inpatient service [37] | |
| M | Provide clinicians with physical reminders of SE and seizure algorithms, such as cards [36] | |
| N | Improve the clinical process to decrease the time from seizure onset to placement of EEG technology [39] | |
| O | Implement advanced EEG seizure detection technology to prevent EEG delay across EMS and inpatient settings | Hospital, Emergency Physician, Neurologist, Epileptologist, Clinic Staff |
| P | Implement pharmacy systems to ensure medication availability and centralization of RM on each hospital floor [37] | |
| Q | Implement EMR-integrated personal seizure diary and medication log to:
| |
| R | Implement urgent epilepsy care clinic access to: | |
| S | Implement electronic care coordination system to:
| |
| T | Equip EMS units with RM and second-line therapy | EMS, Emergency Physician, Neurologist, Epileptologist, Clinic Staff |
| U | Standardize EMS seizure protocols with weight-based dosing [30, 35] | |
| V | Train EMS on seizure detection and diagnosis of prolonged seizure | |
| W | Train EMS on RM administration through “hands-on” seizure simulation modules and mannequins [31] | |
| X | Refresher EMS courses on pediatric care and management [31] | |
| Y | Equip outside institutions with trained medical staff that can administer RM and SAP [24] | Outside Institutions |
[i] EMR: Electronic Medical Record, SAP: Seizure Action Plan, RM: Rescue Medication, SE: Status Epilepticus, EMS: Emergency Medical Services, ASM: Anti-Seizure Medication, ED: Emergency Department.
Figure 1
Acute Treatment in Pre-Hospitalization Setting. Acute seizure care process map that illustrates the flow of epilepsy care management in a tertiary hospital through all care steps that a patient with a seizure may encounter from pre-hospitalization to the ED. Numbers on the process map identify care gaps in acute seizure care management and refer to the corresponding Table 1, which proposes strategies to bridge these gaps. SAP: Seizure Action Plan, RM: Rescue Medication, ED: Emergency Department. Red: Gaps in Seizure Care Management, Green: Does not currently exist as a process.
Figure 2
Acute Treatment in Emergency Department. Acute seizure care process map that illustrates the flow of epilepsy care management in a tertiary hospital through all care steps that a patient with a seizure may encounter from the ED to inpatient care settings. Numbers on the process map identify care gaps in acute seizure care management and refer to the corresponding Table 1, which proposes strategies to bridge these gaps. SAP: Seizure Action Plan, RM: Rescue Medication, ED: Emergency Department. Red: Gaps in Seizure Care Management, Green: Does not currently exist as a process.
Figure 3
Inpatient and Follow-Up Outpatient Care Settings. Acute seizure care process map that illustrates the flow of epilepsy care management in a tertiary hospital through all care steps that a patient with a seizure may encounter from the ED to the inpatient and follow-up outpatient neurology, epilepsy, and primary care clinic settings. Numbers on the process map identify care gaps in acute seizure care management and refer to the corresponding Table 1, which proposes strategies to close these gaps. SAP: Seizure Action Plan, RM: Rescue Medication, ED: Emergency Department, ASM: Anti-Seizure Medication, Outside Institutions: Residential and Educational Non-Medical Institutions, EMR: Electronic Medical Record, EMS: Emergency Medical Services. Red: Gaps in Seizure Care Management, Green: Does not currently exist as a process.
Figure 4
Post-Hospitalization Care Setting. Acute seizure care process map that illustrates the flow of epilepsy care management in a tertiary hospital through all care steps that a patient with a seizure may encounter from the follow-up outpatient neurology, epilepsy, and primary care clinic settings to post-hospitalization care settings. Numbers on the process map identify care gaps in acute seizure care management and refer to the corresponding Table 1, which proposes strategies to close these gaps. SAP: Seizure Action Plan, RM: Rescue Medication, ED: Emergency Department, ASM: Anti-Seizure Medication, Outside Institutions: Residential and Educational Non-Medical Institutions, EMR: Electronic Medical Record, EMS: Emergency Medical Services. Red: Gaps in Seizure Care Management, Green: Does not currently exist as a process.