Medical Professional Publications

Could a Simple Checklist Reduce ED Visits Among Children with Epilepsy?

(From the May 2014 Issue of PediatricsOnline)

Around 1 million Americans visit an emergency department each year for treatment of seizures or epilepsy, most under the age of 5. New research by clinician-scientists at Nationwide Children’s Hospital is examining the causes for these visits and measuring the effectiveness of a simple care management checklist designed to reduce trips to the ED among these patients.

Studies suggest that many people who frequent the nation’s EDs often seek care for conditions that could be treated in a physician or specialist’s office. This holds true for patients with epilepsy. To understand exactly what leads pediatric patients to the ED for epilepsy, a team of neurologists examined records of patients in the Epilepsy Center at Nationwide Children’s who were enrolled in a medical program called Partners for Kids.

Researchers reviewed case records of 120 patients who had visited the ED at least once between 2007 and 2011. Sixty of those patients went to the ED multiple times, accounting for a total of 237 visits over the four-year period, at a cost of more than $2 million. Those who visited the ED only once accounted for a total of 60 visits at a cost of $205,000.

When they delved deeper into the records, the researchers found that the vast majority of frequent ED users either didn’t have emergency seizure medication at home or the dosage of the medication they had was too low; were more likely to have missed follow-up visits with the Epilepsy Center; and had made more calls to the clinic’s triage nurse than those patients who used the ED rarely or not at all.

“We know that there is a lot that can be done to manage this illness in the outpatient clinic, which is a much better venue for these families and their kids. But this study told us that they aren’t utilizing the outpatient clinic and are instead using the emergency department for primary care of their epilepsy,” says Anup D. Patel, MD, an attending pediatric neurologist at Nationwide Children’s and lead author of the study, which was published in May in the journal Epilepsy & Behavior.

The research is related to another study led by Dr. Patel that examined whether a simple care management checklist could help reduce the frequency of ED visits about those who used the facility the most. The checklist, developed as part of a quality improvement initiative, includes a list of questions about the child’s case, medications, parental knowledge of epilepsy and a review of the emergency seizure plan. Dr. Patel identified four patients in the Epilepsy Center who had the highest number of ED visits in 2011.

Following a clinic visit with a neurologist in January 2012, a nurse went over the checklist with parents once a month for three months, then once during the next three months and once more in the last six months of 2012. They tracked the number of ED visits among these four patients during the year.

In 2011, these four patients made 46 visits to the ED. In 2012, that number dropped to 11 — a 76 percent decrease. The patients also experienced a decrease in seizure frequency during the study period.

The research was published in the Journal of Child Neurology and presented in April at the 2014 American Academy of Neurology annual meeting in Philadelphia. Although the study was small, it suggests that widespread implementation of the checklist could improve patient care and reduce ED visits.

“One of the main reasons patients in our other study sought care in the emergency department was because the emergency seizure medication they had at home was dosed too low, but those medications are based on the age and weight of the child. That’s why keeping follow-up visits at the clinic is so important,” says Dr. Patel, who also is an assistant professor of clinical pediatrics and neurology at The Ohio State University College of Medicine. “But the patients who are using the emergency department the most are also the ones who aren’t keeping their clinic appointments. It’s a vicious cycle.”

Dr. Patel is now expanding these studies by studying ED visits among a larger group of patients and doing a more in-depth analysis of what leads those patients to the ED in the first place. He also is planning to do a larger study of the patient care checklist to see if the positive results he saw in the preliminary project would hold true in a larger patient population.

Related citations:
Patel AD. Variables associated with emergency department and/or unplanned hospital utilization for children with epilepsy. Epilepsy & Behavior. 2014 Feb;31:172-5. Epub 2014 Jan 14.

Patel AD. A case series using a care management checklist to decrease emergency department visits and hospitalizations in children with epilepsy. Journal of Child Neurology. 2014 Feb;29(2):243-6. Epub 2013 Sep 20.

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