A quality improvement project with relatively simple interventions resulted in a significant decrease in Emergency Department visits and inpatient admissions, while saving $2 million in health care costs.
Nationwide Children’s Hospital serves almost 3,500 children diagnosed with epilepsy. In 2012 and much of 2013, the Emergency Department was experiencing approximately 17 visits per 1,000 epilepsy patients per month. In the minds of both Emergency Medicine physicians and epilepsy subspecialists, that was too many.
Patients with epilepsy are more effectively treated in the outpatient clinic setting, says Anup Patel, MD, a pediatric epileptologist and member of the Division of Neurology at Nationwide Children’s. So Dr. Patel and colleagues created a quality improvement project to decrease the ED numbers for patients with epilepsy.
Approximately 19 months after the project was implemented, there had been a 28 percent reduction in ED visits, a 43 percent reduction in rate of unplanned hospitalization and an associated health care cost savings of $2 million. The results were reported in a recent issue of Pediatrics, and Dr. Patel is the lead author of the publication.
“We feel that any institution can implement some our interventions and have similar success,” says Dr. Patel, who is also an associate professor of Pediatrics at The Ohio State University College of Medicine. “First, it is better for the patients and their families. Second, it helps free up resources in the Emergency Department. And third, in an era of value-based care, everyone is looking for ways to save money while improving outcomes.”
The QI team identified “key drivers” (or contributing factors) of ED visits, and found they centered on provider-to-provider communication issues and patient/family resources, education, beliefs and comorbidities. Then the team began interventions to target those key drivers.
Most important was the establishment of an Urgent Epilepsy Clinic, says Dr. Patel. It wasn’t really a new clinic at all; an epilepsy nurse practitioner and social worker simply added a few longer appointments into every regular clinic day, reserved for patients and families who exhibited certain “red flags.” A “red flag” might be an unusual amount of anxiety demonstrated by a parent caregiver, or an exceptionally long time spent on the phone with clinic staffers.
The Urgent Epilepsy Clinic appointments lasted at least 90 minutes, giving families a chance to talk through their concerns. And they could be made with only three days’ notice, when regular clinic appointments need to be made weeks in advance.
“These parents were saying they were scared, or they didn’t know what to do during a seizure,” says Dr. Patel. “They would call us, and we might not be able to see them in the clinic immediately. They could end up in the ED. The more immediate, extended appointments available in the Urgent Epilepsy Clinic were allowing our nurse practitioner and social worker to go deep on education with these families. Our social worker also kept in touch with these families regularly, and that follow-up was important as well.”
A second intervention arose, in part, after a 2014 publication from Dr. Patel showed that some children with epilepsy come to the ED because abortive seizure medication was under dosed (or not given at all). Nationwide Children’s built an alert system into its electronic health records – when a provider entered what appeared to be an incorrect dosage based on size and age, the provider would be notified of the proper dose. Providers could also click out to a dosing chart for all ages and weights.
Other interventions included a color-coded seizure action plan, which helped caregivers understand what a baseline seizure looks like and when to call Neurology; and a personalized magnet giving caregivers information about how to give abortive seizure medications.
The QI project team at Nationwide Children’s continues to meet to discuss high utilizers of the ED, in an effort to address the issues that send them there.
Patel AD, Wood EG, Cohen DM. Reduced emergency department utilization by patients with epilepsy using QI methodology. Pediatrics. 2017 Feb; 139(2).
Patel AD. Variables associated with emergency department and/or unplanned hospital utilization for children with epilepsy. Epilepsy & Behavior. 2014 Feb; 31:172-5.
Photo credit: Nationwide Children’s