A quality improvement project with relatively simple interventions resulted in a significant decrease in emergency department (ED) visits and inpatient admissions, while saving millions in healthcare costs, according to a study recently published in Pediatrics.
Nationwide Children’s Hospital, Columbus, Ohio, serves almost 3,500 children diagnosed with epilepsy. In 2012 and much of 2013, the ED experienced approximately 17 visits per 1,000 epilepsy patients per month.
Researchers developed a quality improvement (QI) project utilizing the Institute for Healthcare Improvement model. For the study, they determined rates of ED visits as well as unplanned hospitalizations and associated healthcare costs for epilepsy patients. An interdisciplinary QI team was developed for this project. Plan do study act cycles were used with adjustments made when needed.
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.
An important part of the QI project was the establishment of an Urgent Epilepsy Clinic.
“We reserved a few longer clinic appointments which added a nurse practitioner and social worker to appointments for patients and families who exhibited certain ‘red flags,’” says Anup D. Patel, MD, attending pediatric neurologist and director of the Complex Epilepsy Clinic at Nationwide Children’s Hospital.
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.
“These appointments last 90 minutes, giving families a chance to talk through potential concerns and resources they could contact for follow up questions,” Patel says. “A 90-minute appointment with social work may seem long and resource intensive; however, the return on investment outweighs these issues.
“At times, patients were coming to the ED because abortive seizure medication was under dosed or not given at all,” Patel continues. “Nationwide Children’s built an alert system into our 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. This is an example of how the electronic health record can be leveraged to promote optimal care and improve outcomes for patients.”
Families were provided with a color-coded seizure action plan (conceptually similar to an asthma action plan), which helped caregivers understand what their child’s baseline seizure looks like and when to call neurology. Families were also provided with a personalized magnet describing how to give abortive seizure medications. These interventions reinforce education around activities for seizures that will help in the home setting.
“This is about how to improve the wellness and quality of life of children with epilepsy and keep them from being admitted to the hospital,” says Daniel M. Cohen, MD, associate director of Emergency Medicine at Nationwide Children’s Hospital. “We did this by applying QI methodology that focused on keeping patients with epilepsy out of the ED. We undertook this large project in hopes of providing better quality care for these patients and allowing them to stay at home safely without needing to be seen in our ED.”
Additionally, according to Cohen, this saves significant healthcare dollars and leads to decreased hospitalizations for these patients.
Approximately 19 months after the project was implemented, the study showed a 28% reduction in ED visits and a 43% reduction in the rate of unplanned hospitalization with an associated healthcare cost savings of $2 million.
“Managing patients with epilepsy is most effective in the outpatient clinic setting,” says Cohen. “Epilepsy is an ambulatory sensitive condition. Second, our approach demonstrated a way to free up resources in the ED. And third, in an era of value-based care, everyone is looking for ways to save money while improving outcomes and the quality of life for patients and their families.”
This project serves as an example of how collaboration can lead to better outcomes for patients with epilepsy, according to Patel. “In this case, collaboration and improved communication between the ED and neurology was key, as well as communication revolving around the child and family,” he says. “When a child has a seizure, there is a potential ripple effect for all involved in the continuum of care: home, school, EMS, the ED and the hospital. We would like to see others adopt our approach and expand the utility of this project.”