Abstract
Fesler JR, Belcher AE, Moosa AN, et al. Neurol Clin Pract. 2021;11(5):406-412. doi:10.1212/CPJ.0000000000000922. Objective: To determine whether a pocket card treatment algorithm improves the early treatment of status epilepticus and to assess its utilization and retention in clinical practice. Methods: Multidisciplinary care teams participated in video-recorded status epilepticus simulation sessions from 2015 to 2019. In this longitudinal cohort study, we examined the sessions recorded before and after introducing an internally developed, guideline-derived pocket card to determine differences in the adequacy or timeliness of rescue benzodiazepine. Simulation participants were queried 9 months later for submission of a differentiating identification number on each card to assess ongoing availability and utilization. Results: Forty-four teams were included (22 before and 22 after the introduction of the pocket card). The time to rescue therapy was shorter for teams with the pocket card available (84 seconds [64–132]) compared with teams before introduction (144 seconds [100–162]) (U = 94; median difference = −46.9, 95% confidence interval [CI]: −75.9 to −21.9). The adequate dosing did not differ with card availability (odds ratio 1.48, 95% CI: .43–5.1). At the 9-month follow-up, 32 participants (65%) completed the survey, with 26 (81%) self-reporting having the pocket card available and 11 (34%) confirming ready access with the identification number. All identification numbers submitted corresponded to the hard copy laminated pocket card, and none to the electronic version. Conclusions: A pocket card is a feasible, effective, and worthwhile educational tool to improve the implementation of updated guidelines for the treatment of status epilepticus.
Commentary
Management of status epilepticus can be stressful and chaotic, especially in the emergency department and in the field. This complexity can lead to delays in intervention and variability in care, despite many published guidelines and ubiquitous treatment algorithms. 1 There is a problem—the large body of literature and guidelines for treatment of status epilepticus is housed on the internet, textbooks and journal articles. The quick availability of such information is lacking in a real-time clinical scenario. The authors tried to determine if a laminated pocket card with an algorithm for treatment of status epilepticus would improve time to treatment, standardize dosing, and determine if such a tool would be retained for ongoing use. 2
The authors have identified a very important issue in the treatment of status epilepticus—time to treatment and dosing of a rescue antiseizure medication. The results for their first 2 questions were positive and neutral. In terms of time to treatment, “time to rescue therapy was shorter.” Before introduction of the pocket card, time to treatment was 144 seconds; after initiation of the pocket card, time to treatment was 84 seconds. With regards to benzodiazepine dosing, their second question, their results were neutral. “Adequate dosing did not differ with card availability.” Their third area of study, retention of the card, “At the 9-month follow-up, 32 participants (65%) completed the survey, with 26 (81%) self-reporting having the pocket card available.”
This research is much appreciated. It is practical, directly related to patient care, and the study design is simple and easy for almost any health care worker to follow.
This work is an important first step in addressing real-world clinical issues that affect patient outcome and overall morbidity and mortality in a treatable condition. I would be eager to see a “part 2” of this research that might address some questions this paper was unable to address.
Status epilepticus is a diverse set of diseases and conditions. I assume the pocket card guides treatment for generalized convulsive status epilepticus and does not apply to complex partial status or less fulminant forms of status such as focal motor status and epilepsia partialis continua.
Most important, the participants in the study were Cleveland Clinic caregivers in epilepsy, specifically adult and pediatric neurology resident physicians in their initial year of neurology training, physicians completing a post-residency fellowship in epilepsy, nurse practitioners, physician assistants, and registered nurses from the epilepsy monitoring unit. The Cleveland Clinic is a world-leading, large academic medical center with an exceptional neurology department and epilepsy program. These folks do not so much need the laminated card to function in an emergency—although it is clearly beneficial even for them. In my experience, health care providers most in need of practical, easy to use, guidelines—the pocket card—are workers in smaller and more remote settings. Some remote hospitals do not have a neurologist in-house and most do not have a large epilepsy division. Where we need improvements in management of status epilepticus is not at the Cleveland Clinic and especially not by epilepsy specialists. A potential target group could be emergency room practitioners at smaller institutions and first responders in the field. I suspect that their study design. using study participants who all worked in the field of epilepsy is why dosing was not clearly changed by the use of the card. In my daily practice, I come across very extreme variability in dosing of benzodiazepines as a first line treatment for status epilepticus and this is usually by workers who do not exclusively manage seizures as a career. Maybe first-line responders should be allowed a little more time to formulate and enact a plan that better follows established knowledge and guidelines for diagnosis and treatment of status epilepticus—rather than taking the risk of giving an inappropriate dose of the initial treating agent but doing it faster. A follow-up paper might also include the actual card so that it can be printed, laminated and disseminated widely to the entire medical community. The authors have proven that it improves care—lets all share it.
I commend them for examining whether the format of a pocket-card vs electronic version of the treatment algorithms changed care. As I age, I become less and less comfortable and less confident using new electronic modalities. Generations much younger than I (trainees) have humorously commented on how out-of-date my daily behavior is when trying to look something up. In addition to electronic media, I still use books, paper journals, and laminated pocket cards. As technology evolves, health care workers might actually become more comfortable using a smartphone or an app in a fast-paced clinical setting.
Overall, I want the pocket card. I like pocket-cards in emergency situations. Let us study this topic more and share the utility with the broader health care community.
