Reduced Emergency Department Utilization by Patients With Epilepsy Using QI MethodologyAnup D. Patel, MD, a, b Eric G. Wood, BSISE, MBA, a Daniel M. Cohen, MDa, c
aDepartment of Pediatrics, Nationwide Children’s
Hospital, Columbus, Ohio; and Divisions of bNeurology and cEmergency Medicine, College of Medicine, The Ohio State
University, Columbus, Ohio
Drs Patel and Cohen conceptualized and designed
the study, drafted the initial manuscript, carried out
the initial analyses, and reviewed and revised the
manuscript; Mr Wood drafted the initial manuscript,
carried out the initial analyses, and reviewed and
indicated he has no potential confl icts of interest
to disclose.
At Nationwide Children’s Hospital,
over 600 patients with epilepsy are
seen in the emergency department
(ED) each year. Throughout the United
States, epilepsy or seizure care is the
most common neurologic condition
that presents to an ED, accounting for
more than 1 million visits annually. 1
The majority of these cases are for
children younger than 5 years. 2 Many
such ED visits are preventable for
children with epilepsy. 3 ED visits
are costly and can consume time for
caregivers and patients. 4
Attempts to improve the management
of asthma in children and to decrease
ED utilization by using quality
improvement (QI) have been made
with some success. 5 –9 To date, no
similar studies have been performed
in pediatric epilepsy. A previous study
suggested variables that if changed
may prevent an ED visit in the first
instance. 3 Therefore, we developed a
comprehensive QI project utilizing the
Institute for Healthcare Improvement
model 10 in hopes of decreasing ED
utilization for children with epilepsy.
abstractBACKGROUND: Epilepsy or seizure care is the most common neurologic
condition that presents to an emergency department (ED) and accounts for
a large number of annual cases. Our aim was to decrease seizure-related ED
visits from our baseline of 17 ED visits per month per 1000 patients to 13.6
ED visits per month per 1000 patients (20%) by July 2014.
METHODS: Our strategy was to develop a quality improvement (QI) project
utilizing the Institute for Healthcare Improvement model. Our defined
outcome was to decrease ED utilization for children with epilepsy. Rate of
ED visits as well as unplanned hospitalizations for epilepsy patients and
associated health care costs were determined. A QI team was developed
for this project. Plan do study act cycles were used with adjustments made
when needed.
RESULTS: Nineteen months after implementation of the interventions, ED
visits were reduced by 28% (from 17 visits per month per 1000 patients
to 12.2 per month per 1000 patients) during the past year. The average
number of inpatient hospitalizations per month was reduced by 43%
from 7 admissions per month per 1000 patients to 4 admissions per
month per 1000 patients. For both outcome measures, a 2-sample Poisson
rate exact test yielded a P value < .0001. Health care claims paid were
less with $115 200 reduction for ED visits and $1 951 137 reduction for
hospitalizations.
CONCLUSIONS: Applying QI methodology was highly effective in reducing ED
utilization and unplanned hospitalizations for children with epilepsy at a
free-standing children’s hospital.
QUALITY REPORTPEDIATRICS Volume 139 , number 2 , February 2017 :e 20152358
To cite: Patel AD, Wood EG, Cohen DM. Reduced
Emergency Department Utilization by Patients
With Epilepsy Using QI Methodology. Pediatrics.
2017;139(2):e20152358
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PATEL et al
Our goal was to decrease ED visits
and unplanned hospitalization
to improve the quality of care for
the patient, improve patient and
caregiver experience by providing
improved access to specialty
outpatient care and education, and to
decrease health care costs as a result.
Our primary aim statement defined
our targeted improvement goal: to
decrease ED visits from our baseline
of 17 ED visits per month per 1000
patients to 13.6 ED visits per month
per 1000 patients (20%) by July 2014
and sustain the decrease ( Fig 1). In
addition, a secondary aim was to
decrease unplanned hospitalizations
as defined by a patient being
admitted after being seen in the ED
from 7 admissions per month per
1000 patients to 5.6 admissions per
month per 1000 patients by 20%
from our baseline. The balancing
measures for our project included
readmissions to the hospital within
30 days, overall mortality of our
epilepsy population, and patients
seen again in the ED within 72 hours
of an ED visit.
METHODS
Context
Nationwide Children’s is a
freestanding pediatric hospital
with 427 licensed beds and the sole
pediatric tertiary care facility in
Central Ohio. The ED has 62 beds
and is a level 1 American College
of Surgeons certified pediatric
trauma center with 86 060 visits in
2014. Nationwide Children’s serves
over 3000 children with epilepsy.
Epilepsy patients are seen by a
pediatric neurology service that
includes 29 neurology physicians
with 9 specifically trained in epilepsy
care. In addition, 6 advanced
practice nurses and 1 physician
assistant provide patient care. The
neurology division completes over
7000 epilepsy-related patient care
visits in the outpatient setting each
year. Outpatient clinics occur 5
days a week (Monday to Friday)
from 8 AM to 5 PM. A comprehensive
multidisciplinary outpatient epilepsy
center exists and serves ∼50% of the
active epilepsy patients and occurs 2
days per week. This center is staffed
by the 9 epilepsy physicians and 3
advanced practice nurses. In addition,
the center consists of social work and
other related care providers to assist
epilepsy patients and their families.
Interventions around each key
driver were developed with 5 being
implemented sequentially over the
subsequent 12 months. The 5 major
e2
FIGURE 1Key driver diagram.
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PEDIATRICS Volume 139 , number 2 , February 2017
interventions, annotated in Figs 2
and 3, included the following: (1)
beginning an established urgent
epilepsy clinic (UEC) to improve
access; (2) deploying a seizure action
plan (SAP) to improve knowledge
around home seizure management;
(3) supporting proper dosing of
abortive seizure medications via
the electronic health record (EHR);
(4) providing reminder magnets
with instructions of use for abortive
seizure medications; and (5) review
of previous high utilizers of the ED
for epilepsy care to address unique
issues.
Interventions
UEC
Our first and highest intensity
intervention was the established UEC
that developed the ability to access
outpatient epilepsy care urgently.
The UEC was not created de-novo,
but instead was a reorganization
of an existing clinic to allow for
2 additional appointments with
additional time allocated. The UEC
was staffed by an epilepsy nurse
practitioner and an epilepsy social
worker. The clinic was held 4 days a
week, either morning or afternoon
(Monday, Tuesday, Thursday,
and Friday). Two such clinic
appointments were available per
each session with extended patient
time (60 or more minutes) to ensure
all issues were addressed properly
and education about epilepsy
care was given. Appointments
were scheduled flexibly as add-on
appointments as triggered by the
neurology triage nurses who were
given a list of “red flags” and by
any neurology provider, including
residents while taking night call for
neurology.
SAP
To improve education and enhance
communication among patients with
epilepsy and providers, we developed
a SAP. By analogy, an asthma action
plan has been successfully used
previously. 5 However, minimal work
in this area has been performed
in epilepsy. 11 –14 The action plan
was developed to mirror the
appearance of the asthma action plan.
Information about seizure baseline,
when caregivers should contact
neurology, and other important
information were available on the
plan in a color-coded scheme utilizing
green, yellow, and red zones.
Abortive Seizure Medication Dosing and Magnets
One variable known to increase ED
utilization is not having or having
inappropriate dosing of abortive
seizure medication. 3 Therefore,
e3
FIGURE 2ED visits for epilepsy patients.
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utilizing the EHR, a dosing guide
and alert system was developed to
assist providers in prescribing the
correct dose for abortive seizure
medication. If incorrect doses were
selected, an EHR alert would notify
the prescriber of the recommended
dose. Additionally, a dosing guide
with recommendations on the basis
of age and weight was attached to
the order. To improve education and
reminders for caregivers, a magnet
was given for the prescribed abortive
medication with detailed instructions
on proper medication administration.
It was given in conjunction with the
SAP.
Review of High Utilizing Patients
During the last 9 months (November
2014 to July) of the project, we
deployed extrapolation and review
of data from EPIC by developing
and utilizing a dashboard. We used
Qlikview, which is a data processing
and analysis software tool (Qlik,
Lund, Sweden). This enabled the
presentation of daily updates and
trends of actionable information
including no-shows to our outpatient
epilepsy clinic, ED visits, and
hospitalizations. Review of patients
with high ED utilization occurred
monthly by the QI team to determine
if further action was needed.
Study of the Interventions
For each of the above 5 interventions,
plan do study act (PDSA) cycles were
used with adjustments made as
necessary on the basis of the analysis
of the cycle. By design, we initiated
our highest intensity intervention,
the UEC, first to evaluate the effect of
that isolated intervention. The UEC
was initiated in October 2013. Our
PDSA cycles for each intervention
consisted of obtaining feedback
provided by staff and patients. For
the UEC, feedback was obtained
after the first 20 patients were seen.
Feedback was obtained for all other
interventions implemented. This
approach was felt most useful as
changes to work flow and caregiver
engagement was the major focus of
our interventions.
Measures
To identify patients for this project,
International Classification of Diseases, Ninth Revision codes were
used. Our population consisted of
those with a completed office visit
within a rolling 13 months who had
a primary or secondary diagnosis of
epilepsy (345.xx). Current Procedural Terminology codes were used to
identify the completed office visit.
e4
FIGURE 3Unplanned hospitalizations to the inpatient neurology unit for epilepsy patients.
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PEDIATRICS Volume 139 , number 2 , February 2017
An ED visit was included if the visit
was related to a seizure (780.39)
or epilepsy (345.xx) as either
the primary or secondary reason
listed for the visit. An unplanned
hospitalization was counted if the
ED visit resulted in the patient being
admitted to the inpatient neurology
service at Nationwide Children’s
Hospital.
For the financial analysis, health
care utilizations costs required
estimation, as the outcome was a
lack of ED visit or hospitalization.
Therefore, these costs were
estimated by previous average claims
paid data available during the study
period at our institutions, which
were as follows: $640 per visit per
ED visit and $18 066 per unplanned
hospitalization. We considered the
additional costs attributed to the UEC
in our final total savings calculations
for the level 5 office visit, which
amounts to $133 in each claim paid
for each visit. These add-on cases
were felt to be a portion of the full
effort for the nurse practitioner and
social worker and not additional
utilization of resources. SAP
implementation was monitored
during the project.
The Institute for Healthcare
Improvement model for QI 11
was used as the foundation of
this initiative and study design.
Baseline ED visits were measured
over a retrospective period of 18
months (from January 2012 to
June 2013) before initiating any
interventions. The baseline period
established that ED visits ( Fig 2)
shows a process in control, with
no special cause variation trends
and no seasonality associated with
epilepsy patient care activity. The
same held true for the baseline for
unplanned hospitalizations ( Fig 3).
The improvement time, after the
first successful intervention, was a
19-month period (from November
2013 through July 2015). A 20%
reduction was chosen on the basis of
our group’s consensus of feasibility.
We used mortality and hospital
readmissions as balancing measures
for this project.
Key drivers or barriers for ED
use were identified by using
several techniques such as process
maps and an affinity diagram
from brainstorming sessions. In
addition, previous literature and
best practices were used for key
driver development. 3 Major drivers
identified were as follows: system
and communication issues within and
outside of neurology; lack of access to
resources by family and other health
care providers; patient and caregiver
comorbidities and beliefs; and a need
to enhance education about epilepsy
care for patients and caregivers.
Analysis
For the purposes of our analysis,
we defined a shift in data as 8
consecutive data points below our
baseline. 15 The primary data were
generated from our EHR system
(EPIC). Two analysts performed an
independent review and validation to
verify accuracy of our data queries.
Control charts (a Statistical Process
Control tool) 15 were employed
to monitor the outcome metrics:
monthly baseline ED visits and
unplanned hospitalizations, with
the interventions recorded as
implemented over time ( Figs 2 and 3).
The particular type of chart used
to monitor the ED and inpatient
processes (the U chart) displays the
number of random events occurring
during an opportunity “window” as
measured by calendar days, patient
days, etc, as appropriate for the
type of events being measured. We
used a U chart to control for the
increase in unique patients with
epilepsy seen at our institution,
which started at 3167 patients and
consisted of 3426 patients at our
last data point. Epilepsy ED visits
per 1000 patients per month is our
illustration. The Poisson statistical
distribution, the distribution
assumed by the U chart, is typically
well suited for representing such
events. Accordingly, tests for
statistical significance made use
of the 2-sample Poisson rate test.
For SAP monitoring, tracking of
implementation was monitored when
used within the EHR.
Ethical Considerations
This QI project was discussed
and approved by the Director of
Quality Improvement at Nationwide
Children’s Hospital. Updates were
provided monthly via written reports
and presented quarterly to the QI
administration team consisting of
the Division Chief of Neurology,
Director of Quality Improvement, and
Chief Medical Officer at Nationwide
Children’s Hospital. Institutional
review board approval at our
institution is not required, nor is
a letter of exemption needed to
perform QI as the work performed
was for QI purposes.
RESULTS
Nineteen months after
implementation of the interventions
to reduce ED utilization, ED visits
were decreased from 17 visits per
month per 1000 patients to 12.2
per month per 1000 patients (28%;
Fig 2), P < .0001. Additionally,
the average number of inpatient
hospitalizations per month was
reduced by 43% from 7 admissions
per month per 1000 patients to 4
admissions per month per 1000
patients ( Fig 3) per year, P < .0001.
Improvements occurred over time
with implementation of each of the
5 interventions ( Fig 1). The greatest
impact was associated with use of
the UEC. After implementation of the
established UEC in October 2013, a
shift in our baseline was noted ( Fig 2).
Two hundred ninety-one patients
were seen in this clinic during the
time of the project. Overall, 93%
of the scheduled patients attended
the clinic. The average show rate
for neurology patients at our center
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is 80%. The estimated time spent
per patient was 1.5 hours for the
nurse practitioner for visit time
and documentation, 1.75 hours
per patient for social worker, and
minimal additional administrative
assistant support. A PDSA after
the first 20 patients revealed that
families felt more comfortable with
the epilepsy care after the visit. Most
families have expressed appreciation
of the quickness the appointment
was scheduled and the time spent.
Utilization of the SAP increased
over time through dissemination
mostly from the outpatient clinics
in the Pediatric Epilepsy Center at
Nationwide Children’s Hospital.
SAP implementation improved from
a baseline of 0 to ∼418 (of 3426
epilepsy patients served at our
center) by July 2015. During our
PDSA for the SAP, we sampled 10
families who received the SAP and
surveyed utilizing providers. When
we inquired during our PDSA cycles,
families reported having a better
comfort and understanding of what
to do during an epileptic seizure.
Additional information in the form of
specific instructions on whom to call
was added.
After implementation of the
dosing reminder into our EHR,
the proportion of seizure patients
prescribed an accurate abortive
medication for seizure care improved
when implemented in September
2014 from a baseline of 0 to 100%
after being built into our EHR. In
addition, the instruction magnet for
abortive medications was used for
all patients. Feedback from epilepsy
providers, nurses, and caregivers
of patients were obtained during
the initial PDSA and changes to the
magnet design and instructions were
made before full implementation was
performed.
In regards to health care costs,
given the reduction in ED visits and
unplanned hospitalizations, we
calculated a savings in health care
utilization of $115 200 for ED visits
and $1 951 137 for hospitalizations.
To attribute additional costs of
the UEC, a level 5 follow-up visit
was billed for these appointments
with a claims paid associated with
$133 per visit. Approximately 291
patients were seen in the established
UEC through July 2015. Therefore,
$39 867 was attributed to the cost of
this intervention in generated claims.
Other costs of supplies, material
preparation, and changes to EHR
modules could not be calculated
because they are not separately
collected at our institution and part
of our overall structure.
Our balancing measures
included seizure-related hospital
readmissions, which decreased
from a baseline of 22 in 2012 to
12 in 2014, whereas readmissions
for other neurologic conditions
remained virtually unchanged (18 to
21). A second balancing measure was
mortality of patients with epilepsy in
our population. It remained the same
in the overall epilepsy population
(10 in 2012 and 9 in 2014). A third
measure was patients seen back
in the ED within 72 hours where
our baseline was 4.0% and with
1.7% noted during our intervention
implementation period.
DISCUSSION
Summary
For this QI project, our team was
able to decrease seizure-related
ED visits by 28% and unplanned
hospitalizations by 43% for children
with epilepsy at Nationwide
Children’s Hospital. Cost savings to
the health care system was noted as a
result of the reduction in health care
utilization. Phased interventions for
epilepsy patients to reduce ED visits
and unplanned hospitalizations were
employed with success by improving
access to ambulatory outpatient
epilepsy care and increased
education on epilepsy management.
The intervention determined most
successful was the development of
the established UEC staffed by an
epilepsy nurse practitioner and a
social worker. We felt that the social
work support was equally important
as the medical decision-making.
A significant amount of time spent
in this clinic was for education,
counseling, and addressing
psychosocial risk factors. Given the
psychosocial complexities of helping
families manage seizures, including
parental concerns and anxiety, as
well as school- and work-related
contingencies, the role of social
workers may be important to the
success of our model. Future work is
needed to validate this finding.
Lack of proper knowledge about
epilepsy emergency care was
targeted via the SAP. It was also used
as an educational tool for providers
in discussing how to approach
emergency care for acute seizures.
The SAP appeared to be well received
by our patients and their families
with potential expansion of use to
the school system on the basis of the
informal feedback obtained. Further
studies evaluating improvement on
the impact of epilepsy are ongoing.
Our SAP was different from a recent
published study. 14 This study
discussed limitations that may have
resulted in their lack of change
noted. They note that their SAP was
not color coded and had a lot of
information about daily medications,
which may have confused the patient.
They implemented their plan in the
inpatient setting only. 14 We used
color coding, simplified language,
and implemented the plan in all
care settings. The low rate of SAP
implementation was felt secondary
to the time needed for it to be built
within our EHR and dissemination by
providers. Therefore, it was not likely
a major contributing factor to the ED
and hospital reduction.
Previous literature has demonstrated
that improper dosing or lack of an
abortive medication when applicable
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PEDIATRICS Volume 139 , number 2 , February 2017
may contribute to increased health
care utilization. 3 Often, the medical
provider does not audit dosing to
determine if changes are needed
to account for patient growth.
Reminders to providers using
behavioral economic principles 16, 17
have been used previously with other
medications and can be a successful
technique when built into an EHR
used for prescribing medications.
In addition, the magnets served
as reminders of how to give an
abortive medication and allowed for
additional caregivers not present for
the initial education to have a basic
understanding of abortive medication
administration. Further, it served
to remind caregivers on where the
medication was located within the
home setting. These reminder cues
as a behavioral economic principle 17
can also be helpful for caregivers.
We began reviewing patients with
high ED utilization as an intervention.
A high risk ED utilizing patient is
defined currently as one that has
used the ED for their epilepsy-related
care 4 or more times in the previous
year. Unlike asthma, where high
ED utilization in 1 year does not
necessarily predict subsequent high
utilization, 18 the same cannot be said
about epilepsy. Recent publications
highlighted that high ED utilization
in 1 year is predictive of high ED
utilization the following year. 19 – 21
Interpretation
Applying QI methodology can be very
effective in reducing unnecessary
ED utilization and unplanned
hospitalizations for children with
epilepsy. Reducing such utilization
can have a significant cost savings
to the overall health care system.
In previous studies, it was noted
that such utilization accounted for
the majority of health care costs for
patients with epilepsy. 16
Limitations
Limitations exist in our ability to
calculate a true cost savings because
we could not calculate the exact cost
of intervention implementation. Until
models such as the University of
Utah’s program to calculate true costs
become available, this limitation will
exist in any similar study. 22 Costing
out the professionals’ time provides
the most conservative estimate of
the costs of improvement, which
would allow others who wish to
replicate this effort a more accurate
understanding of the percent effort
required to duplicate the UEC
locally. At our institution, we did
not use additional resources. These
appointments were in addition to
the normally scheduled visits and
considered a portion of the full effort
used in salary determination for our
nurse practitioner and social work
positions.
Another limitation is how 1 specific
intervention affects the entirety of
the study period. To account for this
limitation, interventions were phased
in from our key driver diagram.
Further, randomized control trials,
which traditionally serve as the gold
standard study method, were not
performed and not easily possible
in this setting. Patient care occurs in
real time and interventions need to
be applied actively and aggressively
for active substantial improvement
to be seen. Further, external factors
unknown to the QI team may have
an effect on the overall population of
epilepsy patients seen at Nationwide
Children’s Hospital. Our balancing
measures performed well for the
project, suggesting more harm was
not performed elsewhere in the
system.
CONCLUSIONS
As provisions of the Affordable Care
Act become further implemented, 23
focusing on value and quality,
compared with quantity, will be
increasingly crucial. Health care
currently consumes a great portion
of our gross domestic product with
control of costs while maintaining or
increasing quality of care desperately
needed. Medical providers are
best suited for controlling health
care costs. One technique for cost
reduction is by implementing QI
methodology, which has been
found successful in other models of
care. 24 Efforts to increase outpatient
clinic utilization while decreasing
unnecessary less effective utilization
will continue to improve the patient
experience, increase the quality of
care, and reduce health care costs,
thus achieving the Triple Aim of
Healthcare.
ABBREVIATIONS
ED: emergency department
EHR: electronic health record
PDSA: plan do study act
QI: quality improvement
SAP: seizure action plan
UEC: urgent epilepsy clinic
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Available at: www. pediatrics. org/ cgi/
content/ full/ 135/ 3/ e582
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DOI: 10.1542/peds.2015-2358 originally published online January 20, 2017; 2017;139;Pediatrics
Anup D. Patel, Eric G. Wood and Daniel M. CohenMethodology
Reduced Emergency Department Utilization by Patients With Epilepsy Using QI
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