570623
research-article2015
CPJXXX10.1177/0009922815570623Clinical PediatricsCarapetian et al
Original Article
Emergency Department Evaluation and Management of Children With Simple Febrile Seizures
Clinical Pediatrics 1–7 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815570623 cpj.sagepub.com
Stephanie Carapetian, MD, MS1, Joseph Hageman, MD2,3, Evelyn Lyons, RN, MPH4, Daniel Leonard, MS5, Kathryn Janies, BA6, Kent Kelley, MD3, and Susan Fuchs, MD7,8
Abstract Workup of simple febrile seizures (SFS) has changed as the American Academy of Pediatrics made revisions to practice guidelines. In 2011, revisions were made regarding need for lumbar puncture (LP) as part of the SFS workup. This study surveyed more than 100 emergency departments regarding workup of children with SFS and performed a medical record review of workup that was performed. The survey shows that laboratory workup is done routinely and LP is done infrequently. The majority documents a complete exam. The medical record review demonstrates documentation of the examination, frequent laboratory and infrequent LP evaluation. Consistent with the American Academy of Pediatrics’ revisions, survey and record reviews demonstrate that LP testing is infrequent. Contrary to the guideline, laboratory studies are routinely performed. This study suggests there is an opportunity to improve management of SFS by directing efforts toward finding the source of the fever and away from laboratory workup. Keywords simple febrile seizure, lumbar puncture, quality improvement
Introduction Febrile seizures are the most common convulsive event in childhood, occurring in 2% to 5% of children 6 to 60 months of age,1 with simple febrile seizures (SFS) occurring about 65% to 91% of the time.2 A SFS, as defined by the American Academy of Pediatrics Subcommittee on Febrile Seizures, is a primary generalized tonic–clonic convulsive event, which resolves spontaneously, lasting less than 10 to 15 minutes, without recurrence in a 24-hour period. It is accompanied by fever (temperature >38°C) in a neurologically healthy child aged 6 to 60 months.2,3 As a quality improvement measure in May 1996, the American Academy of Pediatrics published a practice guideline regarding the appropriate neurodiagnostic evaluation of patients with a first simple febrile seizure— specifically lumbar puncture, electroencephalography, blood studies, and neuroimaging.4 In February 2011, this guideline was revised, directing the clinician’s attention to identifying the fever source and away from routine laboratory evaluation (lumbar puncture, blood studies, and urine analysis), neuroimaging, and electroencephalography.2,3 If there is a high suspicion for intracranial infection, a lumbar puncture should be performed.3,4 In
the case of an infant 6 to 12 months of age presenting with seizure and fever, without evidence of intracranial infection, the revised guideline states that the clinician has the “option” of performing a lumbar puncture even if the patient has vaccination deficiencies or an indeterminate immunization status or at any age, or if there was antibiotic pretreatment.3 The original guideline stated that in the previous cases, a lumbar puncture should be 1
Seattle Children’s Hospital, University of Washington, Seattle, WA, USA 2 Comer Children’s Hospital, University of Chicago, Chicago, IL, USA 3 NorthShore University HealthSystem, Evanston Hospital, Evanston, IL, USA 4 Illinois Department of Public Health, Springfield, IL, USA 5 Loyola University, Chicago, IL, USA 6 The American Academy of Pediatrics, Elk Grove Villiage, IL, USA 7 Northwestern University Division of Pediatric Emergency Medicine, Chicago, IL, USA 8 Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA Corresponding Author: Stephanie Carapetian, Division of Pediatric Neurology, Seattle Children’s Hospital, University of Washington, 4800 Sand Point Way NW, Neurology B-5552, Seattle, WA 98105, USA. Email: [email protected]
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“strongly considered.”4 The 2011 revision was made after multiple retrospective studies demonstrated that the original guidelines were not being followed.5 The reasons cited for this were that children with SFS are at low risk for a serious bacterial illness,6 including bacterial meningitis,7 and the incidence of bacterial meningitis presenting solely as fever and seizure is between 0% and 0.6%.8 Quality improvement collaboratives (QIC) are frequently used to improve health care by disseminating new and useful knowledge that can be applied directly to patient care.9 This, in turn, improves patient outcomes secondary to increased use of effective treatment and decreases in wasteful care.10 As a quality initiative, in 1984, the federal government approved legislation to create a Federal Emergency Medical Services for Children (EMSC) program, aimed at addressing the needs of children in emergency medical services.11 This legislation has led to each state and United States territory over time establishing a statewide EMSC program. Following this initiative, in 1994, Illinois EMSC was established and since has received grants to establish and enhance the ability to serve children in times of emergency. This project was funded through the EMSC targeted issues grant with the primary objective, to assess the overall management of pediatric patients with SFS presenting to emergency departments (EDs), as a preliminary step in a QIC.
Methods Participants From January 2010 through April 2011, the Illinois EMSC program conducted a statewide ED QI monitor, which was approved by the Loyola University Chicago Institutional Review Board, consisting of an Internetbased survey investigating the practice and policy of care of pediatric patients presenting with SFS. Each participating ED identified individuals involved in completing the survey, which could include Pediatric Quality Coordinator or qualified ED staff nurse, educator, medical director, or physician. Although the clinical roles differ in the ED, all survey responders were knowledgeable about pediatric emergency care.
patient/parent education, discharge instructions, and staff education. A multidisciplinary team composed of QI specialists, pediatric nurses, pediatricians, emergency medicine physicians and nurses, and data analysts collaborated in the development of a survey tool to extract data reflective of an ED’s general approach to pediatric seizure management. A 17-question survey was designed after an initial planning meeting that included pediatric neurologists, pediatricians, ED medical and nursing staff, prehospital staff, a school nurse representative, and a parent whose children were diagnosed with epilepsy. The survey was reviewed extensively by the Illinois EMSC Facility Recognition Committee and QI Subcommittee composed of ED and pediatric critical care physicians, nurses, and midlevel practitioners as well as QI personnel and statisticians. Each ED facility reported the defined age ranges for their pediatric patients and their corresponding annual ED pediatric volume. Additional questions addressed the areas that potentially affect the quality of pediatric seizure management in the ED, including access to a pediatric neurologist; documentation of a seizure policy/ guideline that is used in the approach to these patients, and whether it specifically addresses pediatric patients; and laboratory and radiological measures used in treatment, plans for follow-up care, and patient/parent education (see Appendix A for the full list of questions). Record Review. To determine whether survey findings correlated with clinical practice, a retrospective chart review was performed. Each participating institution was concomitantly requested to randomly select and review ED charts for up to 10 children presenting to the ED with a diagnosis of SFS from January 2010 through April 2011. Each institution was provided a chart abstraction form (see Appendix B for full list of questions), developed by the Illinois EMSC QI Subcommittee. The record review tool included 24 questions consisting of 30 components. This form sought to gather information characterizing the clinical approach to initial assessment and management of children with seizures. Inclusion criteria for the review were limited to children between the ages of 1 month and 15 years treated by ED physicians and nursing staff.
Study Design
Statistical Analysis
Internet-Based Survey. The 119 participating EDs were asked to complete an Internet-based survey of practices regarding their management of SFS including policies or clinical guidelines, laboratory and radiologic measures, documentation, treatment, neurological services,
Pearson χ2 tests were used to evaluate differences between these groups in both the surveys (P < .05) and record reviews (P < .01). All analyses were performed using SPSS statistical software version 17 (IBM Corporation, Somers, NY).
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Carapetian et al Table 2. Emergency Department (ED) Record Review Results.
Table 1. Survey Results. Routine evaluation Complete blood count with differential Urine analysis Serum blood glucose Electrolytes Blood culture Chest radiograph Computed tomography scan of head Lumbar puncture Electroencephalogram Routine documentation Neurologic status Medication history Respiratory status Seizure semiology Immunization status Past medical and surgical history Previous seizure activity Cardiovascular status Signs of infection Family history Potential exposure or ingestion Discharge instructions Explanation of simple febrile seizure Fever management Management of second seizure Primary care provider referral ED return/call 911 Recurrence risk Neurologist referral
74% 69% 64% 59% 58% 36% 10% 2% 1% 96% 95% 94% 92% 92% 91% 90% 87% 81% 65% 57% 96% 95% 93% 93% 90% 60% 21%
Results Survey Results In 2010-2011, 119 EDs actively participated in the Illinois EMSC QIC. Of the 119 participants, 105 responded to the survey, yielding a response rate of 88%. Evaluation (Table 1) commonly included laboratory tests, such as blood and urine studies, less frequently chest radiograph, and much less frequently lumbar puncture, neuroimaging, or neurodiagnostic testing. The criteria used for performing a lumbar puncture largely consisted of physician decision without any set criteria (74%) and/or clinical presentation (63%). Only 12% of facilities reported that criteria included immunization status of child (unknown or deficient in Haemophilus influenzae and Streptococcus pneumoniae immunizations), and 7% based their decision on recent antibiotic pretreatment. A higher percentage of large (6000 or more ED pediatric visits per year) facilities (21%) included immunization status in lumbar puncture criteria than small (less than 6000 ED pediatric visits per
ED evaluation Serum blood glucose Lumbar puncture Computed tomography scan of head ED documentation Neurologic status assessed Documented past medical history Documented seizure semiology Documented evaluation for fever source ED discharge plan and instructions Discharge home Follow-up with primary care provider Follow-up with neurologist Outpatient electroencephalogram Home with rectal diazepam Home with anti-epileptic medication
40% 4% 12% 96% 96% 90% 97% 87% 97% 5% 3% 2% 2%
year) facilities (2%). Documentation (Table 1) of neurological status was reported by most facilities; however, signs of infection, family history (of seizures), and exposure risk were less frequently documented. Discharge instructions (Table 1) and patient education typically included an explanation of febrile seizure and primary care physician referral. Risk of recurrence was only included 60% of the time, and about one fifth of the facilities recommended neurology follow-up.
Record Review Results One hundred hospitals provided data for the record review, yielding 751 charts available for review. A total of 47% of patients were 6 to 23 months of age and 53% were 24 to 60 months of age. Sixty-one percent of patients arrived to the ED via prehospital transport. ED evaluation (Table 2) less commonly included laboratory evaluation as compared to the survey responses related to routine testing. The frequency of cerebrospinal fluid testing with lumbar puncture was low and consistent with the survey results. The majority of EDs documented (Table 2) past medical history and neurological status as well as seizure semiology. An assessment to identify the fever source was documented in almost all of the patient records. The majority of patients were discharged home. Disposition instructions frequently included a follow-up appointment with primary care physician, but rarely included outpatient neurology referral.
Discussion As recommended in the 2011 American Academy of Pediatrics Guidelines, best practice management for
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SFS includes not performing routine laboratory testing (blood, cerebrospinal fluid, urine) and imaging but instead shifting the workup to identify the source of fever. In this survey of over hundred Illinois EDs, laboratory tests (eg, complete blood count with differential, electrolytes, urine analysis) would be performed as part of the routine evaluation of patients with SFS despite the American Academy of Pediatrics best practice guidelines.3,4 These recommendations were defined from multiple observational studies demonstrating that these studies are invasive and costly and would not provide a clear benefit.3,12-15 Since this survey and the 2010-2011 record review were done mainly at community hospitals, it is likely that the ED physicians were not pediatricians, and would not have been as familiar with the 2011 American Academy of Pediatrics guidelines. This can help explain the continued use of laboratory testing, especially complete blood count and urinalysis. The decreased use of lumbar puncture is likely due to the decreased incidence of meningitis seen in the post–vaccine era.7,9 The study by Trainor et al6 demonstrated in a predominantly community hospital setting, in the pre– Haemophilus influenzae, Streptococcus pneumoniae, and varicella vaccine era, 57% of children with SFS either had an uncomplicated infection as the source of fever (otitis media, upper respiratory tract infection, gastroenteritis, varicella infection) or no source identified (34%). In the groups tested, pneumonia was diagnosed by chest radiograph in 12.5% of patients (46% tested), 5.9% were diagnosed with a urinary tract infection (38% tested), 4 patients (1.3%) were diagnosed with S pneumoniae bacteremia (69% tested), and no patients were diagnosed with meningitis (30% tested). In our study, the survey evaluation for source of the fever was underreported as compared to the record review. As the new recommendations suggest, clinical and laboratory evaluation of the fever source should guide the workup and thus be clearly documented in the patient’s chart. Shaked et al,5 in a retrospective chart review from 2001 to 2005, evaluated the frequency and need for lumbar punctures performed on children 6 to 12 months of age. Their study was done in the post-7-valent pneumococcal conjugate vaccination era, and showed that concomitant with the declining incidence of meningitis secondary to more sophisticated immunizations, practitioners were not following the American Academy of Pediatrics 1996 SFS management guidelines with respect to lumbar puncture testing. Only 50% of their patients with SFS underwent a lumbar puncture, which at the time was urged as a “strong consideration” from the American Academy of Pediatrics. Additionally, they
showed that, of the patients who underwent cerebrospinal fluid testing, none had pleocytosis or a positive culture. The authors argued that “performing lumbar puncture in patients 6 to 12 months of age was conceived in a different epidemiologic era with data not representative of current issues,” thus suggesting the need for guideline revision. In 2009, Kimia et al7 published a large retrospective chart review, from 1995 to 2006, of children 6 to 18 months of age with SFS and evaluated the incidence of meningitis. Of the 271 patients with cerebrospinal fluid testing, none had bacterial meningitis. The authors concluded that there is “no evidence that FSFS [first simple febrile seizure] represents any increase in risk for meningitis, compared with children in the same age group with fever but without FSFS.” They urged physicians to direct their decision to perform a lumbar puncture based on the patient’s clinical presentation rather than focusing on age. Additionally, the authors reviewed the frequency of which lumbar punctures were performed, demonstrating that, among all age groups, there was a decrease in lumbar puncture testing over time. This sentiment was echoed in the 2009 American Academy of Pediatrics Grand Rounds,16 thus prompting the revised guidelines and urging clinicians to focus on symptoms and signs of meningitis as to help determine whether a lumbar puncture is performed. The aim of this study is to evaluate how practitioners would work up a child with SFS after guideline revision in 2011. From this study, survey and retrospective record review results indicate that lumbar puncture testing was done infrequently, consistent with best practice guidelines. Because of the benign nature of SFS and good prognosis, including low likelihood of future development of epilepsy,1 the American Academy of Pediatrics recommends against long-term medication management of SFS with anti-epileptic drugs.17 The survey and record review results indicate that disposition with anti-epileptic drugs is rare, consistent with best practice guidelines. Finally, there is a correlation between survey responses and chart reviews in regard to the performance of a lumbar puncture and head computed tomography scan, as well as documentation of neurological status, seizure semiology, and past medical history, indicating that what the respondents of the survey state correlates with their actual management decisions.
Limitations and Future Implications There are several limitations to this study. The survey completion differed by facility, sometimes performed by
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Carapetian et al a nurse, less frequently by a physician, and sometimes by multiple staff members. A second limitation of this study is that data collected from the record review does not include information about the frequency of blood and urine laboratory studies. Without this information, we are unable to make comparisons of actual practice to reported practice. A third limitation of this study is that the data from the record review stratifies children into 2 age groups, 6 months to 23 months old and 2 years to 5 years old, whereas it would have been helpful to look closely at the ED practices with children under 12 months of age. Despite these limitations, this multicenter QIC demonstrates that the Illinois EDs participating in this project have changed their practice with respect to routinely performing a lumbar puncture in SFS patients, but also shows that ED management of SFS still includes routine laboratory studies. An online learning module has been created to educate ED personnel about the best practice guidelines for SFS workup. Future studies would include examining the response to the learning module and changes in practice, specifically with respect to laboratory and imaging studies.
Conclusions This study demonstrates that there is an opportunity to improve management of SFS by directing efforts toward finding the source of the fever rather than the seizure, and thus away from unnecessary laboratory and imaging studies. This QIC shows that medical professionals, in SFS evaluation, both report a low incidence of routine lumbar puncture and in practice are infrequently performing lumbar punctures, but are underreporting their clinical evaluation for the fever source, whereas in practice are performing a thorough clinical evaluation.
Appendix A Pediatric Simple Febrile Seizure in the ED— Survey Questions 1. How does your emergency department define the pediatric population? 2. What is the average volume of pediatric (defined as 0 through 15 years old) ED visits per year in your facility? 3. What is the average volume of ALL patient (adult and pediatric) ED visits per year in your facility? 4. Does your ED have a documented protocol/policy/guideline/ clinical pathway that addresses the clinical management of seizures (eg, Seizure, Altered Level of Consciousness, Fever)? a. Does your ED’s protocol/policy/guideline/clinical pathway specifically address pediatrics? 5. What laboratory and radiologic measure(s) does your ED routinely require for the management of Simple Febrile Seizures? Check all that apply (continued)
Appendix A (continued) a. CBC with differential b. Blood cultures c. Blood glucose d. Urinalysis e. Urine culture f. Electrolytes g. Strep/RSV swab h. BUN and Creatinine i. Lumbar puncture j. Chest x-ray k. Head CT l. EEG m. MRI/MRA n. EKG o. None 6. W hat documentation does your ED routinely require for the management of Simple Febrile Seizures? Check all that apply a. Respiratory status b. Cardiovascular status c. Neurologic status d. Signs of infection e. Description of presenting seizure f. Immunization history/status g. Previous seizure activity h. Medication history (include antibiotics) i. Medical/surgical history j. Exposure or ingestion history k. Familial history of seizure l. None 7. For Simple Febrile Seizure patients, what are your ED’s criteria for doing an LP? Check all that apply a. Based on child’s age (eg, every child under 12 months) b. B ased on clinical presentation (signs/symptoms of meningitis/ bacteremia; child looks “toxic”) c. B ased on child’s immunization status (unknown or deficient in H influenzae and S pneumoniae immunizations) d. Based on if child has/has been previously/recently treated with antibiotics e. Per physician decision (no set criteria) f. L Ps are not done on patients presenting with simple febrile seizures g. I don’t know hat component(s) are included on your ED’s seizure discharge 8. W instructions/patient education for Simple Febrile Seizure? Check all that apply a. Explanation of febrile seizure b. What to do if another seizure occurs c. When to return to ED/call 911 d. Provide reassurance e. Fever management f. Review risk of reoccurrence g. Conduct medication reconciliation h. Review seizure precautions i. Primary Care Physician referral j. Neurology referral k. None 9. In the past year, has your ED staff received education related to pediatric seizure disorders? 10. D oes your hospital conduct chart reviews of patients with any type of Seizure diagnoses for QI purposes?
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Appendix B Pediatric Simple Febrile Seizure in the ED— Medical Record Review 1. What was the patient’s mode of arrival? Prehospital: If a patient arrived via EMS from the scene, answer Questions #1a-e. a. What level of prehospital service was used? b. Was the child’s airway controlled appropriately? c. Was the child’s neurologic status assessed? d. Was blood glucose level checked by prehospital provider? e. Was a description of the seizure documented (for example: who witnessed seizure, what did the seizure look like, how long did it last, how was the child acting right before seizure, how was the child acting the day before, etc)? Initial ED Assessment: 2. Age of patient (in months or years) 3. Was the child actively seizing upon arrival to the ED? 4. Was the neurologic status assessed? 5. Was blood glucose checked? Choose N/A if blood glucose was checked prehospital. 6. Was full medical and seizure history documented (for example: medications given prior to arrival to treat fever, child/family seizure hx, antibiotic/antiepileptic medication hx, immunization status, hx of incontinence, last feeding/ meal, recent hx of trauma, underlying health problems, surgical hx, recent ingestion, recent exposure, child’s baseline status, age-related assessments, bruising, bites, etc)? 7. Was a description of seizure documented (for example: who witnessed seizure, what did the seizure look like, how long did it last, how was the child acting right before seizure, how was the child acting the day before, etc)? 8. Was an assessment performed to identify the source of the fever? ED Management: 9. Was the child’s airway controlled appropriately? 10. Was a LP performed? 11. Was a head CT performed while child was in the ED? 12. If the child was febrile in the ED (temp. ≥ 100.4°F/38.0°C), was an antipyretic administered? Choose N/A if parent/caregiver gave antipyretic prior to arrival OR if patient no longer febrile. 13. If child was actively seizing, was an anticonvulsant administered? Choose N/A if child was not actively seizing 13a. If yes, was it administered within 15 minutes of child’s arrival? Disposition/Discharge: 14. Was the child’s neurologic status reassessed before disposition? 15. Was the child’s temperature reassessed prior to discharge? 16. What was the child’s disposition from the ED? a. Transferred (T) = transferred to a higher level of care (answer Q.16a) (continued)
Appendix B (continued) b. P ICU Admission (P) = admitted to PICU/ICU (in same hospital) c. Intermediate Care Admission (I) = admitted to an intermediate care bed (in same hospital) d. General Admission (F) = admitted to a general care floor (in same hospital) e. Observed (O) = admitted to an observation unit/ general floor and/or observed in the ED for ≤23 hours (in same hospital) f. H ome (H) = discharged home after a brief period of observation (≤6 hours) (answer Q.17-23) g. Expired (E) = expired in the ED 16a. If transferred, what level/type of patient transport service was used? a. Specialty/Transport Team (S) b. ALS/ILS (A) c. ALS/ILS (with nurse) (A/n) d. BLS (B) e. BLS (with nurse) (B/n) f. Private vehicle (PV) 17. Was an outpatient EEG ordered upon discharge from the ED? Choose N/A if child was transferred or if hospital policy does not require EEG. 18. W as rectal diazepam prescribed in the ED for home use? Choose N/A if already prescribed or if the child was transferred. 19. W as an oral antiepileptic drug (for example: phenobarbital, phenytoin, valproate, etc) prescribed in the ED for home use? Choose N/A if already prescribed or if the child was transferred. 20. D id the child/family receive pediatric seizure patient education prior to discharge? Choose N/A if child was transferred. 21. D id the child/family receive pediatric fever management education prior to discharge? Choose N/A if child was transferred. as the child/family instructed to follow up with 22. W a Primary Care Physician? Choose N/A if child was transferred. 23. W as the child/family instructed to follow up with a Neurologist? Choose N/A if child was transferred.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Emergency Medical Services for Children targeted issues grant.
References 1. Nelson KB, Ellenberg JH. Predictors of epilepsy in children who have experienced febrile seizures. N Engl J Med. 1976;295:1029-1033.
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Carapetian et al 2. Waruiru C, Appleton R. Febrile seizures: an update. Arch Dis Child. 2004;89:751-756. 3. AAP Subcommittee on Febrile Seizures. Febrile seizures: guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127: 389-394. 4. Provisional Committee on Quality Improvement, Subcommittee on Febrile Seizures. Practice parameter: the neurodiagnostic evaluation of the child with a first simple febrile seizure. Pediatrics. 1996;97:769-772. 5. Shaked O, Pena BM, Linares MY, Baker RL. Simple febrile seizures: are the AAP guidelines regarding lumbar punctures being followed? Pediatr Emerg Care. 2009;25:8-11. 6. Trainor JL, Hampers LC, Krug SE, Listernick R. Children with first-time simple febrile seizures are at low risk of serious bacterial illness. Acad Emerg Med. 2001;8: 781-787. 7. Kimia AA, Capraro AJ, Hummel D, Johnston P, Harper MB. Utility of a lumbar puncture for first simple febrile seizure among children 6 to 18 months of age. Pediatrics. 2009;123:6-12. 8. Green SM, Rothrock SG, Clem KJ, Zurcher RF, Mellick L. Can seizures be the sole manifestation of meningitis in febrile children? Pediatrics. 1993;92:527-534. 9. Bergman DA. Evidence-based guidelines and critical pathways for quality improvement. Pediatrics. 1999;103 (1 suppl E):225-232.
10. Margolis P, Provost LP, Schoettker PJ, Britto MT. Quality improvement, clinical research, and quality improvement research: opportunities for integration. Pediatr Clin North Am. 2009;56:831-841. 11. Federal Emergency Medical Services for Children. http:// www.ncsl.org/issues-research/health/emergency-medicalservices-for-children-laws.aspx. Accessed August 20, 2013. 12. Jaffe M, Bar-Joseph G, Tirosh E. Fever and convulsions: indications for laboratory investigations. Pediatrics. 1981;67:729-731. 13. Gerber MA, Berliner BC. The child with a “simple” febrile seizure: appropriate diagnostic evaluation. Am J Dis Child. 1981;135:431-443. 14. Heijbel J, Blom S, Bergfors PG. Simple febrile con vulsions: a prospective incidence study and an evaluation of investigations initially needed. Neuropadiatrie. 1980;11:45-56. 15. Thoman JE, Duffner PK, Shucard JL. Do serum sodium levels predict febrile seizure recurrence within 24 hours? Pediatr Neurol. 2004;31:342-344. 16. Millichap JG. Indications for LP following first febrile seizure reconsidered. AAP Grand Rounds. 2009;21:25. 17. Steering Committee on Quality Improvement and Management, Subcommittee on Febrile Seizures. Febrile seizures: clinical practice guideline for the long-term management of the child with simple febrile seizures. Pediatrics. 2008;121:1281-1286.
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research-article2015
CPJXXX10.1177/0009922815570623Clinical PediatricsCarapetian et al
Original Article
Emergency Department Evaluation and Management of Children With Simple Febrile Seizures
Clinical Pediatrics 1–7 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815570623 cpj.sagepub.com
Stephanie Carapetian, MD, MS1, Joseph Hageman, MD2,3, Evelyn Lyons, RN, MPH4, Daniel Leonard, MS5, Kathryn Janies, BA6, Kent Kelley, MD3, and Susan Fuchs, MD7,8
Abstract Workup of simple febrile seizures (SFS) has changed as the American Academy of Pediatrics made revisions to practice guidelines. In 2011, revisions were made regarding need for lumbar puncture (LP) as part of the SFS workup. This study surveyed more than 100 emergency departments regarding workup of children with SFS and performed a medical record review of workup that was performed. The survey shows that laboratory workup is done routinely and LP is done infrequently. The majority documents a complete exam. The medical record review demonstrates documentation of the examination, frequent laboratory and infrequent LP evaluation. Consistent with the American Academy of Pediatrics’ revisions, survey and record reviews demonstrate that LP testing is infrequent. Contrary to the guideline, laboratory studies are routinely performed. This study suggests there is an opportunity to improve management of SFS by directing efforts toward finding the source of the fever and away from laboratory workup. Keywords simple febrile seizure, lumbar puncture, quality improvement
Introduction Febrile seizures are the most common convulsive event in childhood, occurring in 2% to 5% of children 6 to 60 months of age,1 with simple febrile seizures (SFS) occurring about 65% to 91% of the time.2 A SFS, as defined by the American Academy of Pediatrics Subcommittee on Febrile Seizures, is a primary generalized tonic–clonic convulsive event, which resolves spontaneously, lasting less than 10 to 15 minutes, without recurrence in a 24-hour period. It is accompanied by fever (temperature >38°C) in a neurologically healthy child aged 6 to 60 months.2,3 As a quality improvement measure in May 1996, the American Academy of Pediatrics published a practice guideline regarding the appropriate neurodiagnostic evaluation of patients with a first simple febrile seizure— specifically lumbar puncture, electroencephalography, blood studies, and neuroimaging.4 In February 2011, this guideline was revised, directing the clinician’s attention to identifying the fever source and away from routine laboratory evaluation (lumbar puncture, blood studies, and urine analysis), neuroimaging, and electroencephalography.2,3 If there is a high suspicion for intracranial infection, a lumbar puncture should be performed.3,4 In
the case of an infant 6 to 12 months of age presenting with seizure and fever, without evidence of intracranial infection, the revised guideline states that the clinician has the “option” of performing a lumbar puncture even if the patient has vaccination deficiencies or an indeterminate immunization status or at any age, or if there was antibiotic pretreatment.3 The original guideline stated that in the previous cases, a lumbar puncture should be 1
Seattle Children’s Hospital, University of Washington, Seattle, WA, USA 2 Comer Children’s Hospital, University of Chicago, Chicago, IL, USA 3 NorthShore University HealthSystem, Evanston Hospital, Evanston, IL, USA 4 Illinois Department of Public Health, Springfield, IL, USA 5 Loyola University, Chicago, IL, USA 6 The American Academy of Pediatrics, Elk Grove Villiage, IL, USA 7 Northwestern University Division of Pediatric Emergency Medicine, Chicago, IL, USA 8 Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA Corresponding Author: Stephanie Carapetian, Division of Pediatric Neurology, Seattle Children’s Hospital, University of Washington, 4800 Sand Point Way NW, Neurology B-5552, Seattle, WA 98105, USA. Email: [email protected]
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“strongly considered.”4 The 2011 revision was made after multiple retrospective studies demonstrated that the original guidelines were not being followed.5 The reasons cited for this were that children with SFS are at low risk for a serious bacterial illness,6 including bacterial meningitis,7 and the incidence of bacterial meningitis presenting solely as fever and seizure is between 0% and 0.6%.8 Quality improvement collaboratives (QIC) are frequently used to improve health care by disseminating new and useful knowledge that can be applied directly to patient care.9 This, in turn, improves patient outcomes secondary to increased use of effective treatment and decreases in wasteful care.10 As a quality initiative, in 1984, the federal government approved legislation to create a Federal Emergency Medical Services for Children (EMSC) program, aimed at addressing the needs of children in emergency medical services.11 This legislation has led to each state and United States territory over time establishing a statewide EMSC program. Following this initiative, in 1994, Illinois EMSC was established and since has received grants to establish and enhance the ability to serve children in times of emergency. This project was funded through the EMSC targeted issues grant with the primary objective, to assess the overall management of pediatric patients with SFS presenting to emergency departments (EDs), as a preliminary step in a QIC.
Methods Participants From January 2010 through April 2011, the Illinois EMSC program conducted a statewide ED QI monitor, which was approved by the Loyola University Chicago Institutional Review Board, consisting of an Internetbased survey investigating the practice and policy of care of pediatric patients presenting with SFS. Each participating ED identified individuals involved in completing the survey, which could include Pediatric Quality Coordinator or qualified ED staff nurse, educator, medical director, or physician. Although the clinical roles differ in the ED, all survey responders were knowledgeable about pediatric emergency care.
patient/parent education, discharge instructions, and staff education. A multidisciplinary team composed of QI specialists, pediatric nurses, pediatricians, emergency medicine physicians and nurses, and data analysts collaborated in the development of a survey tool to extract data reflective of an ED’s general approach to pediatric seizure management. A 17-question survey was designed after an initial planning meeting that included pediatric neurologists, pediatricians, ED medical and nursing staff, prehospital staff, a school nurse representative, and a parent whose children were diagnosed with epilepsy. The survey was reviewed extensively by the Illinois EMSC Facility Recognition Committee and QI Subcommittee composed of ED and pediatric critical care physicians, nurses, and midlevel practitioners as well as QI personnel and statisticians. Each ED facility reported the defined age ranges for their pediatric patients and their corresponding annual ED pediatric volume. Additional questions addressed the areas that potentially affect the quality of pediatric seizure management in the ED, including access to a pediatric neurologist; documentation of a seizure policy/ guideline that is used in the approach to these patients, and whether it specifically addresses pediatric patients; and laboratory and radiological measures used in treatment, plans for follow-up care, and patient/parent education (see Appendix A for the full list of questions). Record Review. To determine whether survey findings correlated with clinical practice, a retrospective chart review was performed. Each participating institution was concomitantly requested to randomly select and review ED charts for up to 10 children presenting to the ED with a diagnosis of SFS from January 2010 through April 2011. Each institution was provided a chart abstraction form (see Appendix B for full list of questions), developed by the Illinois EMSC QI Subcommittee. The record review tool included 24 questions consisting of 30 components. This form sought to gather information characterizing the clinical approach to initial assessment and management of children with seizures. Inclusion criteria for the review were limited to children between the ages of 1 month and 15 years treated by ED physicians and nursing staff.
Study Design
Statistical Analysis
Internet-Based Survey. The 119 participating EDs were asked to complete an Internet-based survey of practices regarding their management of SFS including policies or clinical guidelines, laboratory and radiologic measures, documentation, treatment, neurological services,
Pearson χ2 tests were used to evaluate differences between these groups in both the surveys (P < .05) and record reviews (P < .01). All analyses were performed using SPSS statistical software version 17 (IBM Corporation, Somers, NY).
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Carapetian et al Table 2. Emergency Department (ED) Record Review Results.
Table 1. Survey Results. Routine evaluation Complete blood count with differential Urine analysis Serum blood glucose Electrolytes Blood culture Chest radiograph Computed tomography scan of head Lumbar puncture Electroencephalogram Routine documentation Neurologic status Medication history Respiratory status Seizure semiology Immunization status Past medical and surgical history Previous seizure activity Cardiovascular status Signs of infection Family history Potential exposure or ingestion Discharge instructions Explanation of simple febrile seizure Fever management Management of second seizure Primary care provider referral ED return/call 911 Recurrence risk Neurologist referral
74% 69% 64% 59% 58% 36% 10% 2% 1% 96% 95% 94% 92% 92% 91% 90% 87% 81% 65% 57% 96% 95% 93% 93% 90% 60% 21%
Results Survey Results In 2010-2011, 119 EDs actively participated in the Illinois EMSC QIC. Of the 119 participants, 105 responded to the survey, yielding a response rate of 88%. Evaluation (Table 1) commonly included laboratory tests, such as blood and urine studies, less frequently chest radiograph, and much less frequently lumbar puncture, neuroimaging, or neurodiagnostic testing. The criteria used for performing a lumbar puncture largely consisted of physician decision without any set criteria (74%) and/or clinical presentation (63%). Only 12% of facilities reported that criteria included immunization status of child (unknown or deficient in Haemophilus influenzae and Streptococcus pneumoniae immunizations), and 7% based their decision on recent antibiotic pretreatment. A higher percentage of large (6000 or more ED pediatric visits per year) facilities (21%) included immunization status in lumbar puncture criteria than small (less than 6000 ED pediatric visits per
ED evaluation Serum blood glucose Lumbar puncture Computed tomography scan of head ED documentation Neurologic status assessed Documented past medical history Documented seizure semiology Documented evaluation for fever source ED discharge plan and instructions Discharge home Follow-up with primary care provider Follow-up with neurologist Outpatient electroencephalogram Home with rectal diazepam Home with anti-epileptic medication
40% 4% 12% 96% 96% 90% 97% 87% 97% 5% 3% 2% 2%
year) facilities (2%). Documentation (Table 1) of neurological status was reported by most facilities; however, signs of infection, family history (of seizures), and exposure risk were less frequently documented. Discharge instructions (Table 1) and patient education typically included an explanation of febrile seizure and primary care physician referral. Risk of recurrence was only included 60% of the time, and about one fifth of the facilities recommended neurology follow-up.
Record Review Results One hundred hospitals provided data for the record review, yielding 751 charts available for review. A total of 47% of patients were 6 to 23 months of age and 53% were 24 to 60 months of age. Sixty-one percent of patients arrived to the ED via prehospital transport. ED evaluation (Table 2) less commonly included laboratory evaluation as compared to the survey responses related to routine testing. The frequency of cerebrospinal fluid testing with lumbar puncture was low and consistent with the survey results. The majority of EDs documented (Table 2) past medical history and neurological status as well as seizure semiology. An assessment to identify the fever source was documented in almost all of the patient records. The majority of patients were discharged home. Disposition instructions frequently included a follow-up appointment with primary care physician, but rarely included outpatient neurology referral.
Discussion As recommended in the 2011 American Academy of Pediatrics Guidelines, best practice management for
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SFS includes not performing routine laboratory testing (blood, cerebrospinal fluid, urine) and imaging but instead shifting the workup to identify the source of fever. In this survey of over hundred Illinois EDs, laboratory tests (eg, complete blood count with differential, electrolytes, urine analysis) would be performed as part of the routine evaluation of patients with SFS despite the American Academy of Pediatrics best practice guidelines.3,4 These recommendations were defined from multiple observational studies demonstrating that these studies are invasive and costly and would not provide a clear benefit.3,12-15 Since this survey and the 2010-2011 record review were done mainly at community hospitals, it is likely that the ED physicians were not pediatricians, and would not have been as familiar with the 2011 American Academy of Pediatrics guidelines. This can help explain the continued use of laboratory testing, especially complete blood count and urinalysis. The decreased use of lumbar puncture is likely due to the decreased incidence of meningitis seen in the post–vaccine era.7,9 The study by Trainor et al6 demonstrated in a predominantly community hospital setting, in the pre– Haemophilus influenzae, Streptococcus pneumoniae, and varicella vaccine era, 57% of children with SFS either had an uncomplicated infection as the source of fever (otitis media, upper respiratory tract infection, gastroenteritis, varicella infection) or no source identified (34%). In the groups tested, pneumonia was diagnosed by chest radiograph in 12.5% of patients (46% tested), 5.9% were diagnosed with a urinary tract infection (38% tested), 4 patients (1.3%) were diagnosed with S pneumoniae bacteremia (69% tested), and no patients were diagnosed with meningitis (30% tested). In our study, the survey evaluation for source of the fever was underreported as compared to the record review. As the new recommendations suggest, clinical and laboratory evaluation of the fever source should guide the workup and thus be clearly documented in the patient’s chart. Shaked et al,5 in a retrospective chart review from 2001 to 2005, evaluated the frequency and need for lumbar punctures performed on children 6 to 12 months of age. Their study was done in the post-7-valent pneumococcal conjugate vaccination era, and showed that concomitant with the declining incidence of meningitis secondary to more sophisticated immunizations, practitioners were not following the American Academy of Pediatrics 1996 SFS management guidelines with respect to lumbar puncture testing. Only 50% of their patients with SFS underwent a lumbar puncture, which at the time was urged as a “strong consideration” from the American Academy of Pediatrics. Additionally, they
showed that, of the patients who underwent cerebrospinal fluid testing, none had pleocytosis or a positive culture. The authors argued that “performing lumbar puncture in patients 6 to 12 months of age was conceived in a different epidemiologic era with data not representative of current issues,” thus suggesting the need for guideline revision. In 2009, Kimia et al7 published a large retrospective chart review, from 1995 to 2006, of children 6 to 18 months of age with SFS and evaluated the incidence of meningitis. Of the 271 patients with cerebrospinal fluid testing, none had bacterial meningitis. The authors concluded that there is “no evidence that FSFS [first simple febrile seizure] represents any increase in risk for meningitis, compared with children in the same age group with fever but without FSFS.” They urged physicians to direct their decision to perform a lumbar puncture based on the patient’s clinical presentation rather than focusing on age. Additionally, the authors reviewed the frequency of which lumbar punctures were performed, demonstrating that, among all age groups, there was a decrease in lumbar puncture testing over time. This sentiment was echoed in the 2009 American Academy of Pediatrics Grand Rounds,16 thus prompting the revised guidelines and urging clinicians to focus on symptoms and signs of meningitis as to help determine whether a lumbar puncture is performed. The aim of this study is to evaluate how practitioners would work up a child with SFS after guideline revision in 2011. From this study, survey and retrospective record review results indicate that lumbar puncture testing was done infrequently, consistent with best practice guidelines. Because of the benign nature of SFS and good prognosis, including low likelihood of future development of epilepsy,1 the American Academy of Pediatrics recommends against long-term medication management of SFS with anti-epileptic drugs.17 The survey and record review results indicate that disposition with anti-epileptic drugs is rare, consistent with best practice guidelines. Finally, there is a correlation between survey responses and chart reviews in regard to the performance of a lumbar puncture and head computed tomography scan, as well as documentation of neurological status, seizure semiology, and past medical history, indicating that what the respondents of the survey state correlates with their actual management decisions.
Limitations and Future Implications There are several limitations to this study. The survey completion differed by facility, sometimes performed by
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Carapetian et al a nurse, less frequently by a physician, and sometimes by multiple staff members. A second limitation of this study is that data collected from the record review does not include information about the frequency of blood and urine laboratory studies. Without this information, we are unable to make comparisons of actual practice to reported practice. A third limitation of this study is that the data from the record review stratifies children into 2 age groups, 6 months to 23 months old and 2 years to 5 years old, whereas it would have been helpful to look closely at the ED practices with children under 12 months of age. Despite these limitations, this multicenter QIC demonstrates that the Illinois EDs participating in this project have changed their practice with respect to routinely performing a lumbar puncture in SFS patients, but also shows that ED management of SFS still includes routine laboratory studies. An online learning module has been created to educate ED personnel about the best practice guidelines for SFS workup. Future studies would include examining the response to the learning module and changes in practice, specifically with respect to laboratory and imaging studies.
Conclusions This study demonstrates that there is an opportunity to improve management of SFS by directing efforts toward finding the source of the fever rather than the seizure, and thus away from unnecessary laboratory and imaging studies. This QIC shows that medical professionals, in SFS evaluation, both report a low incidence of routine lumbar puncture and in practice are infrequently performing lumbar punctures, but are underreporting their clinical evaluation for the fever source, whereas in practice are performing a thorough clinical evaluation.
Appendix A Pediatric Simple Febrile Seizure in the ED— Survey Questions 1. How does your emergency department define the pediatric population? 2. What is the average volume of pediatric (defined as 0 through 15 years old) ED visits per year in your facility? 3. What is the average volume of ALL patient (adult and pediatric) ED visits per year in your facility? 4. Does your ED have a documented protocol/policy/guideline/ clinical pathway that addresses the clinical management of seizures (eg, Seizure, Altered Level of Consciousness, Fever)? a. Does your ED’s protocol/policy/guideline/clinical pathway specifically address pediatrics? 5. What laboratory and radiologic measure(s) does your ED routinely require for the management of Simple Febrile Seizures? Check all that apply (continued)
Appendix A (continued) a. CBC with differential b. Blood cultures c. Blood glucose d. Urinalysis e. Urine culture f. Electrolytes g. Strep/RSV swab h. BUN and Creatinine i. Lumbar puncture j. Chest x-ray k. Head CT l. EEG m. MRI/MRA n. EKG o. None 6. W hat documentation does your ED routinely require for the management of Simple Febrile Seizures? Check all that apply a. Respiratory status b. Cardiovascular status c. Neurologic status d. Signs of infection e. Description of presenting seizure f. Immunization history/status g. Previous seizure activity h. Medication history (include antibiotics) i. Medical/surgical history j. Exposure or ingestion history k. Familial history of seizure l. None 7. For Simple Febrile Seizure patients, what are your ED’s criteria for doing an LP? Check all that apply a. Based on child’s age (eg, every child under 12 months) b. B ased on clinical presentation (signs/symptoms of meningitis/ bacteremia; child looks “toxic”) c. B ased on child’s immunization status (unknown or deficient in H influenzae and S pneumoniae immunizations) d. Based on if child has/has been previously/recently treated with antibiotics e. Per physician decision (no set criteria) f. L Ps are not done on patients presenting with simple febrile seizures g. I don’t know hat component(s) are included on your ED’s seizure discharge 8. W instructions/patient education for Simple Febrile Seizure? Check all that apply a. Explanation of febrile seizure b. What to do if another seizure occurs c. When to return to ED/call 911 d. Provide reassurance e. Fever management f. Review risk of reoccurrence g. Conduct medication reconciliation h. Review seizure precautions i. Primary Care Physician referral j. Neurology referral k. None 9. In the past year, has your ED staff received education related to pediatric seizure disorders? 10. D oes your hospital conduct chart reviews of patients with any type of Seizure diagnoses for QI purposes?
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Appendix B Pediatric Simple Febrile Seizure in the ED— Medical Record Review 1. What was the patient’s mode of arrival? Prehospital: If a patient arrived via EMS from the scene, answer Questions #1a-e. a. What level of prehospital service was used? b. Was the child’s airway controlled appropriately? c. Was the child’s neurologic status assessed? d. Was blood glucose level checked by prehospital provider? e. Was a description of the seizure documented (for example: who witnessed seizure, what did the seizure look like, how long did it last, how was the child acting right before seizure, how was the child acting the day before, etc)? Initial ED Assessment: 2. Age of patient (in months or years) 3. Was the child actively seizing upon arrival to the ED? 4. Was the neurologic status assessed? 5. Was blood glucose checked? Choose N/A if blood glucose was checked prehospital. 6. Was full medical and seizure history documented (for example: medications given prior to arrival to treat fever, child/family seizure hx, antibiotic/antiepileptic medication hx, immunization status, hx of incontinence, last feeding/ meal, recent hx of trauma, underlying health problems, surgical hx, recent ingestion, recent exposure, child’s baseline status, age-related assessments, bruising, bites, etc)? 7. Was a description of seizure documented (for example: who witnessed seizure, what did the seizure look like, how long did it last, how was the child acting right before seizure, how was the child acting the day before, etc)? 8. Was an assessment performed to identify the source of the fever? ED Management: 9. Was the child’s airway controlled appropriately? 10. Was a LP performed? 11. Was a head CT performed while child was in the ED? 12. If the child was febrile in the ED (temp. ≥ 100.4°F/38.0°C), was an antipyretic administered? Choose N/A if parent/caregiver gave antipyretic prior to arrival OR if patient no longer febrile. 13. If child was actively seizing, was an anticonvulsant administered? Choose N/A if child was not actively seizing 13a. If yes, was it administered within 15 minutes of child’s arrival? Disposition/Discharge: 14. Was the child’s neurologic status reassessed before disposition? 15. Was the child’s temperature reassessed prior to discharge? 16. What was the child’s disposition from the ED? a. Transferred (T) = transferred to a higher level of care (answer Q.16a) (continued)
Appendix B (continued) b. P ICU Admission (P) = admitted to PICU/ICU (in same hospital) c. Intermediate Care Admission (I) = admitted to an intermediate care bed (in same hospital) d. General Admission (F) = admitted to a general care floor (in same hospital) e. Observed (O) = admitted to an observation unit/ general floor and/or observed in the ED for ≤23 hours (in same hospital) f. H ome (H) = discharged home after a brief period of observation (≤6 hours) (answer Q.17-23) g. Expired (E) = expired in the ED 16a. If transferred, what level/type of patient transport service was used? a. Specialty/Transport Team (S) b. ALS/ILS (A) c. ALS/ILS (with nurse) (A/n) d. BLS (B) e. BLS (with nurse) (B/n) f. Private vehicle (PV) 17. Was an outpatient EEG ordered upon discharge from the ED? Choose N/A if child was transferred or if hospital policy does not require EEG. 18. W as rectal diazepam prescribed in the ED for home use? Choose N/A if already prescribed or if the child was transferred. 19. W as an oral antiepileptic drug (for example: phenobarbital, phenytoin, valproate, etc) prescribed in the ED for home use? Choose N/A if already prescribed or if the child was transferred. 20. D id the child/family receive pediatric seizure patient education prior to discharge? Choose N/A if child was transferred. 21. D id the child/family receive pediatric fever management education prior to discharge? Choose N/A if child was transferred. as the child/family instructed to follow up with 22. W a Primary Care Physician? Choose N/A if child was transferred. 23. W as the child/family instructed to follow up with a Neurologist? Choose N/A if child was transferred.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Emergency Medical Services for Children targeted issues grant.
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