Pediatric epilepsy readmissions

Vawter-Lee M, Lutley A, Lake SW, Fledderjohn S, King A, Horn PS, Wesselkamper KR. Pediatric Epilepsy Readmissions: The Who, When, and Why. Pediatr Neurol. 2018 Dec 25. pii: S0887-8994(18)30895-6. doi: 10.1016/j.pediatrneurol.2018.12.007.[Epub ahead of print]

Abstract

Background

Prior studies have demonstrated a pediatric epilepsy readmission rate of 6% to 10% but have not described details of the readmitted patients. We report the characteristics of pediatric patients admitted for epilepsy who were readmitted to the hospital within 30 days of discharge.

Methods

An interdisciplinary team was established to individually review and characterize the 30-day readmissions of patients admitted for epilepsy from May 2014 to October 2016. The team contained both inpatient and outpatient neuroscience nurses, care managers, a quality outcomes manager, and child neurology physicians.

Results

Over a 30-month period we had an all-cause 30-day readmission rate of 8.0%, which was 219 pediatric epilepsy readmissions from 169 patients. We found that 21.5% of readmissions were scheduled, 37% were for progression of chronic epilepsy, 9.6% were for recently diagnosed epilepsy, and 14.6% were for unrelated diagnoses. We classified 21.5% of readmissions as preventable and 64.9% as not preventable. Thirty-five percent of readmissions occurred within seven days of the initial discharge, including 29 of 47 (61.7%) preventable readmissions. The most common reasons for preventable readmissions were problems with the discharge care plan or medication management.

Conclusions

We demonstrate that 21.5% of pediatric epilepsy readmissions were scheduled and 21.5% were judged to be preventable. The majority of preventable readmissions occurred within seven days of index discharge. Characterizing epilepsy readmissions is the first step in being able to reduce readmissions.

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From the article:

Problems with the discharge care plan (readmission category 3) led to 6.4% of readmissions. Examples included not providing clear medication plans, not providing medication refills when discharging over the weekend, discharging before parents being comfortable going home, retrospective feeling from the reviewing team that the patient was discharged too quickly, and not recognizing feeding intolerance. Another example is that multiple patients were discharged before the electroencephalogram (EEG) being read from the epilepsy monitoring unit after undergoing 24-hour monitoring to evaluate for electrical status epilepticus during sleep (ESES). After the EEG was interpreted as showing ESES, each of these patients was readmitted to start treatment.

Problems with medications (readmission category 4) led to 4.1% of readmissions. Examples include several patients with known nonadherence to recommended medical treatment (including some with open medical neglect cases due to seizure medication nonadherence) and a specialty pharmacy shipping an inadequate dosage of a medication, resulting in readmission until the pharmacy shipped the remaining dosages.

We determined that 21.5% (n = 47) of all-cause 30-day readmissions were preventable (scores of 4 or 5) (95% confidence interval 16.5% to 27.4%, Wilson's score exact procedure) ( Table 2 ). The majority, 64.8% (n = 142), of readmissions were not preventable (scores of 1 or 2). Of the 18 readmissions deemed definitely preventable (score 5), 11 were readmissions occurring because of the discharge care plan. The second most common reason for definitely preventable readmissions was medication management (n = 3).

Of the 29 more likely preventable readmissions (score 4), 19 were due to acute or chronic disease progression. The acute disease progression patients were newly diagnosed with epilepsy, and the readmissions were judged to be preventable due to concern that at the time of index discharge the medications were not yet clearly controlling the seizures or the parents were not yet prepared to manage seizures at home.

Patients who were readmitted were initially discharged across all days of the week ( Supplementary Table 1 ). There was no statistical significance between the day of initial discharge and preventability of future readmissions ( P = 0.78, chi-square with six degrees of freedom). Patients were readmitted on all days of the week ( Supplementary Table 1 ). In terms of preventability, there was no statistical significance between the day of readmission and preventability of the readmission ( P = 0.38, chi-square with six degrees of freedom).

Index admission length of stay ranged from less than 24 hours to 28 days ( Supplementary Figure 1 ). The mean index length of stay was 3.1 days, while the mode was 1 day (n = 74). Readmission length of stay ranged from one day to 53 days ( Supplementary Figure 2 ). The mean readmission length of stay was 4.1 days, while the mode was 1 day (n = 68).

Thirty-five percent of readmissions occurred within seven days. Of the 21.5% (n = 47) of readmissions that were preventable (scores 4 or 5), 61.7% (n = 29) were readmitted in zero to seven days. Further analysis showed that time to readmission was shorter for patients with a preventability score of 4 or 5 (mean = 8.5 days, S.D. = 8.2 days), versus patients with a preventability score of 3 (mean = 11.3 days, S.D. = 7.6 days) or patients whose readmissions we judged were not preventable (score of 1 or 2) (mean = 15.7 days, S.D. = 8.8 days). Based on the preventability scores, these three groups were all significantly different from each other with Wilcoxon rank sum P values = 0.02 (scores 1 or 2 versus score 3), P < 0.001 (scores 1 or 2 versus scores 4 or 5), and P = 0.04 (score 3 versus scores 4 or 5)…

By manually reviewing all 219 readmissions over 30 months, the group concluded that 21.5% of all-cause readmissions were preventable. This percentage is similar to the preventability reported by Toomey et al. and Hain et al. in Pediatrics.  Our study demonstrated that the majority of preventable readmissions (61.7%) occurred zero to seven days following index discharge. These are important data to note, as they allow programs to focus on a smaller subset of readmissions.

Our results showed that discharge care plan problems led to most of our preventable readmissions. Identifying this, our team worked to improve our discharge process by emphasizing medication reconciliation accuracy, creating discharge instruction templates with clear escalation plans for common pediatric neurology disorders (such as seizures, migraines, infantile spasms, febrile seizures, idiopathic intracranial hypertension, ketogenic diet, and psychogenic nonepileptic spells) and ensuring appropriate health literacy level of discharge instructions.

After recognizing that we had multiple readmissions for ESES, our division changed how EEGs are ordered for suspected ESES. These patients are now scheduled in such a way that if the first night of EEG monitoring shows ESES the treatment is started before discharge home. Since making this change we have had zero patients readmitted for initiation of ESES treatment, which has saved families both money and the burden of a second hospitalization.

Some preventable readmissions were due to medication management problems. Solutions for the problems we noted included verifying prescriptions were filled and picked up before discharge and having families do teach-back education with nursing staff to demonstrate understanding of how to measure and administer medications. The importance of medication accuracy at discharge has been examined in multiple other studies, both pediatric and adult, that have examined the role of pharmacists in the discharge process and how this affects readmission rates. 

Patients with acute disease progression, who were newly diagnosed with epilepsy, were noted to have a significant number of more likely preventable readmissions. For some of these readmissions, there was concern that at time of index discharge parents were not yet prepared to manage seizures at home. There have been several pediatric studies examining the child and parent perspectives on readmissions and discharges, including how to determine when a family is ready to be discharged and if parents felt a readmission was preventable.  An overall theme is open communication with families to make sure instructions are clear and that families understand the treatment plan.

Many times children with chronic epilepsy are readmitted for breakthrough seizures, and providers assume it is an unavoidable readmission. However, we found that 11% of these (nine of 81) chronic epilepsy readmissions were preventable. These data reflect a not insignificant number of readmissions that should not be dismissed.