Improved availability and quality of care with epilepsy nurse practitioners

Improving Seizure Frequency Documentation and Classification

Background and Objectives

Accurate and reliable seizure data are essential for evaluating treatment strategies and tracking the quality of care in epilepsy clinics. This quality improvement project aimed to increase seizure documentation (i.e., documentation of seizure frequency from 80% to 100%, date of last seizure from 35% to 50%, and International League Against Epilepsy (ILAE) seizure classification from 35% to at least 50%) over 6 months.

Methods

We surveyed 7 epileptologists to determine their perceived seizure frequency, ILAE classification, and date of last seizure documentation habits. Baseline data were collected weekly from September to December 2021. Subsequently, we implemented a newly created flowsheet in our Electronic Health Record (EHR) based on the Epilepsy Learning Healthcare System (ELHS) Case Report Forms to increase seizure documentation in a standardized way. Two epileptologists tested this flowsheet tool in their epilepsy clinics between February 2022 and July 2022. Data were collected weekly and compared with documentation from other epileptologists within the same group.

Results

Epileptologists at our center believed they documented seizure frequency for 84%-87% of clinic visits, which aligned with baseline data collection, showing they recorded seizure frequency for 83% of clinic visits. Epileptologists believed they documented ILAE classification for 47%-52% of clinic visits, and baseline data showed this was documented in 33% of clinic visits. They also reported documenting the date of the last seizure for 52%-63% of clinic visits, but this occurred in only 35% of clinic visits. After implementing the new flowsheet, documentation increased to nearly 100% for all fields being completed by the providers who tested the flowsheet.

Discussion

We demonstrated that by implementing an easy-to-use standardized EHR documentation tool, our documentation of critical metrics, as defined by the ELHS, improved dramatically. This shows that simple and practical interventions can substantially improve clinically meaningful documentation.

Construction of nursing-sensitive quality indicators for epilepsy in China: A Delphi consensus study

OBJECTIVE

The quality and safety of epilepsy care are of great importance because seizures are unpredictable. The aim of this study was to develop a set of nursing-sensitive quality indicators (NSQIs) for assessing and improving the quality of epilepsy nursing care in China.

METHODS

An international literature review, a cross-sectional survey and a qualitative study were conducted to identify candidate NSQIs for epilepsy care and compile a questionnaire. Then, two rounds of electronic Delphi studies were conducted with a panel of 27 independent experts to identify the final NSQIs for epilepsy.

RESULTS

Thirty-nine candidate NSQIs were extracted for the Delphi process. The recovery rates in the first and second rounds of expert consultations were 92.6% and 96.2%, respectively. The experts' authority coefficients of the two rounds were 0.876 and 0.878, respectively. The Kendall W value of the two rounds ranged between 0.094 and 0.200 (p<0.001). Eight structure indicators, 9 process indicators and 7 outcome indicators that represented the following three domains were included in the set of NSQIs for epilepsy: nursing resource allocation, implementation of nursing care, and outcomes of patients with epilepsy.

CONCLUSION

These NSQIs for epilepsy provide a primary foundation for monitoring and improving the quality of epilepsy nursing care in China. However, the effects of these indicators on improvements in epilepsy care and outcomes in patients need to be verified in clinical practice.

Owner perspectives on the impact of veterinary surgeons upon their decision making in the management of dogs with idiopathic epilepsy

BACKGROUND

Idiopathic epilepsy is a prevalent canine condition that can be challenging to manage. A positive vet-owner relationship contributes to satisfaction and compliance, but its impact on management is unclear. The aim of this study was to investigate owner perspectives about the impact of veterinary surgeons on decision making and management.

METHODS

Qualitative methods were utilised, and semi-structured interviews were completed with 21 owners of dogs with epilepsy who lived in England. Transcripts were thematically analysed, and this study discusses the theme 'influences of the veterinary surgeon'.

RESULTS

Many owners felt that more precise expectations could have improved interactions with their veterinary surgeon(s), and their experiences of caring for their dog. Most owners referred to a specialist reported a positive experience, often due to specialists being perceived to have greater experience or knowledge. Owners who reported predominantly negative experiences were often less trusting of the veterinary profession, and more likely to perform self-directed research.

LIMITATIONS

These results represent the experiences of a small subset of owners, and larger scale studies are required to support these findings.

CONCLUSION

Owners appear to value the formation of partnerships of care with their veterinary surgeon, and greater availability of educational resources could further improve owner satisfaction.

The State of Specialized Epilepsy Care in the States: Increased Access, New Tools, but the Same Dismal Underutilization of Epilepsy Surgery

United States Epilepsy Center Characteristics: A Data Analysis From the National Association of Epilepsy Centers

Ostendorf AP, Ahrens SM, Lado FA, et al. Neurology. 2022;98(5):e449-e458. doi:10.1212/WNL.0000000000013130.

Background and objectives:

Patients with drug-resistant epilepsy (DRE) may benefit from specialized testing and treatments to better control seizures and improve quality of life. Most evaluations and procedures for DRE in the United States are performed at epilepsy centers accredited by the National Association of Epilepsy Centers (NAEC). On an annual basis, the NAEC collects data from accredited epilepsy centers on hospital-based epilepsy monitoring unit (EMU) size and admissions, diagnostic testing, surgeries, and other services. This article highlights trends in epilepsy center services from 2012 through 2019.

Methods:

We analyzed data reported in 2012, 2016, and 2019 from all level 3 and level 4 NAEC accredited epilepsy centers. Data were described using frequency for categorical variables and median for continuous variables and were analyzed by center level and center population category. EMU beds, EMU admissions, epileptologists, and aggregate procedure volumes were also described using rates per population per year.

Results:

During the period studied, the number of NAEC accredited centers increased from 161 to 256, with the largest increases in adult- and pediatric-only centers. Growth in EMU admissions (41%), EMU beds (26%), and epileptologists (109%) per population occurred. Access to specialized testing and services broadly expanded. The largest growth in procedure volumes occurred in laser interstitial thermal therapy (LiTT) (61%), responsive neurostimulation (RNS) implantations (114%), and intracranial monitoring without resection (152%) over the study period. Corpus callosotomies and vagus nerve stimulator (VNS) implantations decreased (−12.8% and −2.4%, respectively), while growth in temporal lobectomies (5.9%), extratemporal resections (11.9%), and hemispherectomies/otomies (13.1%) lagged center growth (59%), leading to a decrease in median volumes of these procedures per center.

Discussion:

During the study period, the availability of specialty epilepsy care in the United States improved as the NAEC implemented its accreditation program. Surgical case complexity increased while aggregate surgical volume remained stable or declined across most procedure types, with a corresponding decline in cases per center. This article describes recent data trends and current state of resources and practice across NAEC member centers and identifies several future directions for driving systematic improvements in epilepsy care.

Advanced Practice Provider Care Team Models: Best Practices From an Academic Medical Center

Health care leaders must be innovative to meet the demands of patient access and cost efficiency, all while never compromising patient safety or experience. A clear understanding of the care team model with optimal utilization of all team members is paramount to success. This article discusses 5 nurse practitioner and physician assistant (collectively called advanced practice providers) care team models that regularly occur in health care organizations across the country. Examples of each practice model, a discussion on when each model would be appropriate, as well as data on patient experience and financial return of investment of each model are provided.

Challenges of patients with epilepsy and measures for improving epilepsy care in western China: A qualitative study

OBJECTIVE

The aim of this qualitative study was to explore the challenges that patients with epilepsy (PWEs) face and the opportunities or areas where changes in nursing care may improve epilepsy care in western China.

METHODS

Semi-structured interviews with open-ended questions based on a review of the literature were conducted at the epilepsy center of a tertiary hospital in western China. A total of 18 PWEs, 18 caregivers and 11 neurology nurses were interviewed by using purposive sampling. The data were transcribed verbatim, and a content analysis was used to conduct the framework analysis.

RESULTS

Three key themes were identified, namely, the impact of epilepsy, barriers to epilepsy management, and measures in nursing care for improving epilepsy care. Psychological stress, the side effects of drugs and accidental injury related to seizures were reported to be the main negative impacts on patients. Limited knowledge about epilepsy, poor adherence to therapy, and a lack of effective communication between patients and medical staff were the major barriers to epilepsy management. Strengthening health education, assessing the frequency and type of seizures, screening for psychological disorders and mental intervention, and maintaining continuity of care were identified as crucial measures for nurses to improve epilepsy care.

CONCLUSIONS

This study highlights the challenges among PWEs and opportunities for improving the quality of epilepsy care in western China. Limited knowledge and poor drug adherence are the main barriers to epilepsy management, which might be improved by more health education and continuing care provided by nurses. Assessing seizures, screening for psychological disorders and providing appropriate psychological care would help improve epilepsy care.

Classifying epilepsy pragmatically: Past, present, and future

The classification of epilepsy is essential for people with epilepsy and their families, healthcare providers, physicians and researchers. The International League Against Epilepsy proposed updated seizure and epilepsy classifications in 2017, while another four-dimensional epilepsy classification was updated in 2019. An Integrated Epilepsy Classification system was proposed in 2020. Existing classifications, however, lack consideration of important pragmatic factors relevant to the day-to-day life of people with epilepsy and stakeholders. Despite promising developments, consideration of comorbidities in brain development, genetic causes, and environmental triggers of epilepsy remains largely user-dependent in existing classifications. Demographics of epilepsy have changed over time, while existing classification schemes exhibit caveats. A pragmatic classification scheme should incorporate these factors to provide a nuanced classification. Validation across disparate contexts will ensure widespread applicability and ease of use. A team-based approach may simplify communication between healthcare personnel, while an individual-centred perspective may empower people with epilepsy. Together, incorporating these elements into a modern but pragmatic classification scheme may ensure optimal care for people with epilepsy by emphasising cohesiveness among its myriad users. Technological advancements such as 7T MRI, next-generation sequencing, and artificial intelligence may affect future classification efforts.

Responsive Vagus Nerve Stimulation for Drug Resistant Epilepsy: A Review of New Features and Practical Guidance for Advanced Practice Providers

Vagus nerve stimulation (VNS) is a safe and effective therapy that has been available for over 20 years for adults and children with drug resistant epilepsy (DRE). Since U.S. Food and Drug Administration approval in 1997, VNS has been implanted in over 100,000 patients including over 30,000 children as an adjunctive therapy in reducing the frequency of seizures in patients 4 years of age and older with focal seizures that are refractory to antiseizure medications. VNS Therapy® has evolved over time and currently offers closed-loop, responsive stimulation as well as advanced features that streamline dosing and patient management. Advanced Practice Providers (APPs) such as nurse practitioners, physician assistants and clinical nurse specialists are integral in a comprehensive healthcare team, and dedicated VNS clinics have formed at comprehensive epilepsy centers across the world that are often managed by APPs. This approach improves access, education, and continuity of care for those with VNS or those considering VNS. Here we provide a review for APPs on the VNS Therapy® system focused on new features, dosing, and troubleshooting strategies with the goal to provide guidance to those managing VNS patients.

Telephone-based follow-up of children with epilepsy: Comparison of accuracy between a specialty nurse and a pediatric neurology fellow

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Childhood epilepsy forms a significant burden on the health-care delivery system.

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Telemedicine is a proposed effective alternative in overcoming this burden.

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Even simple mobile phones can be used by paramedical professionals.

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Tele-consultation in childhood epilepsy by pediatric neurology fellow has excellent sensitivity and specificity.

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A specialty nurse has also acceptable sensitivity and specificity in comparison with face-to-face consultation.

Background

Childhood epilepsy forms a significant burden on the health-care delivery system. Only a few pediatric neurologists available in most of the developing countries and caregivers face a lot of financial and logistic hardships, apart from a long waiting period for initial and follow up visits. Telemedicine is a proposed effective alternative in overcoming this burden.

Methods

Telephonic consultation by a pediatric neurology fellow was compared with that of a specialty nurse; both against face-to-face consultation (gold standard). Care-givers of children 4 months-18 years with epilepsy were telephonically consulted 24−48 hours before their scheduled hospital appointment by one specialty nurse and one pediatric neurology fellow at least 24 h apart in a random sequence. During the hospital visit, another pediatric neurology fellow blinded to the telephonic consultation, documented the same after Face-to-Face interview.

Results

In 141 children with epilepsy, 504 critical clinical events were identified. Telephonic consultation by pediatric neurology fellow had a sensitivity of 99 %, 97 %, and 100 % and specificity of 100 % each in detecting whether the child had any breakthrough seizure, any adverse event and whether the drug compliance was adequate or poor respectively, as compared to face-to-face consultation. Telephonic consultation by specialty nurse had a sensitivity of 91 %, 84 %, and 98 % and specificity of 97 %, 99 %, and 81 % in detecting whether the child had any breakthrough seizure, adverse event and whether the drug compliance was adequate or poor respectively. But the specialty nurses fared poorly in identifying atypical seizure semiologies like atonic and myoclonic seizures and documenting an exact number of breakthrough seizures, as well as few subjective adverse effects like behavioral abnormality and scholastic worsening, which was performed excellently by the pediatric neurology fellow.

Conclusions

Telephonic consultation in childhood epilepsy by pediatric neurology fellow has excellent sensitivity and specificity. A specialty nurse has also acceptable sensitivity and specificity in comparison with a face-to-face consultation.

Towards a pragmatic epilepsy classification: Future considerations

The Integrated Epilepsy Classification was recently proposed to merge the 2017 International League Against Epilepsy classification and the four-dimensional epilepsy classification updated in 2019. The efforts in developing the concept of an Integrated Epilepsy Classification scheme are encouraging. However, consideration of brain age, validation in contexts that differ in socioeconomic status and with poor healthcare infrastructure, and incorporation of a team-based approach are necessary. These advancements allow for better clinical management of people with epilepsy and empower people with epilepsy globally.

Stereoelectroencephalography and the Role of the Nurse

BACKGROUND

Stereoelectroencephalography (SEEG) is an invasive diagnostic surgical procedure used to identify specific areas of seizure activity in the brain. SEEG has been shown in both adult and pediatric populations to be a safe and effective tool for preoperative decision making. USES: This is used in patients with medically refractory epilepsy who are potential candidates for brain surgery to control seizures. It is preferred over other invasive diagnostic procedures because of lower risk, reduced discomfort, and shorter operating times.

OUTCOMES

It has a distinct role in obtaining meaningful data that leads to more precise surgical options. All of this results in better seizure control and improved quality of life for the patients.

CONCLUSION

Knowledge of the SEEG procedure, its benefits, complications, and the neuroscience nurse's role will improve care for surgical patients and improve outcomes.

Bridging the childhood epilepsy treatment gap in northern Nigeria (BRIDGE): Rationale and design of pre-clinical trial studies

Epilepsy is the most common serious childhood neurological disorder. In the low- and middle-income countries (LMICs) of Africa, children with epilepsy suffer increased morbidity and mortality compared to their counterparts in high-income countries, and the majority do not receive treatment - the childhood epilepsy treatment gap. Reports of the childhood epilepsy treatment gap in Africa are likely underestimates; most surveys do not include several common childhood seizure types, including most types of non-convulsive epilepsy. Efforts to scale up childhood epilepsy care services in the LMICs of Africa must contend with a shortage of physicians and diagnostic technology [e.g., electroencephalograms (EEGs)]. One pragmatic solution is to integrate epilepsy care into primary care by task-shifting to community health extension workers. The aims of this project (BRIDGE) are to: 1) train, develop, and pilot task-shifted epilepsy care teams; 2) develop and pilot innovative childhood epilepsy screening and diagnostic paradigms adapted to the local Hausa language/culture in Kano, northern Nigeria; and, 3) quantify and map the childhood epilepsy treatment gap, using geographic information systems (GIS), to target limited resources to areas of greatest need. Task-shifted teams will diagnose and manage childhood epilepsy using an innovative epilepsy screening tools and diagnostic and management paradigms in environments with limited EEG access. If validated and demonstrated efficacious in clinical trials, this project can be taken to scale across broader areas of west Africa's LMICs that share language and culture. BRIDGE has the potential to enhance access to basic childhood epilepsy care and establish the foundation for childhood epilepsy clinical trials in west Africa.

The provision of epilepsy care across Europe 2017: A 17-year follow-up survey

OBJECTIVE

To assess the resources available in the provision of epilepsy care across Europe and the developments since the International League Against Epilepsy (ILAE) survey published in 2003 (data collected in 2000).

METHODS

An updated online version of the European Epilepsy Services Inventory was distributed to all European chapters of the ILAE (N = 47) and responses were obtained from 33 chapters (response rate 70%). To assess trends and allow comparisons with the survey published in 2003, the responding countries were divided into 4 groups (Western, Central, Southern, and Eastern). Responses from European Union (EU) member states are reported as a subgroup (N = 23), since the current survey is a part of the EU-funded European Study on the Burden and Care of Epilepsy (ESBACE, www.esbace.eu).

RESULTS

The total number of physicians involved in epilepsy care had increased since 2000, with the largest increase seen for neurologists. The gap between the best- and the least-provided areas with regard to the competence of the providers had diminished. However, the density of comprehensive multidisciplinary epilepsy teams had not changed to any greater degree. The main problems reported by the chapters were to a large extent the same as in 2000 and included lack of specialists and specialist care, lack or underuse of epilepsy surgery, and problems regarding financing and resource allocation. Several chapters also highlighted problems with healthcare structure and organization.

SIGNIFICANCE

Although there have been some improvements concerning the availability of care for people with epilepsy in Europe over the last 17 years, there are still a number of problem areas with little improvement or where there are important regional differences.

Innovative approaches reaching underserved and rural communities to improve epilepsy care: A review of the methodology of the Connectors Project

OBJECTIVE

The Connectors Project, a collaboration between the Epilepsy Foundation and UCB Pharma, was a multiyear project designed to improve epilepsy care in underserved communities. A core objective of the Connectors Project was to pilot new and innovative approaches to epilepsy awareness and education in rural and underserved areas, including standardized curricula for healthcare providers and patients.

METHODS

A series of consensus conferences explored opportunities and barriers to epilepsy care throughout the United States including access to local Epilepsy Foundations, neurologists, and epilepsy centers. Data from QuintilesIMS™ were examined for access to newer antiepileptic drugs (AEDs)-a proxy for quality of epilepsy care-in different regions. State factors (e.g., local epilepsy foundation office, access to newer vs. older AEDs, and geographic density and diversity) were used in selecting four states as examples of rural and underserved areas to pilot the awareness and educational programs. For each state, a work team assessed challenges and opportunities, tailored educational curricula, and developed strategies for effective delivery of the educational programs. Interventions were held between June 2016 and June 2017. Interventions consisted of outreach and awareness programs, in-person health education to healthcare providers and patients/families, and digital health education.

RESULTS

Michigan, Nevada, Oklahoma, and West Virginia were identified as pilot states representing geographically diverse areas, ranging from a state with a large high-density population center with several epilepsy centers and a local Epilepsy Foundation office (Michigan) to a state with predominately rural areas and a few small urban cores, two epilepsy centers, and no in-state Epilepsy Foundation office (West Virginia). State work teams tailored interventions and examined options for type, intent, ease of use, and impact. All states implemented outreach and awareness initiatives and in-person health education for patients and healthcare providers; use of digital health education was variable. Measurement of the interventions was agreed to be performed by the use of patient and physician surveys and reevaluation of data from QuintilesIMS for access to newer AEDs.

CONCLUSION

Local Epilepsy Foundation offices successfully connected healthcare providers in rural and underserved areas to epilepsy education designed to enhance quality care in epilepsy. Educational opportunities for people with epilepsy and their families addressed critical gaps in accessing quality epilepsy care and self-management. Tailored and innovative educational approaches can be used to increase awareness levels and to overcome geographic challenges in reaching underserved populations. Relationship building and repeated, consistent engagement with healthcare providers and patients can assist in improving communication and self-management skills among patients with epilepsy.

Development of an Epilepsy Nursing Communication Tool: Improving the Quality of Interactions Between Nurses and Patients With Seizures

Background: Nurses have become increasingly involved in overseeing the management of patients with complex medical conditions, including those with epilepsy. Nurses who are not specialists in epilepsy can play a central role in providing optimal care, education, and support to their patients with epilepsy, given the proper tools. Objective: Our objective was to create a tool that can be used by nurses in the clinic setting to help facilitate discussion of topics relevant to enhancing medical care and management of patients with epilepsy. To address this need, a panel of epilepsy nursing experts used a patient-centered care approach to develop an Epilepsy Nursing Communication Tool (ENCT). Methods: An initial set of topics and questions was created based on findings from a literature review. Eight nurse experts reviewed and revised the ENCT using focus groups and discussion forums. The revised ENCT was provided to nurses who care for patients with epilepsy but had not been involved in ENCT development. Nurses were asked to rate the usability and feasibility on a 5-point scale to assess whether the tool captured important topics and was easy to use. Results: Ten nurses provided usability and feasibility assessments. Results indicated strong tool utility, with median scores of 4.5, 4, and 4 for usefulness, ease of use, and acceptability, respectively. Conclusions: The preliminary ENCT shows promise in providing a tool that nurses can use in their interactions with patients with epilepsy to help address the complexity of disease management, which may help improve overall patient care.