Bridging the gap in epilepsy care: A single-center experience of 3700 outpatient tele-epilepsy visits.

We describe the largest-to-date single-center implementation of tele-epilepsy. Beginning in 2017, all patients at a single tertiary care academic epilepsy center were offered the option to complete outpatient follow-up visits via video-conferencing using personal devices. A retrospective review of all patients who self-selected virtual visits over nearly 3 years showed 2140 patients completed 3698 tele-epilepsy visits, with 41% completing more than one visit during the study period. Based on the distance from the center to the home address, 26.7% of patients were local (≤50 miles), 30.5% were near regional (51-150 miles), 20.1% were far regional (151-270 miles), and 22.7% were remote (>270 miles), from 43 different states. An estimated 928 696 miles of travel was prevented, with a median travel distance saved of 124.5 miles (interquartile range = 45.0-253.0). The mean visit time was 15.7 (±10.4) minutes. More than 90% of patients gave the visit and provider experience the maximum rating, with a nearly 60% response rate on the post-visit survey. Virtual outpatient follow-up care provides a convenient way to connect with epilepsy specialists and reduce the burden of care by cutting travel time. Our experience demonstrates that outpatient tele-epilepsy is feasible, sustainable, and scalable.

Evidence of a Rapid Shift in Outpatient Practice During the COVID-19 Pandemic Using Telemedicine.

Introduction: During the current pandemic, measures for preventing SARS-CoV-2 virus exposure has severely impacted the delivery of outpatient clinical care to patients with a chronic neurological condition. Telemedicine has emerged as an obvious choice to counter these impediments. However, its potential for maintaining outpatient care at pre-pandemic levels during these rapidly changing times is untested. Therefore, we analyzed our experience in a tertiary care epilepsy center. Methods: We divided the study period from March 1, 2020 to April 15, 2020 into a baseline, transition (to telemedicine), and current phase. We divided outpatient encounters into clinic, virtual (using Cleveland Clinic Express Care Online platform), and telephone (including commercial video conferencing platforms). Results: Completed outpatient visits during baseline and current period were 595 and 590, respectively. Nearly 1 out of 4 patients missed outpatient visits during the transition period. The virtual visits accounted for 19.7% of completed visits during baseline and increased to 66.8% during the current period. There were no telephone visits during the baseline phase but accounted for 26.1% of completed visits during the current phase. Less than 1 percent of completed visits in the current phase were in the clinic. Conclusion: We provide evidence that telemedicine's robust and rapid scalability can help maintain a seamless transition of outpatient care during the pandemic.

Characteristics and Attendance of Patients Eligible for the PASS Clinic: A Transition of Care Model After Acute Symptomatic Seizures.

Background and Objectives: Most acute symptomatic seizure (ASyS) patients stay on antiseizure medications (ASM) long-term, despite low epilepsy development risk. The Post-Acute Symptomatic Seizure (PASS) clinic is a transition of care model for ASyS patients who individualize ASM management with the goal of a safe deprescription. We evaluated patients discharged on ASMs after a witnessed or suspected ASyS to analyze their PASS clinic visit attendance and its predictors. Methods: A single-center, retrospective cohort study of adults without epilepsy who were discharged from January 1, 2019, to September 30, 2019, on first-time ASMs due to witnessed or suspected ASyS (PASS clinic-eligible). We fit a cause-specific Cox proportional hazards model to analyze factors associated with PASS clinic attendance, which depends on survival in this patient population that has a high early postdischarge mortality (a competing risk). We checked for multicollinearity and the assumption of proportional hazards. Results: Among 307 PASS clinic-eligible patients, 95 (30.9%) attended the clinic and 136 (44.3%) died during a median follow-up of 14 months (interquartile range = 2-34). ASyS occurred in 60.2% (convulsive 47%; electrographic 26.7%) of patients. ASMs were continued in the absence of ASyS or epileptiform abnormalities (EAs) in 27% of patients. Multivariable analysis revealed that the presence of EAs (HR = 1.69, 95% CI 1.10-2.59), PASS clinic appointments provided before discharge (HR = 3.39, 95% CI 2.15-5.33), and less frequently noted ASyS etiologies such as autoimmune encephalitis (HR = 2.03, 95% CI 1.07-3.86) were associated with an increased clinic attendance rate. Medicare/Medicaid insurance (HR = 0.43, 95% CI 0.24-0.78, p = 0.005) and the presence of progressive brain injury (i.e., tumors; HR = 0.55, 95% CI 0.32-0.95, p = 0.032) were associated with reduced rate of PASS clinic attendance. Discussion: Our real-world data highlight the need for appropriate postdischarge follow-up of ASyS patients, which can be fulfilled by the PASS clinic model. Modest PASS clinic attendance can be significantly improved by adhering to a structured discharge planning process whereby appointments are provided before discharge. Future research comparing patient outcomes, specifically safe ASM discontinuation in a PASS clinic model to routine clinical care, is needed.

The Efficacy and Use of a Pocket Card Algorithm in Status Epilepticus Treatment.

OBJECTIVE: To determine whether a pocket card treatment algorithm improves the early treatment of status epilepticus and to assess its utilization and retention in clinical practice. METHODS: Multidisciplinary care teams participated in video-recorded status epilepticus simulation sessions from 2015 to 2019. In this longitudinal cohort study, we examined the sessions recorded before and after introducing an internally developed, guideline-derived pocket card to determine differences in the adequacy or timeliness of rescue benzodiazepine. Simulation participants were queried 9 months later for submission of a differentiating identification number on each card to assess ongoing availability and utilization. RESULTS: Forty-four teams were included (22 before and 22 after the introduction of the pocket card). The time to rescue therapy was shorter for teams with the pocket card available (84 seconds [64-132]) compared with teams before introduction (144 seconds [100-162]) (U = 94; median difference = -46.9, 95% confidence interval [CI]: -75.9 to -21.9). The adequate dosing did not differ with card availability (odds ratio 1.48, 95% CI: 0.43-5.1). At the 9-month follow-up, 32 participants (65%) completed the survey, with 26 (81%) self-reporting having the pocket card available and 11 (34%) confirming ready access with the identification number. All identification numbers submitted corresponded to the hard copy laminated pocket card, and none to the electronic version. CONCLUSIONS: A pocket card is a feasible, effective, and worthwhile educational tool to improve the implementation of updated guidelines for the treatment of status epilepticus.

Post-acute symptomatic seizure (PASS) clinic: A continuity of care model for patients impacted by continuous EEG monitoring.

OBJECTIVE: We present a model for the outpatient care of patients undergoing continuous electroencephalography (cEEG) monitoring during a hospitalization, named the post-acute symptomatic seizure (PASS) clinic. We investigated whether establishing this clinic led to improved access to epileptologist care. METHODS: As part of the PASS clinic initiative, electronic health record (EHR) provides an automated alert to the inpatient care team discharging adults on first time antiepileptic drug (AED) after undergoing cEEG monitoring. The alert explains the rationale and facilitates scheduling for a PASS clinic appointment, three-month after discharge, along with a same-day extended (75 minutes) EEG. We compared the initial epilepsy clinic visits by patients undergoing cEEG in 2017, before ("Pre-PASS" period and cohort) and after ("PASS" period and cohort) the alert went live in the EHR. RESULTS: Of the 170 patients included, 68 (40%) suffered a seizure during the mean follow-up of 20.9 ± 10 months. AEDs were stopped or reduced in 66 out of 148 (44.6%) patients discharged on AEDs. Pre-PASS cohort included 45 patients compared to 145 patients in the PASS cohort, accounting for 5.8% and 9.9% of patients, respectively, who underwent cEEG during the corresponding periods (odds ratio [OR] = 1.8, 95% CI = 1.26-2.54, P = .001). The two cohorts did not differ in terms of electrographic or clinical seizures. The PASS cohort was significantly more likely to be followed up within 1-6 months of discharge (OR = 4.6, 95% CI = 2.1-10.1, P < .001) and have a pre-clinic EEG (51.2% vs 11.1%; OR = 8.39, 95% CI = 3.1-22.67, P < .001). SIGNIFICANCE: PASS clinic, a unique outpatient transition of care model for managing patients at risk of acute symptomatic seizure led to an almost twofold increase in access to an epileptologist. Future research should address the wide knowledge gap about the best post-hospital discharge management practices for these patients.

SIRPIDs: prevalence and outcome in critically ill patients.

PURPOSE: To determine the prevalence, associated factors, and outcomes of critically ill patients with stimulus-induced rhythmic, periodic, or ictal discharges (SIRPIDs) on long-term video-EEG (VEEG). METHODS: After IRB approval, we retrospectively reviewed patient characteristics and VEEG findings of all consecutive critical care unit patients who underwent VEEG monitoring between January 2012 and September 2012. RESULTS: The prevalence of SIRPIDs was 12.1% (4 of 33 patients; exact 95% confidence interval, 3.4%-28.2%). Factors associated with SIRPIDs versus non-SIRPIDs patients included a higher prevalence of subclinical status epilepticus (100% vs. 17.2%, P = 0.003), longer total VEEG recording time (286 vs. 56.9 hours, P = 0.0004), and acute traumatic brain injury (75.0% vs. 17.2%, P = 0.036). Sex, age, a history of epilepsy, nonstatus epileptic seizures, other EEG periodic patterns, and background rhythm reactivity on VEEG did not correlate with the presence of SIRPIDs. The presence or absence of SIRPIDs had no bearing on outcome; however, the population studied was very small. CONCLUSIONS: This small series suggests that the presence of subclinical status epilepticus and traumatic brain injury correlated with the presence of SIRPIDs signifying that SIRPIDs may be due to a more focal etiology and may represent a more ictal pattern than previously thought. Longer recording times in those patient populations may yield more cases of SIRPIDs in which to base further studies.