Factors associated with rapid pediatric acute seizure emergency treatment: Quality Improvement in Time to Treat Status Epilepticus baseline cohort

Adam P Ostendorf; Gabrielle Brown-Mitchell; Tobias Loddenkemper; Lindsey A Morgan; Brian Appavu; Raquel Farias-Moeller; Dana Harrar; Craig Press; Janette Mailo; Nicholas S Abend; William D Gaillard; Shasha Bai; Mariah Eisner; Emily Kroshus; Kathryn Vannatta; Howard P Goodkin; QuITT‐SE Study Group

doi:10.1002/epi.70344

Factors associated with rapid pediatric acute seizure emergency treatment: Quality Improvement in Time to Treat Status Epilepticus baseline cohort

Epilepsia. 2026 Jul 3. doi: 10.1002/epi.70344. Online ahead of print.

Authors

Adam P Ostendorf¹, Gabrielle Brown-Mitchell¹, Tobias Loddenkemper², Lindsey A Morgan³, Brian Appavu⁴, Raquel Farias-Moeller⁵, Dana Harrar⁶, Craig Press⁷, Janette Mailo⁸, Nicholas S Abend⁷, William D Gaillard⁶, Shasha Bai⁹, Mariah Eisner¹⁰, Emily Kroshus¹¹, Kathryn Vannatta¹, Howard P Goodkin^{11

12}; QuITT‐SE Study Group

Collaborators

QuITT‐SE Study Group:
Karen Allen, Megan Fredwall, Allison Nelson, Megan Rose, Corinne McCabe, Hannah Lehmann, Jared Haught, Lauren McHenry, William Korab, Amanda Courtney, Angela Turner, Coral Crandell, Sophie Rotter-Aboyoun, Zoe Munsey, Mikaela Morales, Jacqueline Lee-Eng, Sahar Rostamian, Elijah Simon, Luisa Fernanda Atunes Ortega, Alyssa Chen, Kristin Reid, Heather Kennedy, Courtney Englehardt, Jensen Kuchrawy, Abigail Howe, Nora Reilly, Lora Pixley, Amy Liljestrand, Annalee Antonetty, Agnieszka Kielian, Jennifer Gettings, Lillian Voke, Shannon Manzi, Lauren Fleser, Jeffrey Bolton, Madeline Chiujdea, Deborah Shiers, Michele Jackson, Stephanie Dailey, Lynn McDaniel, Jared Barkes, Brittany Dunn, Laure Cromwell, Irene Kelly, Kimberlee Meegan, Anne Vasiliadis, Julia S Keenan, Sarah Vepraskas, Ronda Werner, Kimberly Zimmanck, Rupa Nallamothu, Sarah Otterson, Kaley Marrari, Lalaine Dungca, Nigel Negm, Sarah Kiel, Chris Kennie-Richardson, Ariel Hierhozer, Katherine Dyer, Meera Singavi, Molly Green, Nate Evans, Caitlin Keiter, Jessica Johnson, Sara Molisani, Darshana Parikh, Veronica Zielinkski, Rachael Huber, Brody Giblin, Allix Edsill, Jessica Zook

Affiliations

¹ Nationwide Children's Hospital and Ohio State University, Columbus, Ohio, USA.
² Boston Children's Hospital, Boston, Massachusetts, USA.
³ Seattle Children's Hospital and University of Washington, Seattle, Washington, USA.
⁴ Honor Health Neurology, Bob Bove Neuroscience Institute, Scottsdale, Arizona, USA.
⁵ Division of Pediatric Neurology, Department of Neurology, Children's Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
⁶ Center for Neuroscience and Behavioral Health, Children's National Hospital, George Washington University, Washington, District of Columbia, USA.
⁷ Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
⁸ Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, USA.
⁹ Emory University School of Medicine, Atlanta, Georgia, USA.
¹⁰ Biostatics Resource, Nationwide Children's Hospital, Columbus, Ohio, USA.
¹¹ Department of Pediatrics, University of Washington, Seattle, Washington, USA.
¹² Department of Neurology, University of Virginia School of Medicine, Charlottesville, Virginia, USA.

PMID: 42397688
DOI: 10.1002/epi.70344

Abstract

Objective: Status epilepticus (SE) treatment is more effective when benzodiazepines (BZDs) are given soon after SE diagnosis. The Quality Improvement in Time to Treat Status Epilepticus (QuITT-SE) trial is a multicenter, randomized, stepped-wedge effectiveness-implementation hybrid study aimed at improving time to SE treatment. We report the QuITT-SE baseline cohort and test the hypothesis that acute seizure emergency episodes treated promptly differ in clinical and demographic features from those with delayed treatment.

Methods: Data were summarized from 371 consecutive acute seizures episodes treated with a BZD in the inpatient, non-intensive care unit (ICU) setting from 207 individual patients across eight centers per the QuITT-SE protocol. To test our hypothesis, we utilized a multivariable negative binomial mixed effects model with random intercepts to estimate the incidence rate ratios for variables of interest for time to BZD treatment.

Results: The median age was 7 years (IQR = 3-12). Nonelective ICU transfers occurred with 26% of episodes, including 13% within 6 h of the episode. The median time from seizure onset to BZD treatment was 6 min (IQR = 4-10), with 74% of all episodes and 63% of SE treated within 10 min. BZD administration was faster when nurses made the treatment decision, when the intranasal (IN) route was used, when the patient received prior rescue medication within 24 h, or with certain elective admission types. Seizures were shorter when BZD administration was faster or when treatment was with IN midazolam versus intravenous lorazepam (median = 8 min [IQR = 6-15] vs. 10 min [IQR = 7-17], p = .04). Patients were less likely to be transferred to the ICU if they received IN midazolam (odds ratio = .3, p = .007).

Significance: Delayed BZD administration occurs in one third of SE treatment. Prolonged seizures and ICU transfers are associated with modifiable risk factors. Baseline drivers of delayed acute seizure treatment may be addressed using the QuITT-SE interventions, the study of which is currently ongoing.

Keywords: benzodiazepine; pediatric; seizure; status epilepticus; treatment delay.

Grants and funding

R01NS133037/NH/NIH HHS/United States