Interfacility Transfers for Seizure-Related Emergencies in the United States.

Acton EK, Blank LJ, Willis AW, Hamedani AG. Interfacility Transfers for Seizure-Related Emergencies in the United States. Neurology. 2022 Oct 11; 99(24):e2718-27.

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Abstract:

BACKGROUND AND OBJECTIVES: Interfacility transfer protocols are important for seizure-related emergencies, the cause of approximately 1% of all emergency department (ED) visits in the U.S., but data on current practices are lacking. We assessed the prevalence, temporal trends, and patterns of interfacility transfers following seizure-related ED visits. METHODS: We performed a retrospective longitudinal cross-sectional analysis of ED dispositions for seizure-related emergencies among adult and pediatric populations using the Nationwide Emergency Department Sample (NEDS). We used joinpoint regression to analyze annual trends in ED visits and transfer rate from 2007-2018. Logistic regression models using data from 2016-2018 explored the patient- and hospital-level factors associated with transfer versus admission. Sampling weights were applied to account for the complex survey design of NEDS. RESULTS: Using nationally representative data from 2007-2018, there were 7,372,065 weighted ED visits for seizure-related emergencies, including 419,368 (5.6%) visits for a primary diagnosis of status epilepticus. We found that 2.3%-5.6% of all these seizure-related ED visits resulted in an interfacility transfer, and that the rate of transfer increased significantly over time. Among ED visits specifically for status epilepticus, interfacility transfers resulted from 19.8%-23.24% of visits, which also increased over time. Multivariable logistic regression of adult and pediatric visits for status epilepticus revealed transferring hospitals were more likely to be non-metropolitan (adjusted odds ratio (AOR) 2.2, 95% confidence interval (CI) 1.6-2.9), and less likely to have continuous electroencephalography (cEEG) capabilities (AOR 0.3, CI 0.3-0.4). Transferred patients were more likely to be children (AOR 1.5 CI 1.3-1.6 for those 1-4 years old; AOR 1.5 (1.3-1.7) for ages 5-14), have acute cerebrovascular disease (AOR 1.4, CI 1.1-1.8) and have received mechanical ventilation (AOR 1.5, CI 1.4-1.7). DISCUSSION: By 2018, approximately 1 in 19 seizure-related and 1 in 5 status epilepticus ED visits resulted in interfacility transfers. In order of strength of association, illness severity, ED seizure volume, comorbid meningitis and traumatic brain injury, non-rural location, cEEG capabilities, and pediatric age favored admission. Rural location, lack of cEEG capabilities, and comorbid stroke favored transfer. Thoughtful deployment of novel EEG technologies and tele-neurology tools may help optimize triage and prevent unnecessary ED transfers.