396 - Provider Perspectives on Emergency Department Care of Children with New Unprovoked Seizures: A Mixed Methods Study

Publication Number: 4388.396

Amy D. Thompson, Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, DE, United States; Claire Loiselle, Nemours Children's Hospital, Wilmington, DE, United States; Alexandra M. Mapp, ChristianaCare - iREACH, Wilmington, DE, United States; Deborah L. Hammett, NemoursAlfred I. duPont Hospital for Children, Wilmington, DE, United States; Elizabeth Wright-Jin, Nemours Children's Hospital, Wilmington, DE, United States; Courtney Nelson, Nemours Children's Hospital, Wilmington, DE, United States; Michael J. Hansen, Christiana Care Health System, Newark, DE, United States; Mackenzie Seymour, Nemours Children's Hospital, Wilmington, DE, United States; Talia Gillespie, Nemours Children's Hospital, Wilmington, DE, United States; Ime Nkanta, Nemours Children's Hospital, Wilmington, DE, United States; Kimberly D. Williams, Christiana Care Health System, Wilmington, DE, United States

Background: National guidelines advise against routine labs and CT imaging in the emergency department (ED) for children who return to baseline after a first-time, generalized, unprovoked seizure. Despite these recommendations and evidence that these tests rarely impact management, many children still undergo testing.

Objective: 1.) To explore factors influencing ED provider management of pediatric seizures. 2.) To identify barriers and facilitators impacting provider adherence to management standards.

Design/Methods: We conducted an explanatory sequential mixed methods study using an electronic cross-sectional survey and semi-structured interviews. Pediatric emergency medicine (PEM) and emergency medicine (EM) providers from six Delaware EDs were recruited via purposive sampling. An expert panel developed the survey and interview guide, focusing on pediatric seizure guideline knowledge, management preferences, and attitudes towards potential tools to assist with guideline adherence. Survey data were analyzed using descriptive and chi-square statistics. Physicians who completed the survey were subsequently invited for interviews, which continued until thematic saturation. Two research teams coded transcripts using template analysis, meeting regularly to resolve discrepancies. The final themes were mapped to the Capability, Opportunity, Motivation–Behavior (COM-B) model and the Theoretical Domains Framework (TDF).

Results: 103 providers completed the survey; 16 participated in interviews (Table 1). Survey results showed that only 50% of providers reported moderate or high awareness of guidelines discouraging routine CT use, with PEM providers more aware than EM (66.7% vs 36.4%, p<.002). Although 89.6% of PEM providers reported “often” or “always” adhering to guidelines, 25% would still order a CT, 33.0% an ECG, and 39.6% labs in a typical first-time case. EM providers were even more likely to order these tests (CT 47.3%, ECG 69%, labs 89.1%). Our interview analysis demonstrates that provider alignment with guidelines is influenced by several determinants including environmental resources, guideline knowledge and skills in managing family expectations. Key facilitators included access to guidelines and pediatric neurology; practicing outside a tertiary pediatric center was a common barrier.

Conclusion(s): Nonadherence to pediatric seizure guidelines is shaped by knowledge gaps, provider skills, and environmental resource constraints. The impact of social influences on clinical decision-making was a key theme. Using the COM-B/TDF frameworks, future implementation tools can be mapped to these specific barriers.

Table 1: Study Participant Demographics
Table 1 Study Participant Demographics.pdf

TABLE 2: COM-B and TDF Domains with Corresponding Select Themes and Illustrative Quotes
TABLE 2 COM-B and TDF Domains with Corresponding Select Themes and Illustrative Quotes.pdf