doctors and nurses talking

Hill CE, Raab J, Roberts D, Lucas T, Pollard J, Kheder A, Litt B, Davis KA. Epilepsy & Behavior, 86(2018):1-5.

About 1 in 3 people with epilepsy have refractory epilepsy and do not have control of their seizures with medications. There is a higher risk for injury (morbidity) and death (mortality) in people who have poorly controlled seizures.

  • Studies have shown that in people who have drug resistant seizures with a focal onset, surgery can offer a 50-80% improvement in seizure control.
  • For people with drug resistant generalized onset seizures, surgery can often provide a way to reduce certain types of seizures or the frequency of seizures.

Despite the real possibilities for improved seizure control and quality of life, it is estimated that only 1% of people with drug resistant epilepsy undergo surgery in a timely manner.


The purpose of this study by Hill and colleagues was to increase the availability and decrease the delay of evaluation for surgery at an epilepsy center for people with drug resistant epilepsy.

Description of Study

  • This study was a quality improvement (QI) project completed at an epilepsy center (University of Pennsylvania).
  • The study compared pre-intervention (2014-2015) data with post-intervention (2016-2017) data for people with drug resistant epilepsy who underwent presurgical evaluation in an epilepsy monitoring unit (EMU).
    • The pre-intervention period included 546 people.
    • The post-intervention period included 638 people.
  • A multidisciplinary team from the epilepsy center worked together to create a “presurgical pathway process map” to make sure people were proceeding through surgical evaluations in a similar way.
  • They also looked at the causes for delays people had when being evaluated for surgery.
  • A dedicated epilepsy surgery nurse manager was put in place as the central person who would oversee, coordinate, and speed the process of getting people through the presurgical evaluation pathway. This included monitoring and guiding their progress through the EMU, the presentation of their cases at surgical conference, and the completion of surgery.
  • Not all people were recommended for surgical evaluation.
  • The improvement measures for this study included
    • Time from initial EMU presurgical admission to case presentation in epilepsy surgical conference (Stage 1)
    • Time from epilepsy surgery conference to surgery completion (Stage 2)
    • Time from initial EMU presurgical admission to surgery completion (Stage 3)

Summary of Study Findings

  • When comparing the pre-intervention period to post-intervention period, the study was able to show:
    • 36% increase in the EMU to surgery conference presentation stage
    • 92% increase in the conference to surgery completion stage
    • 43% increase for the full pathway of EMU to surgery completion
  • The amount of time spent by people traveling through the full pathway from the EMU admission to completed surgery was longer, 219 vs 164 days, with the presurgical process map and the epilepsy nurse manager intervention.
  • The proportion of people evaluated in the EMU who were advanced to surgery was similar between pre- and post-intervention time periods (5.1% vs 6.3%).

What does this mean?

  • This study points to the importance of reviewing the processes in place to evaluate people with drug resistant epilepsy for surgery.
  • This study supports using an epilepsy nurse manager who can provide central oversight for people with epilepsy who are going through the presurgical pathway.
  • Evaluating systems and processes that are in place at an epilepsy center and using an epilepsy nurse manager may result in significant growth and access to surgical evaluation for people with drug resistant epilepsy.
  • Further improvements are needed to address health system bottlenecks that can increase the length of time from presurgical testing to surgery.
  • Developing standardized presurgical testing pathways and clearly stated time goals would be helpful for epilepsy centers. This type of planning will help to improve care for people with drug resistant epilepsy.

Article published in Epilepsy & Behavior, September 2018.

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Authored By: 
Elaine Kiriakopoulos MD, MSc
Authored Date: 
Reviewed By: 
Joseph I. Sirven MD
Sunday, September 16, 2018