Fesler 1

Neurology: Clinical Practice Publish Ahead of Print

DOI: 10.1212/CPJ.0000000000000922

D
TE
The efficacy and use of a pocket card algorithm in status epilepticus treatment

Jessica R. Fesler MD, MEHP1, Anne E. Belcher PhD, RN2, Ahsan N. Moosa MD1,
MaryAnn Mays MD3, Lara E. Jehi MD, MHCDS1, Elia M. Pestana Knight MD1, Deepak
K. Lachhwani MD1, Andreas V. Alexopoulos MD, MPH1, Dileep R. Nair MD1, Vineet
Punia MD, MS1
EP
1
Epilepsy Center, Neurological Institute, Cleveland Clinic
2
Johns Hopkins University School of Education
3
Neurological Institute, Cleveland Clinic
C

Corresponding Author:
Jessica R. Fesler
Primary email: feslerj@ccf.org
C

Manuscript word count (< 3000 words): 2983

Abstract word count (< 250 words): 234
Title count (< 96 characters): 13 words (79 characters with spaces)
Number of References (< 40): 25
A

Number of Figures (<5): 4

Neurology® Clinical Practice Published Ahead of Print articles have been peer reviewed and

accepted for publication. This manuscript will be published in its final form after copyediting,

page composition, and review of proofs. Errors that could affect the content may be corrected

during these processes.

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 2

Search Terms: All Education [46]; Methods of education [49]; Status epilepticus [297];
pocket card; simulation

Supplementary Data: none

Study Funding: No targeted funding reported.

Disclosure: The authors report no disclosures relevant to the manuscript.

D
Abstract:

TE
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

EP
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

C

rescue benzodiazepine. Simulation participants were queried 9-months later for

submission of a differentiating identification number on each card to assess ongoing

C

availability and utilization.

Results: Forty-four teams were included (22 before and 22 after the introduction
A

of the pocket card). The time to rescue therapy was shorter for teams with the pocket

card available [84 seconds (64 – 132)] compared to teams before introduction [144

seconds (100 – 162)] (U = 94; median difference = -46.9, 95% CI = -75.9 to -21.9). The

adequate dosing did not differ with card availability (OR 1.48, 95% CI: 0.43-5.1). At 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

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 3
the identification number. All identification numbers submitted corresponded to the hard

copy laminated pocket card, 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.

D
Take Home Points

• Frequent inappropriate dosing and timing of benzodiazepine relates to poor

TE
outcomes in status epilepticus and necessitates new methods of educating care

teams.

• Investigation into the feasibility and efficacy of a status epilepticus treatment

EP
algorithm and dosing pocket card shows promise in improving the care of the

interprofessional team in a simulated scenario.

• A physical resource is preferred and utilized more than a digital copy.

• Time to first rescue therapy in a simulated case of status epilepticus was shorter
C

for teams who had the pocket card available.

• The continued availability of the pocket card to a majority of recipients at 9-month

C

follow-up indicates potential for sustained utilization and improvement in status

A

epilepticus treatment later in clinical practice.

Introduction

Status epilepticus is a neurological emergency associated with considerable

mortality and long-term deleterious effects on neurological function.1 Seizure duration is

the only modifiable factor related to patient outcomes.2-3 Both timeliness and adequacy

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 4
of treatment in the initial critical period leads to improved prognosis.4-6 Specifically, early

and adequate dosing of benzodiazepine has the most evidence for prompt seizure

termination and is emphasized as paramount in all published guidelines.7-11 Improving

education of caregivers who encounter this scenario by increasing familiarity with and

understanding of a standardized initial approach to management has the potential yield

of improving patient care and outcomes.

D
Substantial time and effort is required to create and update evidence-based

guidelines but the greatest influence on clinical care comes in the implementation. Non-

TE
adherence to status epilepticus guidelines is frequent, even in simulated

environments.12 Under-dosing and delayed dosing of benzodiazepine is common and

related to poor outcomes.13 A recent call for guideline-based improvements in education

EP
has been issued.12 Guidelines require adaptation to the environment in which they will

be applied and must be optimized for provider type and context. Creation and

continuous updating of a pocket card to keep pace with new evidence is time and

resource consuming, and only worthwhile if utilized in clinical practice and translates to
C

improved patient care.

The purpose of this study is (a) to assess if a pocket card algorithm improves the
C

treatment of status epilepticus in a simulated scenario and (b) to define the utility of the

pocket card in clinical practice.

A

Methods

Setting and Participants

This study was conducted at the Cleveland Clinic Epilepsy Center. In 2015, an

interprofessional simulation training was created as a multidisciplinary endeavor to

solidify and update knowledge on evidence-based management of status epilepticus.

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 5
Participants included Cleveland Clinic caregivers in epilepsy, specifically adult and

pediatric neurology resident physicians in their initial year of neurology training,

physicians completing a post-residency fellowship in epilepsy, nurse practitioners,

physician assistants, and registered nurses from the epilepsy monitoring unit. The

training was conducted in the Cleveland Clinic Simulation and Advanced Skills Center

as a high-fidelity simulation, standardized with a written sequence of conditions based

D
on participant actions to minimize variability in the application of the treatment algorithm.

High-fidelity simulation is a health-care education tool employing state-of-the-art

TE
mannequins, which have sophisticated features to appear life-like and reproduce

physiological conditions. They have respirations, pulses, cardiac sounds, speech, peri-

oral cyanosis, pupillary responses, and can imitate a convulsive seizure by shaking. The
EP
simulation is conducted in a room as close to the actual treatment environment as

possible with typically available equipment including emergency supplies and real time

vital monitoring. The simulated scenario entailed an adult patient presenting in status

epilepticus. The case was managed by a team which included at minimum one licensed
C

independent practitioner (physician, nurse practitioner, or physician assistant) and a

registered nurse. Any one session included two to four participants on the care team.
C

The subsequent debriefing was facilitated by physician faculty with subspecialization in

epilepsy and nurse managers. The sessions were video recorded and archived since
A

initiation.

Intervention

In 2018, the simulation was enhanced by adding a status epilepticus treatment

algorithm pocket card, which was notably the only pre-session content change for the

training sessions during this study period. This algorithm, including rescue medications

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 6
and doses, was adapted from published national guidelines by the American Epilepsy

Society to the institutional context by an interprofessional team including pharmacists,

epileptologists, neurocritical care physicians, and nurse managers.7 All participants

received both a laminated pocket card and electronic PDF before the simulation session

(Figure 1).

Evaluation

D
To address the first aim of determining if a pocket card treatment algorithm

improved the quality of treatment in a simulated setting, the management of patients in

TE
simulation sessions before and after introduction of the pocket card were compared.

Improved treatment was defined as the timeliness and appropriate dosing of rescue

medications, represented in all published guidelines as the standard of care.7-9 The

EP
primary outcome was a change in parameters that could influence treatment efficacy,

specifically percentage who received an adequate dose of benzodiazepine for the

clinical scenario and the timeliness of treatment . The potential variability in the

simulation scenario protocol that could result from the active feedback loop of facilitator
C

observation of care team decisions, led the authors to choose time to initiation of the

first benzodiazepine dose as a more standardized way to measure and compare the
C

care teams initiation of proper treatment and any effect of the educational intervention

than total time to administer an adequate dose, which could have more confounders. A
A

dose was considered effective if at least 6 mg of lorazepam or the equivalent was given.

This was considered the appropriate dose based on patient weight and determined by

control of seizure activity before a higher dose is reached pending the team’s actions

per the scenario protocol. Retrospective review of recorded simulation videos was

undertaken by an epilepsy faculty for both the historical cohort and the intervention

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 7
group, independently confirmed by a second reviewer blinded to the research question.

Any discrepancies were reconciled with a joint video review.

To assess the utility of the pocket card in the clinical setting, the self-reported

utilization and continued availability of the pocket card were queried from all simulation

participants at 9 months after simulation. Participants were not informed the continued

availability would be queried at a later time. All participants who received the status

D
epilepticus pocket card were sent an optional web-based follow-up survey. Pocket card

availability at follow-up was assessed by entering a differentiating identification number

TE
located on each card as an attempt to objectively confirm ready access to the pocket

card in addition to the self-reported continued clinical use. Only aggregate and non-

identifiable results were reported. A secondary outcome of interest was which form of
EP
the pocket card, the electronic or laminated hard copy version, was used.

Data collection and Analysis

All simulation participants and session data were included in the study. Twelve

participants opted not to complete the follow-up survey and five were lost to follow-up.
C

Descriptive statistics were used to calculate mean percentages for discrete variables

and medians with interquartile ranges for continuous variables. Statistical differences
C

between the historical group and the intervention group were analyzed using Odds

Ratio and Mann Whitney U test. A significance level was set as alpha = 0.05.
A

Standard protocol approvals, registrations, and patient consents

The study was approved by the Cleveland Clinic Foundation Institutional Review

Board.

Data Availability

The anonymized data will be shared by request from any qualified investigator.

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 8
Results

Forty-four teams of caregivers participated in the status epilepticus simulation

over the study period, with 22 teams in the intervention cohort which received the

pocket card and 22 teams in the historical cohort before creation of the pocket card.

One group in the interventional cohort was excluded because the recording failed to

start at the onset of simulation and thus appropriate data could not be obtained. There

ED
was a significant difference in the timeliness of rescue therapy, with the median (Q1 –

Q3) time to first dose of benzodiazepine in the historical cohort being 144 seconds (100

– 162) compared to 84 seconds (64 – 132) in the group with the pocket card available

(U = 94; median difference = -46.9, 95% CI = -75.9 to -21.9). The proportion of groups

T
that gave adequate dosing of rescue medication during the simulation did not differ with
EP
pocket card availability (Odds Ratio 1.48, 95% CI: 0.43-5.1) with 15 teams (68%) in the

intervention cohort and 13 teams (59%) in the historic cohort giving adequate doses of

benzodiazepines for the clinical scenario.

Forty-nine individual participants received the pocket card treatment algorithm

C

and dosing guide prior to their simulation session. Approximately 9 months after the

simulation session, 32 participants (65%) completed the optional follow-up web-based

C

survey. Notably, 5 of the 49 participants were lost to follow-up. They did not receive the

survey because they were no longer in training or in practice at the institution.

A

At 9-month follow-up, 26 (81%) survey respondents reported having the pocket

card still available for clinical use (Figure 2). Furthermore, 11 (34%) respondents

including 3 nurses, 3 residents, 2 fellows, 3 advanced practice providers (APP) were

able to confirm ready access to the pocket card at the time by correctly entering the

identification number on the pocket card. The self-reported utilization of the pocket card

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 9
during the intervening 9 months was reported as sometimes, often, or always by 20 out

of 32 (63%) participants (Figure 3). All (100%) respondents who entered a

differentiating identification number used the laminated hard copy version, with none

entering the number corresponding to the electronic version. When reporting

preference for the version of the pocket card, most respondents (18 total, 56%) selected

the laminated hard copy, but a portion (12 total, 38%) felt both versions were useful

D
(Figure 4).

Discussion

TE
Pocket Card as an Educational Tool

Simulation in neurology, particularly for emergencies like status epilepticus, is

increasingly utilized and encouraged in medical training of clinicians.16-17 A status

EP
epilepticus simulation emphasizing mastery learning was shown previously to be both

feasible and effective.14 Cognitive load is an important component in all learning, but

especially in potentially high-pressure situations such as simulation training and

emergency scenarios.18 Reducing cognitive load also helps improve retention of

C

material.19-20 A pocket card reference can reduce cognitive load by increasing

knowledge and comfort.21-22 Pocket cards can be easily accessed to help implement
C

and standardize practice among busy clinicians, especially in emergency scenarios.23

Desirable features of pocket cards are the ease-of-use, portability, and convenience.24 A
A

pocket card for palliative care was previously evaluated with focus groups to define

desirable features, which included a smaller size card with larger font, color, and the

presence of dosages.22, 24 All of these features were incorporated in the study

intervention in an effort to optimize utility. The study pocket card underwent several

reviews by a group of experts, which included epilepsy specialists, nurses, and

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 10
pharmacists, with many revisions before implementation. Periodic feedback and

updates are required to improve the quality, clinical relevance, and utilization of the

card.

Pocket Card Efficacy

In both the historical and intervention cohorts, all care teams appropriately

selected a benzodiazepine for first line treatment and did not differ in adequate dosing

ED
of rescue therapy. However, access to the pocket card was associated with faster time

to initiation of treatment.

The goal in this high-stake clinical scenario is complete adherence to the

guidelines to improve patient outcomes in every team with every patient. Although this

T
simulation training is intended for relatively novice practitioners, the goal remains to
EP
improve the adequate dosing from the 68% in the intervention cohort to 100%. There is

evidence that repeating the simulation until mastery may achieve this goal, but it is not

clear if this has a retained effect in clinical practice.14 Although all participants in the

intervention cohort received the electronic and laminated versions of the pocket card,
C

there is likely variability in the time spent in independent review and thus individual

participant familiarity with the card, which has implications for the opportunity for
C

efficacy. Reviewing the pocket card with all participants before the simulation might

improve and homogenize the exposure to the pocket card and further improve the
A

treatment of the team.

Because participants know they are attending training for status epilepticus, they

are primed for the diagnosis and treatment. This anticipation could lead to better

performance than in clinical practice. The time to benzodiazepine is anticipated to be

much faster in the simulation than in clinical practice also because of logistical

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 11
differences inherent to the simulated environment. The time to detect and respond to

the seizure, access the medical record, retrieve the dose of medication, and contact the

provider are projected to be longer in a real world clinical setting. Most guidelines

recommend administering the first dose of rescue therapy within 5 minutes and almost

all teams achieved that window within the simulation. However, the earlier dosing in the

intervention group implies participants had an increased comfort with proceeding to the

ED
first step in the algorithm when they had the pocket card reference. It is established that

later dosing of benzodiazepine therapy is associated with a longer duration of

convulsions and higher fatality rate.15 Although there is no concrete data available to

infer the exact difference in timing required to improve outcome in this context, authors

T
hold likely still ‘time is brain’. Thus, in actual practice, this time difference may signify a
EP
clinically relevant improvement in the treatment of status epilepticus.

Pocket Card Utility

The majority of participants self-reported continued use of the pocket card nine

months after introduction, which suggest clinical utility. Status epilepticus is a rare
C

enough condition that not all participants may have encountered this clinically during the

study period. The reported use may underestimate utility by not capturing all who would
C

use the card in the future, which two participants directly commented in the survey. The

survey completion rate is satisfactory with 65% of participants completing the optional 9-
A

month follow-up survey, with near equal percentage across participant roles. Surveys

were sent to all interprofessional team members, but the pocket card may not be as

valuable or relevant to nursing practice as to that of physicians and APPs. This may be

an explanation for the self-reported retention of the pocket care being slightly higher in

percentage of physician trainees (fellows and residents) than APPs or nurses (Figure

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 12
2). However, more nurses and APPs self-reported utilization of the pocket card as either

“always” or “often” than physician trainees at 9-month follow up (Figure 4). As above,

this result may reflect how often the participant had encountered the clinical scenario,

supposed to be more likely for APPs or nurses, who are always treating patients with

epilepsy, rather than physician trainees who rotate on different services and in different

clinical contexts.

D
Studies have shown that pocket cards are a preferred educational tool even

when other options for learning are available.23 The clinical utilization of any pocket card

TE
is related to the context and the user’s perception of clinical relevance, which itself has

many mitigating factors. It can be speculated that pocket cards may be more valuable

for novice practitioners. As participants become more experienced and fluent with the
EP
card content, it may be less useful. Combined with the inevitable likelihood of eventual

misplacement of both the physical and digital copies, we anticipate the pocket card

utilization would decrease with time. One participant commented, “It doesn't replace

knowledge but helps organize my thoughts when developing a rapid plan of care.”
C

Pocket cards across different contexts have been self-reported in small samples

to be used by 76 to 90% at 2 to 6 month follow-up.23-25 This study has a similar

C

percentage with 81% of survey respondents reporting continued availability at a longer

follow-up of 9 months. To overcome the bias of self-reporting, which may over estimate
A

actual availability, we asked respondents to confirm ready availability by entering the

identifying number at the time of follow-up. As expected, a smaller proportion, 11 (34%)

participants, confirmed availability at 9-months by entering the identification number.

There are limitations to this method, expecting some participants will take the survey

when not on clinical duty and be less likely to have the pocket card available. Therefore

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 13
it likely underestimates the true availability. Several participants noted this directly in the

survey comments. Nonetheless the conservative number of 1 in 3 participants that

definitively have the physical card with them 9-months later is enough to confirm utility

in clinical practice.

Pocket Card Format

Surprisingly, none of the entered identification numbers correlated to the

D
electronic version of the pocket card. All submitted identifying numbers correlate with

the physical laminated hard copy. One might theorize the electronic version would be

TE
more accessible and potentially have a longer “life” than a physical version, but this

study does not support that assumption. One prior study showed web-based resources

were self-reported to be used less than a pocket card resource, but qualify that the web-
EP
based resource required log in and several steps to access as a possible explanation.23

The PDF electronic version in this study could be saved easily on any portable device

and later accessed with a few clicks. Most participants expressed a preference for the

laminated hard copy, though some did prefer to have both available.
C

Study Limitations

The limitations of this study include that it is conducted at a single institution with
C

a relatively small sample size in a very specific clinical context, all of which may limit the

generalizability of the results. The participants in the simulation have different roles,
A

differing experience and knowledge, and made up heterogeneous care teams, which

may have influenced the results. Further studies evaluating the use of the pocket card

in different settings in which status epilepticus may be encountered could further

validate its value. The potential variability in the simulated scenario based on care team

actions limited the ability to compare in a standard way the total time to administration of

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 14
an adequate dose, which is a measure worth considering in future study design.

Simulation, though high fidelity, is not equivalent to performance in the clinical

environment and transference of knowledge and skills must be considered and studied

further. Optional surveys carry an inherent bias.

Conclusion

A status epilepticus treatment algorithm and dosing chart pocket card adapted

D
from published guidelines is effective in improving the care of the treatment team in a

simulated scenario. For educators, the creation and continuous updating of a pocket

TE
card to keep pace with evidence-based practice is worth the investment of time and

resources based on the efficacy and continued utilization of the pocket card in clinical

practice. Even in an era of ubiquitous technology, this study suggests that a physical
EP
resource is preferred and more utilized than a digital copy. A pocket card is a feasible,

effective, and worthwhile educational tool to pursue to improve the implementation of

updated guidelines for the acute treatment of status epilepticus.

C
C
A

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited

Appendix 1: Authors
Author
Jessica R. Fesler MD,
MEHP
Anne E. Belcher PhD, RN Johns Hopkins University,
Ahsan N. Moosa MD
MaryAnn Mays MD
EP
Lara E. Jehi MD, MHCDS
Elia M. Pestana Knight MD
C
Deepak M. Lachhwani MD
Andreas V. Alexopoulos
C
MD, MPH
Dileep R. Nair MD
A
Vineet Punia MD, MS
Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
Fesler 15
Location Contribution
Cleveland Clinic, Statistical analysis, Study
Cleveland design and
conceptualization, data
D
collection, analysis, and
interpretation, drafted the
manuscript
TE
Conceptualized study;
Baltimore Data interpretation,
Manuscript revision
Cleveland Clinic, Study design and
Cleveland manuscript revision for
intellectual content
Cleveland Clinic, Study design and
Cleveland manuscript revision for
intellectual content
Cleveland Clinic, Study design and
Cleveland manuscript revision for
intellectual content
Cleveland Clinic, Study design and
Cleveland manuscript revision for
intellectual content
Cleveland Clinic, Manuscript revision for
Cleveland intellectual content
Cleveland Clinic, Study design and
Cleveland manuscript revision for
intellectual content
Cleveland Clinic, Conceptualized study
Cleveland
Cleveland Clinic, Statistical analysis; Data
Cleveland collection, analysis,
interpretation; manuscript
revision for intellectual
content
 Fesler 16

Acknowledgements

Authors would like to thank the additional members of the team who helped

develop and implement the status epilepticus simulation which include Cynthia Sutton

MSN, RN, CRRN (Cleveland Clinic Epilepsy Nurse Manager), Lisa Bell RN MSN, MHA,

D
NE-BC (Cleveland Clinic Pediatric Epilepsy Nurse Manager), Erica Yates MSN, APRN,

ACNS-BC, CRRN, RN-BC (Cleveland Clinic Clinical Nurse Specialist), Michelle

TE
Feliciano M.Ed. CHSE-A (Cleveland Clinic simulation education specialist), Danielle

Harris (simulation administrator) and Shannon Larisch (simulation program coordinator).

We would acknowledge the assistance of the Johns Hopkins Master of Education in

EP
Health Professions program, for which this work was a partial fulfillment of the degree

requirements. Authors are also thankful to the learner participants.

References
C

1. Claassen J, Lokin JK, Fitzsimmons BF, Mendelsohn FA, Mayer SA. Predictors of

functional disability and mortality after status epilepticus. Neurology 2012;58:139–

C

142.

2. Sutter R, Kaplan PW, Ruegg S. Outcome predictors for status epilepticus - what
A

really counts. Nat Rev Neurol 2013;9:525–534.

3. Hill CE, Parikh AO, Ellis C, Myers JS, Litt B. Timing is everything:

where status epilepticus treatment fails. Ann Neurol 2017;82:155–165.

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 17
4. Rao S, Mahulikar A, Ibrahim M, et al. Inadequate benzodiazepine

dosing may result in progression to refractory and non-convulsive status

epilepticus. Epileptic Disord 2018;20(4):265–269.

5. Chin RF, Verhulst L, Neville BG, Peters MJ, Scott RC. Inappropriate emergency

management of status epilepticus in children contributes to need for intensive care.

J Neurol Neurosurg Psychiatry 2004;75:1584–1588.

D
6. Towne AR, Pellock JM, Ko D, DeLorenzo RJ. Determinants of

mortality in status epilepticus. Epilepsia 1994;35:27–34.

TE
7. Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline:

Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the

Guideline Committee of the American Epilepsy Society. Epilepsy Currents

EP
2016;16(1):48–61.

8. Brophy GM, Bell R, Claassen J, et al. Guidelines for the Evaluation

and Management of Status Epilepticus. Neurocritical Care 2012;17(1):3–23.

9. Meierkord H, Boon P, Engelsen B, et al. EFNS guideline on the

C

management of status epilepticus in adults. European Journal of Neurology

C

2010;17:348–355.

10. Wasterlain CG, Chen JW. Mechanistic and pharmacologic aspects of status
A

epilepticus and its treatment with new antiepileptic drugs. Epilepsia 2008;49(9):63–

73.

11. Lowenstein DH. Status Epilepticus. New England Journal of Medicine 1998;

338(14):970–976.

12. Sutter R, Tisljar K, Opic P, et al. Emergency management of status

epilepticus in a high –fidelity simulation. Neurology 2019; 93:1–11.

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 18
13. Sathe AG, Tillman H, Coles L, et al. Underdosing of

benzodiazepines in patient with status epilepticus enrolled in Established Status

Epilepticus Treatment Trial. Academic Emergency Medicine 2019;26(8):940–943.

14. Malakooti MR, McBride ME, Mobley B, et al. Mastery of status

epilepticus management via simulation-based learning for pediatrics

residents. Journal of Graduate Medical Education 2015;7(2):181–186.

D
15. Gainza-Lein M, Sanchez Fernandez I, Jackson M et al. Association

TE
of time to treatment with short-term outcomes for pediatric patients with refractory

convulsive status epilepticus. JAMA Neurol 2018;75(4):410–418.

16. Micieli G, Cavallini A, Santalucia P,Gensini G. Simulation in

neurology. Neurological Sciences 2015;36(10):1967–1971.

EP
17. Sánchez-Ledesma M, Juanes J, Sáncho C, Alonso-Sardon M,

Goncalves J. Acquisition of competencies by medical students in neurological

emergency simulation environments using high fidelity patient simulators. Journal

C

of Medical Systems 2016;40(139):1–7.

C

18. Haji FA, Cheung JJ, Woods N, et al. Thrive or overload? The effect
A

of task complexity on novices’ simulation‐based learning. Medical Education

2016;50(9):955–968.

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 19
19. Issa N, Schuller M, Santacaterina S, et al. Applying multimedia design principles

enhances learning in medical education: Multimedia design principles to enhance

learning. Medical Education 2011;45(8):818–826.

20. Brown G, Manogue M. AMEE Medical Education Guide No. 22: Refreshing

lecturing: a guide for lecturers. Medical Teacher 2001;23(3):231–244.

21. Critchley PP, Grantham M, Plach N. An evaluation of the use of and

D
satisfaction with the palliative care pain and symptom pocket card. J Palliat Care

2002;18:307–311.

TE
22. Balkin EM, Ort K, Goldsby R, Duvall J, Kim CD. Pocket Reference

Card Improves Pediatric Resident Comfort in Caring for Children at End of Life.

Journal of Palliative Medicine 2017;20(4):409–414.

EP
23. Jefferies A, Shah V. Clinicians prefer simple educational tools for

implementing practice change. Medical Teacher 2011;33:602–606.

24. Mikhael, J, Baker L, Downar J. Using a Pocket Card to Improve

End-of-life Care on Internal Medicine Clinical Teaching Units: A Cluster-

C

randomized Controlled Trial. J Fen Intern Med 2008;23(8):1222–1227.

25. Reynolds M, Larsson E, Hewitt R, Garfield S, Franklin BD.

C

Development and evaluation of a pocket card to support prescribing by junior

doctors in an English hospital. Int J Clin Pharm 2015;37:762–766.

A

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 20

Figure 1

Sample of the study pocket card

D
TE
EP
C
C
A

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 21

Figure 2

Self-reported possession of the pocket-card at 9-month follow-up

D
Figure 3
TE
EP
Self-reported utilization of the pocket-card in clinical practice at 9-month follow-up
C
C
A

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 Fesler 22

Figure 4

Stated preference of pocket card version

D
TE
EP
C
C
A

Copyright © 2020 American Academy of Neurology. Unauthorized reproduction of this article is prohibited
 The efficacy and use of a pocket card algorithm in status epilepticus treatment
Jessica R. Fesler, Anne E. Belcher, Ahsan N. Moosa, et al.
Neurol Clin Pract published online August 28, 2020
DOI 10.1212/CPJ.0000000000000922

This information is current as of August 28, 2020

Updated Information &
Services
Subspecialty Collections
Permissions & Licensing
Reprints
including high resolution figures, can be found at:
http://cp.neurology.org/content/early/2020/08/27/CPJ.00000000000009
22.full.html
This article, along with others on similar topics, appears in the
following collection(s):
All Education
http://cp.neurology.org//cgi/collection/all_education
Methods of education
http://cp.neurology.org//cgi/collection/methods_of_education
Status epilepticus
http://cp.neurology.org//cgi/collection/status_epilepticus
Information about reproducing this article in parts (figures,tables) or in
its entirety can be found online at:
http://cp.neurology.org/misc/about.xhtml#permissions
Information about ordering reprints can be found online:
http://cp.neurology.org/misc/addir.xhtml#reprintsus

Neurol Clin Pract is an official journal of the American Academy of Neurology. Published continuously
since 2011, it is now a bimonthly with 6 issues per year. Copyright © 2020 American Academy of
Neurology. All rights reserved. Print ISSN: 2163-0402. Online ISSN: 2163-0933.