Implementation of the seizure code in a tertiary hospital: Effects on emergency care times and clinical outcomes in severe seizures

OBJECTIVE: To assess the impact of implementing the Seizure Code (SC), a structured multidisciplinary emergency protocol for severe seizures, on care times and clinical outcomes at a tertiary hospital. METHODS: Single-center, retrospective observational study including episodes of severe seizures in patients aged 18 years or older managed between January 2023 and December 2024, comparing pre-SC and post-SC periods. The primary outcome was time from seizure onset to administration of the first anti-seizure medication (ASM). Secondary outcomes included other care intervals, process indicators, and clinical outcomes. Care intervals were analyzed with accelerated failure time models (percentage change in median time), length of stay in a competing-risks framework, and binary outcomes with Firth-penalized logistic regression (odds ratios, OR), all adjusted for prespecified covariates and clustered by patient. RESULTS: Of 1959 episodes identified, 378 (175 pre-SC, 203 post-SC) met SC activation criteria. Time to the first ASM, the primary outcome, did not differ significantly (27% shorter, 95% CI -15% to 53% for benzodiazepines; 27%, -6% to 50% for others). Time to urgent video-EEG (VEEG) was 48% shorter (29%-61%) and the neurological assessment-VEEG interval 63% shorter (31%-80%). Pre-notification by Emergency Medical Services increased (22.9% vs. 37.8%; p = 0.003). Hospital stay (7.48 vs. 5.08 days; subdistribution hazard ratio for discharge alive 1.36, 1.02-1.89) and intensive care unit stay (3.20 vs. 1.48 days) were shorter. Thirty-day seizure recurrence was lower (8.0% vs. 3.0%; adjusted OR 0.33, 0.12-0.84). Mortality and functional status at discharge did not differ. SIGNIFICANCE: The primary outcome, time to first anti-seizure medication, was not significantly shorter after implementation of the structured emergency protocol. The observed benefits were concentrated in secondary process and resource-utilization indicators: implementation of the Seizure Code was associated with faster access to urgent VEEG, shorter hospital and intensive care unit stays, and lower 30-day seizure recurrence, without a significant effect on mortality. These findings support protocolized emergency pathways in severe seizures. PLAIN LANGUAGE SUMMARY: Severe seizures are emergencies in which fast, coordinated care matters. We compared how patients were treated at one hospital before and after a new protocol, the Seizure Code, was introduced. Afterwards, patients had urgent video-EEG (a recording of brain activity) sooner and spent fewer days in hospital and in the intensive care unit, and fewer had another seizure within 30 days. However, the time to the first anti-seizure medication did not change significantly, and deaths and disability at discharge were unchanged.