Abstract
Long-term video-EEG monitoring in the epilepsy monitoring unit (EMU), while generally a safe procedure (1, 2), can be associated with adverse events. The majority of EMUs have experienced falls, status epilepticus, and postictal psychosis during monitoring (3); although rare, fatalities and near-fatalities have also occurred in the EMU (2, 4). Even patients with psychogenic nonepileptic seizures are prone to adverse events, usually falls, at a significant rate (5). Provocative procedures such as antiepileptic drug (AED) withdrawal and sleep deprivation increase the risk for adverse events, particularly if there is a history of generalized tonic-clonic seizures (GTCs) as a proportion of them will inevitably experience difficult to control seizures that may require intubation and treatment in the intensive care unit (ICU). Such risks should be understood, prior to monitoring, by both the treating physician as well as the patient. Nonetheless, because video-EEG monitoring is an elective procedure for which possible morbidities are predictable and potentially systematically preventable, safety in the EMU must always be the primary goal of any admission plan.
Despite potential hazards and acknowledged importance of safety measures, there is a wide variation in practice with regard to drug withdrawal, seizure observation, and rescue protocols (6) in the EMU and a clear lack of consensus between epilepsy centers. Implementation of the safety measures may be costly, especially when additional personnel are involved. Automated safety alerts may miss critical events owing to the high false-positive rate that are ignored and can lead to delay in responding to seizures (7).
Because of the importance of this issue, the American Epilepsy Society formed a workgroup to search for evidence and best practices regarding safety measures for patients admitted to the EMU. The first product of this effort was a survey published by Shafer et al. in 2011, identifying the extent to which adverse events occurred in the EMU, including falls, status epilepticus, postictal psychosis, and pulling of implanted electrodes (3).
In their most recent article, “A consensus-based approach to patient safety in epilepsy monitoring units: Recommendations for preferred practices” (8), Shafer et al. build upon these findings to establish a set of consensus practice recommendations for enhancing patient safety in the EMU. First, a set of statements regarding safety were developed by four work-groups in the key areas: seizure observation, seizure provocation, management of acute seizures, and activity/environment. Because the authors found that literature searches revealed lack of evidence, expert consensus was sought using the Delphi methodology. This methodology consists of a series of iterative questionnaires and anonymous feedback (9). A set of statements from the workgroups were consolidated by a screening committee, evaluated by a small group of independent experts, and then further revised. The resulting statements were then submitted to the Delphi process; they were sent in an e-mailed survey to a select group of American Epilepsy Society (AES) members, an expert group, and workgroup members. Respondents rated each of the safety statements on a scale between one (completely agree) and nine (completely disagree). A second survey was sent, with each item's mean and spread; the participants were asked to reevaluate them. Items where rating showed a strong agreement (at least eight) were accepted. These exhaustive efforts generated a set of 30 safety recommendations with strong consensus.
Some of the seemingly more important recommendations did not reach sufficient consensus to be included. For example, the question of whether continuous observation is needed for all patients all the time did not reach consensus. Given the relatively stringent criteria needed for a recommendation to reach acceptable consensus, a lack of consensus on a particular recommendation should not necessarily indicate that the safety measures need not be implemented. For example, the use of a pulse oximeter did not reach consensus, but it may nevertheless be considered because of ease of implementation, low cost, and effectiveness as an adjunctive alarm device.
Will adherence to these safety measures translate to improvement in safety outcomes? There is some encouraging data to suggest that it will. After instituting EMU safety process improvements that included staff education, expanded EMU staffing, fall prevention protocols, and enhanced communication hand-offs, one large EMU was able to achieve significant decrease in missed seizures and a small, though statistically insignificant, decrease in rate of falls (10). Further studies are definitely warranted to determine the extent of improved outcomes as a result of these recommendations.
As these recommendations were carefully selected to represent the strongest consensus amongst the participating expert panel, we recommend all EMUs to consider them in assessing their safety standards. In particular, clearly developed and communicated individualized plans to address these safety issues should be implemented. The following is a summary distilled from the article to help EMUs maintain the focus on safety. A formal checklist is currently being developed.
Patients at high risk, particularly for falls, are screened prior to admission. Clear chain of command for communication/decision making is identified in the chart. Non-medical staff (family members, aides, volunteers) who are participating in seizure observation have received instruction regarding seizure observation and their role in maintaining patient safety. Cardiac monitor is in place with a minimum of a single-lead EKG. Continuous observation is in place for patients with invasive electrode monitoring, at high risk for injury, or undergoing AED withdrawal. Description or video recording of events is reviewed with patient/witnesses to confirm that the typical event has been captured. Safety of bathroom facilities, including degree of staff assistance/supervision, is assessed. Patients are educated regarding changes in mood, pain, or other comorbid conditions that may be affected by tapering AEDs. Physicians who are able to manage seizure emergencies are available in house 24/7. Intravenous (IV) access or alternative methods for drug administration are established at the beginning of the monitoring period. Seizure precautions and seizure first aid are utilized and should at a minimum include the following:
Responding to changes in consciousness, mental status, or behavior; Monitoring vital signs during acute seizures, and during and after administration of IV AEDs; Turning patients on their side as soon as possible after a seizure and removing hazards from the vicinity; Ensuring that suction and oxygen are available; Providing padded side rails; Assessing patients frequently until return to baseline; Recording the length of the event and documenting observations; Establishing criteria for when to inform the responsible physician about a seizure, when to intervene with rescue medications, and when and how to resume preadmission AEDs; Developing EMU-specific protocol for response to seizures. Discharge planning at a minimum should consist of the following:
When and who to call for emergency help; When to contact the patient's epileptologist and/ or psychiatrist for changes in seizures, behavior, or mood; AED changes that occurred during monitoring period and medications to be taken after discharge; How to manage seizures after discharge, including use of rescue or “as needed” meds for temporary treatment of seizures if clinically indicated; Timing of follow-up appointments; Safety precautions, activity limitations, when to resume normal activity; Recognition and treatment of postictal psychosis or other changes in mood or behavior that may occur after discharge.