Variations in clinical practice and standards of care at epilepsy monitoring units have raised concerns about patient safety among experts in the field.
These concerns are based on the results of recent surveys of American Epilepsy Society members that showed that many epilepsy monitoring units (EMUs) differ significantly in how and when patients are supervised and how often protocols are used during monitoring.
Although the general safety of EMUs is not in doubt, the inconsistencies in practices that were identified in the surveys have led epilepsy specialists to consider what can be done to ensure that the units function as safely as possible.
Four work groups of leaders in epilepsy care convened at the recent annual meeting of the AES in Seattle to identify the shortcomings in care that can occur in patient observation and seizure provocation and to manage emergent seizures and monitor the safety of patient activities in the EMU.
“There are descriptive studies in the literature, but [there is] essentially no evidence-based information on the best way of doing things,” Dr. Paul M. Levisohn of the Children's Hospital, Aurora, Colo., said in an interview.
Because so little data are available to support which clinical practices are best, the work groups hope to “give institutions the tools and skills to begin to identify the areas in which there might be gaps in care so that they can [be] addressed,” said Janice M. Buelow, Ph.D., of Indiana University, Indianapolis, who chaired the symposium at the meeting where the work groups met.
“The idea is to set up systems that protect patients” in ways that are analogous with the protocols that are used in operating rooms to ensure that everything is ready and everyone understands what is planned, said Dr. Levisohn, who is on the AES Practice Standards Task Force and who helped develop the first survey.
But the size of facilities and scope of services offered at EMUs vary substantially, so no one set of recommendations or guidelines will fit all, said Dr. Alison Pack of Columbia University, New York, who is a member of one of the work groups.
The work groups discussed areas for safety evaluations and future research and talked about the importance of making individual plans for each patient, as well as how much supervision is required and who should be doing it.
Others asked what types of accommodations for safety are appropriate for EMU facilities. Some participants wondered if exercise should be allowed, and if so, what types would be best.
Now that initial efforts have been made to identify best clinical practices and areas in which there is room for improving care, the working groups hope to build a national consensus on recommendations for patient safety in EMUs, Dr. Buelow said in an interview.
The results of the first AES-sponsored survey showed that many EMUs did not have protocols for a variety of scenarios. Of the 257 physician respondents, 60% said they occasionally have patients stop taking antiepileptic drugs (AEDs) on admission to an EMU, 34% said that AEDs were never stopped, and 6% reported that AEDs were always stopped.
A little more than half of the respondents reported that their EMU had five or more dedicated monitoring beds.
Overall, 33% of the physicians said that registered nurses provided continuous, 24 hour per day supervision, whereas 21% said that EEG technologists supervised and 20% said that a monitoring technician supervised. Another 26% said that they did not provide continuous supervision.
A second survey that was sent to nurses elicited 39 responses. Nearly all of the nurses said that patients were admitted to their EMU for video EEG monitoring so that they could undergo surface or invasive long-term monitoring or receive neurologic or psychosocial evaluations.
The nurses' replies indicated that most of the EMUs in which they worked lacked protocols for drug withdrawal (74%), drug initiation (77%), treatment of status epilepticus (71%), and sleep deprivation (51%). About half of the nurses reported that patients received constant observation during video EEG monitoring, whereas 38% reported that observation was only intermittent.
About 79% of nurses said that patients were allowed to exercise after admission to an EMU, but only 85% reported that exercising patients were required to have supervision. Nearly 70% said that patients used the bathroom without supervision.
More than 90% of the nurses said that their EMU used padding or had an intravenous access line as precautions against injury.
When patients underwent invasive EEG monitoring, the nurses reported stricter control over exercise, privacy in going to the bathroom, and the degree of observation.
A third survey of AES members, which was completed by 70 respondents in November, elicited details about specific events that had occurred at least once in EMUs during the previous year. Only one person from each EMU was instructed to reply. The events reported by the highest proportion of respondents included falls (69%), status epilepticus (63%), and postictal psychosis (54%).
Other injuries that occurred at least once included lacerations (21%), aspiration pneumonia (10%), cardiac arrest (7%), fractures (6%), falls with concussion (4%), and death (3%).
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