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Epilepsy Curr. 2013 Mar-Apr; 13(2): 61.
PMCID: PMC3639569

Editorial Comment (Safety in the EMU: Reaching Consensus)

Video-EEG monitoring studies (V-EEG) conducted as part of a diagnostic or presurgical evaluation pose a variety of risks, ranging from falls, increased seizure frequency that can potentially evolve to status epilepticus, psychiatric complications (e.g., postictal psychosis), intracranial bleeds in the case of invasive studies with intracranial electrodes and occasionally death [1]. Yet, most of these risks are preventable with the proper training of staff, education of patients and family members and implementation of “adequate” seizure observation protocols. In fact, to prevent or at least minimize the occurrence of such adverse events, The National Association of Epilepsy Centers (NAEC) has recommended the use of continuous seizure observation (CSO) for any patient undergoing a V-EEG [2].

Unfortunately, protocols to conduct inpatient diagnostic and presurgical V-EEG vary significantly among institutions, ranging from the use of portable units wheeled into a private room without any seizure observation by an EEG technologist and/or nurse to a V-EEG unit with four or more hard-wired rooms from which the EEG and video data are fed into a central monitoring room where they are closely observed by around-the clock specialized EEG technologists, who in-turn alert nurses (and physicians) as soon as any clinical event and/or electrographic seizure is detected. In an attempt to reach consensus of optimal protocols to be implemented among all centers, a task-force of the American Epilepsy Society, headed by Patty Shaffer set-out to develop recommendations, based on a consensus-based approach [3], which is summarized in an article by Lee and Shah in this issue.

The ised by the failure of experts to reach consensus on the need for CSO was surprising, as this is a pivotal step not only for the prevention of adverse events in the EMU but is also necessary for diagnostic purposes (see below). While the authors' finding may be “an artifact” of the Delphi process, or as they point-out in their discussion, the expression of different interpretations of the concept of “continuous observation”, they acknowledge that “much discussion took place at all phases of this process from workgroups to expert panels to rater analysis”. Consensus for CSO was reached for patients in whom antiepileptic drugs (AEDs) are been tapered down or those undergoing V-EEG with intracranial electrodes. The authors summarized some of the arguments recorded against CSO in their discussion: “…for example, what happens when an observer takes a break, uses the rest room, or inadvertently looks away for seconds. Patients being monitored may also require periods of privacy when it is not possible to constantly observe their behavior” [3].

We acknowledge the high cost involved in having specialized EEG technologists and/or nursing staff and the fact that CSO does not ensure 100% detection of clinical and/or electrographic events. Yet, these arguments should not be used as an excuse to curtail its use. In fact, additional precautions can be implemented to minimize such shortcomings. Hospital charges for continuous V-EEG monitoring typically more than standard bed charges to cover the technical costs of monitoring and surveillance. Furthermore, the following circumstances must also be considered when weighing the need for CSO:

  1. Testing of the patient's responsiveness during an event is important to distinguish epileptic vs. psychogenic non-convulsive events. Thus, the absence of CSO may limit the diagnostic yield of these (very costly) studies in patients without overt convulsive activity.
  2. Most V-EEG units with more than 1 bed are likely to have at least one patient in whom AEDs are been tapered down or discontinued (including those patients with suspected non-epileptic seizures). Thus, the argument to limit CSO to such patients (with AED reduction or withdrawal) applies to most if not all V-EEG units. Observers can realistically monitor multiple patients.

We recognize that in this time of limited resources, the risk and benefit of implementing relatively costly programs must be carefully weighed-in. Yet, we worry that “the lack of consensus” on the need of CSO reported in the paper by Shafer et al. [3] could be interpreted by hospital administrators as an excuse to limit its availability in EMUs. Clearly, this was not the message of the workgroup, only that consensus could not yet be reached on this important issue.

REFERENCES

1. Shafer PO, Buelow J, Ficker DM, Pugh MJ, Kanner AM, Dean P, Levisohn P. Risk of adverse events on epilepsy monitoring units: a survey of epilepsy professionals. Epilepsy Behav. 2011;20:502–505. [PubMed]
2. Labiner D.M., Bagic A.I., Herman S.T., Fountain N.B., Walczak T.S., Gumnit R.J. Essential services, personnel, and facilities in specialized epilepsy centers—revised 2010 guidelines. Epilepsia. 2010;51:2322–2333. [PubMed]
3. Shafer P.O., Buelow J.M., Noe K., Shinnar R., Dewar S., Levisohn P.M. A consensus-based approach to patient safety in epilepsy monitoring units: Recommendations for preferred practices. Epilepsy & Behav. 2012;25:449–446. et al. [PubMed]

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