Abstracts

Rationale: The Epilepsy Monitoring Unit (EMU) provides a unique, important environment to assess patients' seizures both clinically and electrographically. In the EMU, the ictal exam is crucial for neuroanatomic localization of seizure onset, which, in turn, informs medical and neurosurgical management. Uniform clinical assessment of seizures can be challenging as seizures occur with great heterogeneity. Important clinical data is lost with suboptimal ictal examination and may result in prolonged EMU stay to capture additional seizures. Currently, there is substantial variation in ictal exam performance in our EMU. This quality improvement project aimed to optimize the EMU ictal exam to encourage rapid and reliable execution. Additional goals were to improve healthcare provider satisfaction and reduce EMU length of stay. Methods: Applying quality improvement methodology, we assessed the current condition through observation of a sample of ictal exams recorded by our EMU monitoring software (NATUS) and three neurologist reviewers tallied errors and omissions. With a multidisciplinary team of epileptologists, neurology house staff, nurses, and EEG techs, we performed a root cause analysis of variations in care. We then developed responsive, targeted countermeasures as well as a plan for implementation and collection of process, outcome, and balancing metrics. Results: Observation of ictal exams revealed the most common errors and omissions to be testing of naming, code word presentation, narration of seizure semiology, testing of motor function, and safety maneuvers (Figure 1). From the root cause analysis, we found the issues precluding optimal ictal testing were confusion among staff regarding ictal exam protocol when a seizure is recognized, inadequate education of nurses and EEG techs around the rationale for the exam and its components, lack of awareness of patient-specific goals, and unsatisfactory staffing. Drawing from consensus guidelines1 and our local process analysis, we developed a standardized, streamlined ictal exam (Figure 2). The EMU staff attended a training session in which the principles of semiology were reviewed and the staff practiced the new exam through role-playing exercises.2 Ictal exam cue cards (“badge buddies”) were distributed, the updated ictal exam was posted in every EMU patient room, and we initiated a practice of discussing patient-specific considerations with the staff in daily rounds. To assess post-intervention performance, we will sample 10 ictal exam videos every month and use a rubric to score duration and quality of ictal exam completion. Additionally, we will survey EEG tech and nursing satisfaction at three and six months after the education intervention. Lastly, we will monitor patient length of stay before and after the intervention. Conclusions: We anticipate the implementation of a standardized ictal exam in the EMU will ensure clinically relevant patient behavior is consistently assessed, decrease the time required to administer the exam, increase EEG tech and nursing confidence in their performance, and improve patient safety.Citations:1. Beniczky S, Neufeld M, Diehl B, et al. Testing patients during seizures: a European consensus procedure developed by a joint taskforce of the ILAE--Commission on European Affairs and the European Epilepsy Monitoring Unit Association. Epilepsia 2016;57(9):1363-1368. 2. Goldenberg D, Andrusyszyn M, Iwasiw C. The effect of classroom simulation on nursing students' self-efficacy related to health teaching. Journal Of Nursing Education [serial online]. July 2005;44(7):310-314. Funding: None