Abstracts

Rationale: Safety of patients admitted to the epilepsy monitoring unit (EMU) for seizure evaluation is of paramount importance. However, practice patterns regarding EMU referral, admission rules (e.g., withholding medications before/during admission) or EMU stay (e.g., rate of medication decrease or continuous vs. intermittent supervision) vary widely with some of them (e.g., potential for missing seizures) raising significant patient safety concerns. Therefore, in the first quarter of 2011 our team implemented several local parameters for EMU admission management including a missed seizures/events measure. The goal was to identify missed seizures/events and, if necessary, to implement patient safety improvements in response to the identified problems. Methods: The EMU is staffed by technologists watching monitors 24/7. All EEG and video recordings of patients managed in the EMU between first Tuesday and first Friday of each month (72 hours) are reviewed independently by 2 members of EMU staff (REEGT and RN). We categorized responses to epileptic seizures as A) missed seizure [(1A1) Any GTC or CPS seizure discovered on review or later report by patient or family that were missed by EMU staff; (1A2) SPS where the patient pressed the event button but there was no interaction; (1A3) GTC where there was no interaction within 2 minutes of seizure onset; (1A4) CPS where the patient was physically at risk (e.g., wandering, fall) if there was no interaction within 2 minutes of seizure onset]; B) not a missed seizure [intercom interaction only for SPS]; C) not missed but inadequate interaction [Bedside or intercom interaction but not appropriate first aid provided]; D) Missed electrographic seizure or SPS detectable by EEG only. Parallel measures were developed for psychogenic non-epileptic seizures. Proportion of missed seizures/events was calculated and complications assessed.Results: Data from 3 reviews of 72 hours were available. Out of 61 seizures/events recorded, 11 were missed (18%; 10 D; 1 2A3 (GTC-like PNES with no interaction within 2 minutes of event onset)). None of the complex partial seizures or generalized seizures were missed; all had interaction within 2 minutes of seizure onset. Of the 10 missed epileptic seizures all were simple partial. One PNES was missed due to delayed interaction (more than 2 minutes of event onset). The patient hit her button after having symptoms similar to prior seizures as she was talking with a family member. The patient remained safe during her symptoms and continued her conversation. EEGT entered the room shortly after the 2 minute mark to provide appropriate interaction. Conclusions: Safety measures are important in the EMU setting because of patients undergoing monitoring either with decreased or off of AEDs. Although 18% of the recorded seizures were missed, none of the missed seizures resulted in negative patient outcomes. Safety measures are important as they allow for monitoring of staff performance and modification of EMU procedures in order to avoid negative outcomes. Involving non-MD staff in performance improvement projects makes patient safety a team effort.