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3. Findings
3.1. Phase 1
3.1.1. Results of literature review
Only two workgroups (seizure provocation and acute seizures)
had any literature reporting outcomes or best practices; unfortunately, the majority of published studies did not specifically address issues in epilepsy monitoring units. In the other groups, most literature described challenges or practices of individual units orspecific disciplines.
No patient safety guidelines, preferred practices or consensus
statements in the target areas specific to patient safety in epilepsy
were identified.
3.1.1.1. Seizure observation. The seizure observation workgroup examined
factors that must be considered when determining appropriate observation systems. These included the frequency of measurement, type of measurement ordetection system, type of observer or evaluator, ratio of observers to patients, and risk factors for safety, such as the nature of events being observed, provocative techniques, medical and psychiatric comorbidities, other patient-specific risk factors and available resources. Only one study evaluated the type of observers used and noted no difference in types of patient companions who provided seizureobservation in a one‐bed EMU, except that immediate family members had higher scores in identifying seizure onset
[17]. The workgroup found no specific criteria that addressed types
of seizure observation other than the use of video‐EEG telemetry,
types of staff that may be used, and need for safe environments.
3.1.1.2. Seizure provocation. The seizure provocation workgroup evaluatedantiepileptic drug (AED) withdrawal, the most common technique
used to provoke seizures in EMU patients. The available
literature included many factors such as the rate of taper, number
and type of AEDs being tapered, seizure variables, and a variety of
patient‐ and drug‐specific issues [13,18–21] demonstrating the
complexity of AED withdrawal and the need to be mindful of
patient‐ and drug‐specificissues. Another study reported specific
steps in AED reduction and the importance of individualized plans
in AED reduction, based on a review of the literature and survey
findings from 37 international epilepsy centers [22]. Other provocative
techniques discussed in the literature include use of sleep deprivation
[23] and hyperventilation [24,25]. Techniques used less
commonly includepsychological techniques [26], exercise [27], caffeine
[28], alcohol [29], or self-reported precipitants such as stress
or anxiety [18,30,31]. Unintended consequences of seizure provocation
were relatively rare but potentially serious and included
prolonged seizures, seizure clusters, status epilepticus, cardiac arrhythmias
or ischemia, postictal pyschosis, as well as other medical
complicationsor injuries [7,9,32–38].
3.1.1.3. Acute seizure. The acute seizure workgroup reviewed management
of seizures that ranged from treatment of individual seizures to
clusters and status epilepticus. Seizure duration has been found to be
longer in seizures recorded on an EMU [39], thus emphasizing the
need for early identification and response to typical seizures and having
a mechanism to abortacute seizures quickly. While discontinuing
AEDs generally does not change the location of a seizure focus, more
rapid propagation of seizure activity may occur that can cause difficulties
localizing a seizure focus, activate secondary foci, and increase the risk of secondary generalization [21]. The study group found general
seizure first aid measures that are designed to keep a person safeduring
a seizure and prevent complications such as aspiration or injuries,
but these measures have not been rigorously evaluated [8,40]. The review
further yielded a variety of protocols for seizure clusters and
other emergencies [6,7,21,41–45], such as cardiac [46,47] and respiratory
complications [33,40]. These stress the need for EMUs to have the
capability to prevent, treat and manage...