Personalized safety measures reduce the adverse event rate of long-term video EEG

Movement Termination of Slow-Wave Sleep-A Potential Biomarker?

The duration of slow-wave sleep (SWS) is related to the reported sleep quality and to the important variables of mental and physical health. The internal cues to end an episode of SWS are poorly understood. One such internal cue is the initiation of a body movement, which is detectable as electromyographic (EMG) activity in sleep-electroencephalography (EEG). In the present study, we characterized the termination of SWS episodes by movement to explore its potential as a biomarker. To this end, we characterized the relation between the occurrence of SWS termination by movement and individual characteristics (age, sex), SWS duration and spectral content, chronotype, depression, medication, overnight memory performance, and, as a potential neurological application, epilepsy. We analyzed 94 full-night EEG-EMG recordings (75/94 had confirmed epilepsy) in the video-EEG monitoring unit of the EpiCARE Centre Salzburg, Austria. Segments of SWS were counted and rated for their termination by movement or not through the visual inspection of continuous EEG and EMG recordings. Multiple linear regression was used to predict the number of SWS episodes that ended with movement by depression, chronotype, type of epilepsy (focal, generalized, no epilepsy, unclear), medication, gender, total duration of SWS, occurrence of seizures during the night, occurrence of tonic-clonic seizures during the night, and SWS frequency spectra. Furthermore, we assessed whether SWS movement termination was related to overnight memory retention. According to multiple linear regression, patients with overall longer SWS experienced more SWS episodes that ended with movement (t = 5.64; p = 0.001). No other variable was related to the proportion of SWS that ended with movement, including no epilepsy-related variable. A small sample (n = 4) of patients taking Sertraline experienced no SWS that ended with movement, which was significant compared to all other patients (t = 8.00; p < 0.001) and to n = 35 patients who did not take any medication (t = 4.22; p < 0.001). While this result was based on a small subsample and must be interpreted with caution, it warrants replication in a larger sample with and without seizures to further elucidate the role of the movement termination of SWS and its potential to serve as a biomarker for sleep continuity and for medication effects on sleep.

Evidence based noninvasive presurgical evaluation for patients with drug resistant epilepsies

PURPOSE OF REVIEW

To review the current practices and evidence for the diagnostic accuracy and the benefits of presurgical evaluation.

RECENT FINDINGS

Preoperative evaluation of patients with drug-resistant focal epilepsies and subsequent epilepsy surgery leads to a significant proportion of seizure-free patients. Even those who are not completely seizure free postoperatively often experience improved quality of life with better social integration. Systematic reviews and meta-analysis on the diagnostic accuracy are available for Video-electroencephalographic (EEG) monitoring, magnetic resonance imaging (MRI), electric and magnetic source imaging, and functional MRI for lateralization of language and memory. There are currently no evidence-based international guidelines for presurgical evaluation and epilepsy surgery.

SUMMARY

Presurgical evaluation is a complex multidisciplinary and multiprofessional clinical pathway. We rely on limited consensus-based recommendations regarding the required staffing or methodological expertise in epilepsy centers.

Measuring quality and safety of epilepsy monitoring units in Brazil: Adoption of quality indicators

PURPOSE

Drug-resistant epilepsy affects a substantial proportion (30-40 %) of patients with epilepsy, often necessitating video-electroencephalography (video-EEG) monitoring. In 2016, Sauro et al. introduced a set of measures aimed at improving the quality and safety indicators reported in video-EEG evaluations. This study aims to report our experience with the implementation of these measures.

METHODS

We analyzed video-EEG data regarding quality and safty from a period spanning January 2016 to January 2018, involving a total of 101 patients monitored in our video-EEG unit.

RESULTS

Among the patients included in the study, a definitive diagnosis was attainable for 92.1 %, with 36.6 % experiencing a change in diagnosis and 65.3 % undergoing a change in treatment as a result of the video-EEG evaluation. Additionally, the referral question was fully addressed in 60.4 % of admissions, and video-EEG was considered to be very useful or extremely useful in 66.4 % of cases. Adverse events were observed in 26.7 % of patients, with the most common being the progression of focal seizures to bilateral tonic-clonic seizures (11.9 %) and the occurrence of seizure clusters (5.9 %).

CONCLUSION

Our findings support the implementation of Sauro et al.'s set of measures, as they provide valuable criteria for improving the reporting of video-EEG quality and safety indicators. However, challenges may arise due to variations in terminology across studies and the lack of standardized criteria for defining essential questions in video-EEG evaluations. Further research utilizing these measures is necessary to enhance their effectiveness and encourage consistent reporting of results from epilepsy monitoring units.

Epilepsy monitoring unit practices and safety among NAEC epilepsy centers: A census survey

OBJECTIVE

An epilepsy monitoring unit (EMU) is a specialized unit designed for capturing and characterizing seizures and other paroxysmal events with continuous video electroencephalography (vEEG). Nearly 260 epilepsy centers in the United States are accredited by the National Association of Epilepsy Centers (NAEC) based on adherence to specific clinical standards to improve epilepsy care, safety, and quality. This study examines EMU staffing, safety practices, and reported outcomes.

METHOD

We analyzed NAEC annual report data and results from a supplemental survey specific to EMU practices reported in 2019 from 341 pediatric or adult center directors. Data on staffing, resources, safety practices and complications were collated with epilepsy center characteristics. We summarized using frequency (percentage) for categorical variables and median (inter-quartile range) for continuous variables. We used chi-square or Fisher's exact tests to compare staff responsibilities.

RESULTS

The supplemental survey response rate was 100%. Spell classification (39%) and phase 1 testing (28%) were the most common goals of the 91,069 reported admissions. The goal ratio of EEG technologist to beds of 1:4 was the most common during the day (68%) and off-hours (43%). Compared to residents and fellows, advanced practice providers served more roles in the EMU at level 3 or pediatric-only centers. Status epilepticus (SE) was the most common reported complication (1.6% of admissions), while cardiac arrest occurred in 0.1% of admissions.

SIGNIFICANCE

EMU staffing and safety practices vary across US epilepsy centers. Reported complications in EMUs are rare but could be further reduced, such as with more effective treatment or prevention of SE. These findings have potential implications for improving EMU safety and quality care.

Minimum standards for inpatient long-term video-EEG monitoring: A clinical practice guideline of the international league against epilepsy and international federation of clinical neurophysiology

The objective of this clinical practice guideline is to provide recommendations on the indications and minimum standards for inpatient long-term video-electroencephalographic monitoring (LTVEM). The Working Group of the International League Against Epilepsy and the International Federation of Clinical Neurophysiology develop guidelines aligned with the Epilepsy Guidelines Task Force. We reviewed published evidence using The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. We found limited high-level evidence aimed at specific aspects of diagnosis for LTVEM performed to evaluate patients with seizures and nonepileptic events (see Table S1). For classification of evidence, we used the Clinical Practice Guideline Process Manual of the American Academy of Neurology. We formulated recommendations for the indications, technical requirements, and essential practice elements of LTVEM to derive minimum standards used in the evaluation of patients with suspected epilepsy using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Further research is needed to obtain evidence about long-term outcome effects of LTVEM and establish its clinical utility.

Minimum standards for inpatient long-term video-electroencephalographic monitoring: A clinical practice guideline of the International League Against Epilepsy and International Federation of Clinical Neurophysiology

The objective of this clinical practice guideline is to provide recommendations on the indications and minimum standards for inpatient long-term video-electroencephalographic monitoring (LTVEM). The Working Group of the International League Against Epilepsy and the International Federation of Clinical Neurophysiology develop guidelines aligned with the Epilepsy Guidelines Task Force. We reviewed published evidence using the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) statement. We found limited high-level evidence aimed at specific aspects of diagnosis for LTVEM performed to evaluate patients with seizures and nonepileptic events. For classification of evidence, we used the Clinical Practice Guideline Process Manual of the American Academy of Neurology. We formulated recommendations for the indications, technical requirements, and essential practice elements of LTVEM to derive minimum standards used in the evaluation of patients with suspected epilepsy using GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Further research is needed to obtain evidence about long-term outcome effects of LTVEM and to establish its clinical utility.

Risk incidence of fractures and injuries: a multicenter video-EEG study of 626 generalized convulsive seizures

OBJECTIVE

To evaluate the incidence and risk factors of generalized convulsive seizure (GCS)-related fractures and injuries during video-EEG monitoring.

METHODS

We analyzed all GCSs in patients undergoing video-EEG-monitoring between 2007 and 2019 at epilepsy centers in Frankfurt and Marburg in relation to injuries, falls and accidents associated with GCSs. Data were gathered using video material, EEG material, and a standardized reporting form.

RESULTS

A total of 626 GCSs from 411 patients (mean age: 33.6 years; range 3-74 years; 45.0% female) were analyzed. Severe adverse events (SAEs) such as fractures, joint luxation, corneal erosion, and teeth loosening were observed in 13 patients resulting in a risk of 2.1% per GCS (95% CI 1.2-3.4%) and 3.2% per patient (95% CI 1.8-5.2%). Except for a nasal fracture due to a fall onto the face, no SAEs were caused by falls, and all occurred in patients lying in bed without evidence of external trauma. In seven patients, vertebral body compression fractures were confirmed by imaging. This resulted in a risk of 1.1% per GCS (95% CI 0.5-2.2%) and 1.7% per patient (95% CI 0.8-3.3%). These fractures occurred within the tonic phase of a GCS and were accompanied by a characteristic cracking noise. All affected patients reported back pain spontaneously, and an increase in pain on percussion of the affected spine section.

CONCLUSIONS

GCSs are associated with a substantial risk of fractures and shoulder dislocations that are not associated with falls. GCSs accompanied by audible cracking, and resulting in back pain, should prompt clinical and imaging evaluations.

Epilepsy monitoring units can be safe places; a prospective study in a large cohort

OBJECTIVE

No international guideline is available for minimum safety measures at epilepsy monitoring units (EMUs), although recommendations for preferred practices exist. These are mostly based on expert opinion, without evidence of effectiveness. We do not apply all of these preferred practices at our EMU setting. We audited adverse events and diagnostic utility at our EMU over one year.

METHODS

From May 2018 to May 2019, we prospectively collected data concerning adverse events and diagnostic utility of all EMU admissions (noninvasive video-electroencephalogram (EEG) recordings); during these admissions, individuals can be ambulant within their EMU room.

RESULTS

There were 1062 admissions comprising 1518 EMU days. In 2% of the admissions, a complication occurred, mostly a fall without injury (n = 6). In almost half of the falls, this was from the bed. Complications occurred most often during admissions for presurgical evaluation. Antiseizure medication (ASM) was tapered in 86% of presurgical cases, but no serious injury occurred, and occurring seizures were effectively treated with intranasal midazolam if needed.

CONCLUSIONS

The overall adverse event rate was low. Falls are the most common adverse event comparable with previously published fall rates at other EMUs where people are restricted to their bed. We showed that restricted ambulation at a well-monitored EMU is not necessary and possibly unwanted. No serious injury due to tapering of ASM occurred, and intranasal midazolam was shown to be effective as acute seizure treatment.

Considerations in preparing a multicenter study: Lessons learned from the Epilepsy Monitoring Unit Comfort Questionnaire (EMUCQ) validation feasibility study

PURPOSE

It is recommended to perform a pilot testing before conducting a validation study of a novel questionnaire. Pilot studies may serve different purposes. The aim of this study was to assess the feasibility of a multicenter validation study, to recruit additional study centers, and to undertake orientating descriptive item analysis of the 44-item Epilepsy Monitoring Unit (EMU) Comfort Questionnaire (EMUCQ).

METHODS

During a six-month sampling period, the EMUCQ was administered to eligible EMU patients. The patients filled out the questionnaire at two time points. Additional centers were recruited in Germany and Austria, and ethics votes obtained. In descriptive item analysis central tendency, variability, item distribution and item difficulty were calculated.

RESULTS

A total of 44 EMU patients participated in the study. Eight additional EMUs agreed to join the planned validation study. Recruitment of the centers took four months. Another six months passed to obtain all the ethics votes. Floor and ceiling effects could be detected in 32 items. One item with the lowest median showed the low item difficulty. Another five items showed medians with the height of 6. In four items, high difficulty indices could be observed.

CONCLUSION

A good network has turned out to be very helpful while planning a multicenter study. Enough time must be scheduled, because obtaining an ethics vote may take quite a long time. No conclusive statements regarding item properties could be made as this was a feasibility study.

Assessing comfort in the epilepsy monitoring unit: Development of an instrument

BACKGROUND/PURPOSE

Some patients perceive the experience of hospitalization in an epilepsy monitoring unit (EMU) to be an uncomfortable one. In order to provide comfort-enhancing measures, nurses need to assess comfort levels. For this purpose, Kolcaba developed the General Comfort Questionnaire (GCQ), which may be modified for usage in specific settings. The objective of this study was to develop an instrument to assess comfort of adult patients during hospitalization in an EMU, namely the Epilepsy Monitoring Unit Comfort Questionnaire (EMUCQ).

METHODS

The GCQ was translated from American English into German following the guidelines of the International Society for Pharmacoeconomics and Outcome Research (ISPOR). Three native German speakers with good command of the English language did forward translations. An expert who grew up bilingual did a backtranslation. For use in an EMU, literature-based setting-specific items were added. In a qualitative-descriptive study, cognitive debriefing with 25 patients was conducted using cognitive interviews. Qualitative data analysis was based on the framework method. In a quantitative-descriptive study, nine clinical experts assessed content validity.

RESULTS

For setting-specific modification, 12 items pertaining to surroundings, feeling observed, and feeling afraid of a seizure were added to the translated GCQ. Based on the initial content validity rating, 26 items remained unchanged, 12 items underwent revisions, and 14 items were omitted. Eight items were put aside for a follow-up rating in the context of cognitive debriefing. Cognitive interviewing revealed problems regarding the interpretation of items and missing items. According to the results, 27 items remained unchanged, 11 items were reworded, and six items were added. The final content validity rating showed item-content validity indices (I-CVI) between .33 and 1, and an average CVI on a scale level (S-CVI/ave) of .84.

CONCLUSIONS

Enhancing comfort is a fundamental nursing goal in demanding situations. Therefore, the contribution of nurses to the quality of individualized patient care is a substantial one. The EMUCQ is a valuable tool to support the assessment of comfort levels. The ISPOR guidelines proved to be useful to ensure high quality of the translated instrument. Using cognitive interviews enhanced the understandability of items and supported modification of the GCQ. At present, S-CVI/ave value of the EMUCQ is acceptable. Further testing is necessary.

Enhancing validity through cognitive interviewing. A methodological example using the Epilepsy Monitoring Unit Comfort Questionnaire

Aims

To identify problematic items, assess completeness and user‐friendliness, and undertake modifications to enhance face validity of the newly developed Epilepsy Monitoring Unit Comfort Questionnaire.

Design

Qualitative‐descriptive cross‐sectional study.

Methods

Five iterative rounds of cognitive interviewing were conducted with members of the target population between July ‐ November 2017. Think‐aloud technique, verbal probing, and observation were used, to assess how respondents understood and answered questions. Data analysis was based on the framework method; an eight‐column framework matrix was created for this purpose.

Results

In 25 interviews, problems regarding completeness of the item pool, comprehension of items, retrieval of information, judgment while finding answers and reporting the appropriate responses could be detected. According to the results, 27 items remained unchanged, 11 items were reworded, and six items were added. Instructions section of the questionnaire was reworked, too.

Conclusion

Although time‐consuming, cognitive interviewing turned out to be a valuable approach for revealing problems in an instrument, which would, otherwise, remain undetected and threaten validity.