Safety in the EMU: Reaching Consensus.

Epilepsy Resources and Updates Long-term video-EEG monitoring in the epilepsy monitoring unit (EMU), while generally a safe procedure (1, 2), can be associated with adverse events. The majority of EMUs have experienced falls, status epilepticus, and postictal psychosis during monitoring (3); although rare, fatalities and near-fatalities have also occurred in the EMU (2, 4). Even patients with psychogenic nonepileptic seizures are prone to adverse events, usually falls, at a significant rate (5). Provocative procedures such as antiepileptic drug (AED) withdrawal and sleep deprivation increase the risk for adverse events, particularly if there is a history of generalized tonic-clonic seizures (GTCs) as a proportion of them will inevitably experience difficult to control seizures that may require intubation and treatment in the intensive care unit (ICU). Such risks should be understood, prior to monitoring, by both the treating physician as well as the patient. Nonetheless, because video-EEG monitoring is an elective procedure for which possible morbidities are predictable and potentially systematically preventable, safety in the EMU must always be the primary goal of any admission plan. Despite potential hazards and acknowledged importance of safety measures, there is a wide variation in practice with regard to drug withdrawal, seizure observation, and rescue protocols (6) in the EMU and a clear lack of consensus between epilepsy centers. Implementation of the safety measures may be costly, especially when additional personnel are involved. Automated safety alerts may miss critical events owing to the high false-positive rate that are ignored and can lead to delay in responding to seizures (7). Because of the importance of this issue, the American Epilepsy Society formed a workgroup to search for evidence and best practices regarding safety measures for patients admitted to the EMU. The first product of this effort was a survey published by Shafer et al. in 2011, identifying the extent to which adverse events occurred in the EMU, including falls, status epilepticus, postictal psychosis, and pulling of implanted electrodes (3). In their most recent article, " A consensus-based approach to patient safety in epilepsy monitoring units: Recommendations for preferred practices " (8), Shafer et al. build upon these findings to establish a set of consensus practice recommendations for enhancing patient safety in the EMU. First, a set of statements regarding safety were developed by four work-groups in the key areas: seizure observation, seizure provocation , management of acute seizures, and activity/environment. Because the authors found that literature searches …