CHAPTER

EMU Safety Concerns

Susan Hollar and Deborah LaBelle-Scarfo

There are a variety of challenges, details, and protocols associated with epilepsy monitoring unit (EMU) admissions. While any inpatient admission involves many challenges, this patient population comes with a unique set of safety concerns. Many issues have not been researched enough to provide a uniform standard of care among all epilepsy centers. Recent focus on patient safety in the EMU has encouraged discussion and facilitated a move toward standards of safe care in the EMU. In 2010, the National Association of Epilepsy Centers (NAEC) published guidelines for epilepsy centers that emphasized the need for safety protocols (1). On March, 30, 2012, the Institute of Medicine (IOM) released a landmark report on the epilepsies titled, “Epilepsy across the Spectrum: Promoting Health and Understanding” (2). The report highlights numerous gaps in the knowledge and management of epilepsy and recommends actions for improving the lives of those living with this disorder. Successful monitoring in the EMU requires a balance between the risks associated with seizures and the need to gain diagnostic data (3).

MEDICATION TAPERING

Management of the patient’s antiepileptic drugs (AEDs) for the monitoring admission should be considered carefully. AED withdrawal is the most common technique used for seizure provocation (1). The concern of AED taper or withdrawal causing status epilepticus is primary. It is of vital importance for the treating physician to be familiar with the patient’s history regarding prior AED changes or tapers, the patient’s response to such changes, and current seizure frequency. Clear, concise directions should be given to the patient regarding how AEDs will be tapered or withdrawn during their EMU admission. Careful consideration is given to the tapering or withdrawal of AEDs before admission for safety reasons. Updates regarding changes to the patient’s AED regimen should be given to the EMU patient and their family members daily. Often the goal of this admission is to capture a number of the patient’s typical seizures; however, any change in AED regimen creates the risk of altering the seizure type. The patient who has complex partial seizures on a regular basis may have only tonic–clonic seizures due to medication changes.

Considerations involving the tapering/withdrawal decision can be straightforward, while other factors affecting the patient merit consideration. Depending on the facility’s admission process, elective admissions may be up for cancelation if the hospital’s overall census is at a maximum level. Availability of the specific room needed for monitoring, waiting for patient discharges, and getting rooms cleaned all have the potential of placing the patient scheduled for admission to the EMU without a room, or waiting in the admissions area for a prolonged period of time. These situations have to be considered when holding or tapering AEDs prior to the actual admission. A patient that has a seizure in the admissions area is a patient sent to the emergency department (ED) regardless of the severity of the seizure. This situation creates added frustration for the patient, causes potential delay of monitoring, and additional expense for the patient and or their insurance company.

The other consideration when making the determination of tapering or withdrawing medications is length of stay. Delaying a taper until admission may result in an extended length of stay. In the authors’ experience, this fact has become a greater influence on protocol than it would have several years ago. These factors can elevate the risk of safety issues before the patient enters the EMU.

PATIENT OBSERVATION

All safety measures revolve around the patient’s behavior during an event. One of the most challenging pieces of care in the EMU is how to provide continual observation of the patient. Before the NAEC’s 2010 guidelines, there were no mandates for continuous monitoring of patients in an EMU. The 2010 guidelines for continuous observation of patients in the EMU provide current best practice (4).

Current technology provides expanded options for continuous real-time observation. There are as many variations of accomplishing this as there are EMUs. The critical service the observer provides is their attentiveness to the patient’s seizure behaviors. It is preferred that they have the ability to recognize ictal activity and to alert staff in a timely manner to provide seizure assessment and emergency rescue, if needed. Some EMUs rely on the patient’s family to provide in-room observation. Relying on a family member for a 24-hour observation has obvious limitations. At times, this observation may be supplemented with in-room sitters. Many centers utilize staff to observe patients by live remote observation. A staff member trained in behavior observation, camera control, and a mechanism to alert nursing staff (remote observer) is the accepted minimum of care. A combination of all of the above is ideal.

FALLS AND INJURIES

Falls risk in any hospitalized patient is of great concern. The patient with epilepsy should be considered to have an elevated risk for falls while an inpatient in the EMU, particularly if they have a history of falls with seizures (5). If a patient requires hospitalization for continuous monitoring in an EMU, they should be considered a fall risk regardless of their final diagnosis or medications. Careful screening by the healthcare team upon admission is of vital importance. There are several approaches to this safety risk. Some units implement a tiered approach based on the patient population. Patients who are not having any of their AEDs adjusted, with no known history of generalized seizures and no history of falls are considered low falls risk and receive no additional safety measures. Patients who do have adjustments made to their AED regimen, or have known generalized tonic–clonic seizures are considered high risk for falls. This population should also have an activity level ordered by the provider of “out of bed with assist only” restrictions. Patients can be given a safety belt device to be worn while out of bed. Some organizations allow the patient to opt-out of the use of the belt. This requires a document that clearly explains the risk of injury from falling during the admission. The patient must agree to release the facility from responsibility of injury sustained as a result of a fall. Then again, many centers do not offer an opt-out option for this population. Each facility has its own set of highly visible identifiers to use for the high falls risk population. Special colored nonskid socks, bracelets, door markers, and chart markers are commonly used to identify the patient at risk for falls.

Many EMUs require patients undergoing phase II monitoring with intracranial electrodes to utilize the belt, to use a bedside commode, and require “up to chair with full assist” restrictions. The few studies that have been conducted demonstrate most falls or injuries occur when the patient is in the bathroom. This supports the use of bedside commodes for the highest-risk patients, which includes all surgical patients. When patients refuse to use a bedside commode, the care nurse should be present outside of the bathroom door with the door ajar so that they can respond quickly to a seizure that may occur while the patient is toileting. Other less restrictive measures include requiring an adult family or friend observer who remains with the patient at all times. The observer alerts the staff to any seizure or event putting the patient at risk. Patients should be placed on falls precautions and be out of bed with assist only.

The balance of quality of life and minimizing risk of fall or injury while being monitored is a difficult balance. Acknowledging the restrictions and explaining the reasons for the additional safety measures is the best approach for all parties involved.

The room environment is an additional safety concern. The bed should be equipped with padding on the side rails to avoid injury to the patient. Bed pads that are custom made for the bed fit best around the rails. If these are not available, heavy blankets securely taped around the railings can be utilized. Some organizations utilize floor pads beside the bed, but there are no supporting studies on the benefit of the padding.

Intravenous (IV) access for drug administration is established upon admission. When IV access is not possible, an alternative method for drug administration should also be established at the beginning of the monitoring admission (6).

Daily activities such as bathing, dressing, and eating are already modified during the monitoring admission. During bathing and dressing, a family member or staff member should be present in the room in the event of a seizure while the patient is off camera. Patients should bath at bedside or with their observer present in the bathroom. Surgical patients should bathe at bedside with assistance from nursing staff.

Exercise while being monitored in an EMU is often achieved with a stationary bike for the patient with scalp electrodes only. This should only be allowed with staff assistance in the room. Surgical patients should not be allowed on stationary bikes. A safer option for this patient is a hand-operated pedaler that allows the patient to remain seated in the bed. Surgical patients may require compression stockings and compressive devices to reduce the risk of deep venous thrombosis.

Remote observers must be provided with a description of the typical event for each patient being observed. This should include specific details for the onset of each type of seizure. This allows the observer to focus on early detection of the event onset without depending on the patient or family member. If the observer is not in a situation to respond to the event, a quick method to alert nursing staff must be established (ie, an emergency phone or alarm).

EDUCATION OF STAFF AND PATIENT’S FAMILY

Nursing care in the EMU focuses on the needs of the patient and should be based on current best practice. Competencies in the care of patients with seizures should be developed to include knowledge of seizure types; the goals of EMU monitoring, ictal and postictal care, and seizure safety (7). Care nurses should demonstrate competency that seizure precautions for each patient are instituted upon admission to the EMU. This includes Falls Risk Assessment, functioning suction equipment, the ready availability of supplemental oxygen supplies, proper room set up per established seizure precaution protocols, and adequate response to a seizure. The care nurse should also know the importance of getting the patient’s seizure history from the patient and the patient’s family member to help plan for their care. The nurse’s role is to observe, keep the patient safe, and record the details of a seizure. EMU nursing staff should be trained in the importance of testing a patient during a seizure, making sure that nobody is blocking the camera and that the patient is uncovered so that the patient’s motor response during and after a seizure can be recorded. Research indicates that specialty training, in-services, lectures, and continuing education classes all increase the nurse’s confidence in caring for this population (7). Education should be provided by personnel who specialize in the care of the patient with seizures. Many epilepsy centers employ a nurse or an advanced practice provider who specializes in the care of this population. Periodic lectures given by the epileptologists also enhance the staff’s knowledge and confidence level as well as team building between caregivers. Creating a resource guide is also helpful, whether it is available as a paper book or electronically. It is best practice to have this information in one spot, known to all care nurses in the EMU.

Educating the patient’s family member(s) is also important. The family member should be instructed on location of seizure notification devices as well as nurse notification devices to help in the response time and data gathering. The family member can be integral in testing the patient’s awareness during a seizure. The family member may also serve as the best witness of the patient’s seizure characteristics.

DISCHARGE PLANNING

Discharge planning for the EMU patient who has had AEDs tapered or withdrawn is as important as the admission plan. The EMU patient’s discharge plan begins upon admission. Once the data needed to make a diagnosis are obtained, AEDs are restarted. The provider and the patient work together in the decision to maintain the current medication regimen or to change it in some manner. A patient typically remains an inpatient for 24 hours once medication is restarted. There should be adequate time for the levels to be therapeutic before discharge. This may require additional doses. If they have rescue medication prescribed, they should have access to that for the travel home. It should be recognized that most EMUs do not allow inpatients to have their home medications with them, so they may not have their home rescue medications upon departure from the hospital.

PHASE II ELECTRODE SET UP

It is important to have qualified technologists involved in the Phase II monitoring set up. Protocols to verify input naming, location, and montage set up should be developed and utilized. This should include verification with neuroimaging post grid or strip placement. This program requires two qualified technologists to be involved in the hook up (8). During the hook up, the two technologists should be in protected time, where they are not allowed to be interrupted in an effort to minimize errors. The set up begins with a map of the intracranial electrode placement drawn by the epileptologist or the surgeon. Documentation of the inputs and maps should be maintained as part of the monitoring record. Once the inputs have been entered and the cables connected, verification of the set up should be documented.

The physical hook up is an important phase as well. The cables should be secured with a stress loop on the top of the patient’s head. All cables should be routed and secured as much out of the patient’s reach as possible. A technologist should be present when dressing changes occur to ensure the safety of the cables and that all cables remain intact.

It is recommended that patients with intracranial grids or strips undergoing MRI scanning have the cables separated so they are not touching each other or overlapping. Some manufacturers offer boots to cover the ends of the electrodes for MRI scanning purposes; they should then be separated and secured for the scan.