Patients referred to tertiary epilepsy centers frequently have complex and long-standing epilepsy. Many have frequent seizures, most are refractory to antiseizure medicines, and many report seizure-related injuries. Inpatient video-electroencephalography monitoring (VEM) has many indications and is pivotal to the diagnosis and treatment of seizure disorders. Nurses specialized in epilepsy care are an integral part of the medical team and play an essential role in patient care and education.

This chapter discusses the principles of nursing care in the inpatient VEM unit and the challenges inherent in safe care of patients during monitoring. A high level of nursing proficiency is essential to effective, efficient, and safe monitoring. Nursing care in the VEM unit is provided by two levels of practitioner; the bedside nurse and the advanced practice nurse (APN). Nursing care of patients undergoing an elective admission for seizure diagnosis demands a different skill set from other diagnostic groups seen in a general neuroscience setting. Patients with epilepsy are not acutely ill, but the effects of a chronic, episodic disorder frequently manifest in behaviors such as anxiety, depression, low self-esteem, and embarrassment. In communicating with patients, these issues need to be sensitively considered. Furthermore, the treatment goals in epilepsy are to control seizures completely and to reverse the spectrum of disability associated with the disease.

The National Association of Epilepsy Centers (NAEC) was formed in 1989 for the purpose of defining the services, personnel, and facilities that constitute a specialized epilepsy center. ¹ The NAEC defines a specialized epilepsy center as one that provides services exclusively to people with intractable epilepsy and is staffed by a multidisciplinary team with special training and experience in treating epilepsy. Epilepsy care is divided into four levels. (See Chapter 5 for a full description of these levels.) Inpatient VEM is a service provided by third- and fourth-level centers, but it is offered most often in fourth-level, large tertiary or academic institutions. These specialized centers provide complex evaluations of epilepsy, including evaluation with intracranial electrodes, and a range of surgical procedures. The provision of nurses skilled in recognizing, testing, and treating seizures is the hallmark of the VEM unit. Fourth-level centers require the supervisory skills of an APN (clinical nurse specialist or nurse practitioner) to provide coordination and oversight of both the nursing services and the coordinated care of patients as they progress through a multiphase treatment program.

VEM is expensive in terms of personnel, equipment, and time. However, these costs can be offset against the savings from improved diagnosis and treatment.² VEM is effective and is estimated to result in a change of epilepsy management for 73% of the patients who undergo it.³ There are cost benefits for patients rendered seizure free by surgery and for those patients not requiring antiepileptic drug (AED) treatment, such as those with a confirmed diagnosis of psychogenic nonepileptic seizures (PNES).⁴ The coordinated care provided by the specialist epilepsy nurses makes a positive contribution to controlling the cost of monitoring.⁵ A Canadian study⁵ on the effectiveness of including a specialist nurse in the medical team revealed the substantial contribution of this professional to organizational outcomes beyond just cost. The contributions of the specialist nurse include reducing length of hospital stay, optimizing the utilization of resources, and facilitating comprehensive, patient-centered care.

VEM is most frequently performed in the setting of neuroscience nursing care units. Several beds in the unit will be dedicated for evaluating patients with seizures. Monitoring units will accommodate pediatric and/or adult populations. The design of the unit reflects the many activities that occur there. It needs to be possible to monitor and record seizures, review and analyze data, and archive records. Much variation exists across the United States in the size and design of units, administrative policy, and how monitoring is performed. In general, patients are confined to a bed space monitored by video camera (Figure 7-1). Some institutions employ trained observers, either nursing staff, EEG technicians, or a monitoring technician, to provide round-the-clock supervision of patients from a central monitoring station (Figure 7-2). When seizures occur, the observer will communicate with the patient and alert the bedside nurse that the patient needs immediate attention. In settings where there is no continuous supervision, parents and family members may be required to remain with the patient in order to alert the nursing staff whenever a seizure occurs. Some units have a bank of monitors placed in a central location, so that they can be easily visualized by all the staff as they go about their daily activities. Staffing patterns need to take into account the resources of a particular setting.

Several challenges are inherent in the administration of an effective, safe, and efficient monitoring unit. The design and furnishing of the unit will be centered on patient safety and the very specific needs of this patient population.⁶ Privacy issues are an important consideration when patients are on continuous video monitoring. Monitor technicians and nurses are able to communicate with patients over an intercom and to hear conversations in the room. As such, they need to be sensitive to the issues of privacy. Monitoring units are held to an elevated standard of ethical care with respect to privacy issues.

Patient Screening and Unit Flow

The provision of VEM is an expensive resource in terms of staffing and equipment. Undergoing a video-EEG study is time consuming for patients and costly to third-party payers. Most admissions to the unit are elective. They are usually planned well in advance, although acute, interhospital transfers may be requested for patients experiencing uncontrolled seizures at hospitals without the capability to perform continuous VEM. The scheduling of elective admissions is governed by the availability of recording equipment and the anticipated number of days required to capture several seizures in a particular patient. To run a cost-effective service, it is important to maintain a consistent flow of patients into and out of the unit. To maintain an optimal patient census, a streamlined administrative process is required, as well as a carefully conceived protocol for effectively and safely evoking and recording seizures.

Preadmission screening should take into account the patient’s typical pattern of seizure occurrence, known seizure triggers, and baseline seizure frequency. These factors may influence the success of VEM and the use of techniques to provoke seizures. It is helpful to know in advance about any special care needs. These may include a range of needs, from assistance with activities of daily living in the case of patients with sensory handicaps or cognitive delay, to anticipating the more serious risks of postictal psychosis, status epilepticus, and combative behavior during or after seizures. This information is essential for individualizing care plans with respect to safe tapering of AEDs and the safe care of patients undergoing more complex intracranial studies. APNs dedicated to the epilepsy program play an invaluable role in the supervision of unit flow, preparation of patients for admission, and preparation of the clinical staff to provide care. VEM may be contraindicated when patients are pregnant or if the patient is experiencing an extended period of freedom from seizures. When the general health of the patient is poor, provoking seizures may not be in the patient’s best interests, and it may be better to delay monitoring.

Informed Consent

Prior to applying the electrodes and starting VEM, it is important for patients to sign a carefully written, legal consent-for-treatment form. This includes permission to video record seizures and behavior, as well as permission to evoke seizures by sleep deprivation, hyperventilation, and other means. It is helpful to include safety precautions in this consent form, including the use of vest and soft restraints. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards of care and Title 22 guidelines are strict with respect to the use of restraints in patient care and require carefully structured hospital policy. Prior permission from the patient to use a vest restraint is sensible and provides an added sense of security for patients, families, and staff.⁷ If approached in a spirit of cooperation, a reasonable level of patient compliance can be anticipated. Use of a vest restraint is mandatory in the care of patients undergoing intracranial monitoring in most units. If recordings are to be used for teaching purposes, permission has to be obtained from the patient. An example of a currently used consent form is given in Appendix A. Interestingly, a study of practice in 42 VEM services worldwide⁸ did not address the issue of informed consent or the use of restraints for injury prevention. This topic is important for the management of medicolegal risk. The role of and correct use of restraints in medical care currently receive high emphasis from health care monitoring boards in the United States.

Nurses have a key role to play in the diagnosis and treatment of seizure disorders. In the VEM unit, care is centered on the observation and reporting of seizures so that improvements in future treatment can be made. VEM affords the opportunity to increase patients’ knowledge about their disease and its treatment options. The inpatient experience affords an opportunity to increase patient confidence in self-management skills and to promote safe, quality living.

The bedside nurse dedicated to the care of patients with epilepsy and the specialist epilepsy nurse (APN) work together to improve the quality of care. Furthermore, the APN is an important liaison between the nursing team and the rest of the medical team.

The focus of the bedside nurse is on the following tasks:

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  Seizure recognition and testing, as well as accurate reporting and recording of events. Seizure recognition begins with a good nursing history, including a detailed description of the patient’s seizures, both from the patient and from reliable witnesses.

  
  
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  Care during seizures to prevent seizure-related injury

  
  
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  Prevention of the potential complications associated with reduced mobility during the hospitalization

  
  
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  Provision of emotional and physical comfort and psychosocial support

The focus of the APN is on the following tasks:

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  Ensuring that the patient is prepared for hospital admission, including knowledge regarding the purpose of the admission, approximate length of stay, safety restrictions, potential risks, and what to expect upon discharge

  
  
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  Ordering and coordinating diagnostic studies

  
  
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  Ensuring the patient understands the diagnosis and treatment plan, has appropriate follow-up, and is safe to go home at the end of the monitoring

  
  
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  Educating bedside nurses about the care of patients with epilepsy, including safe care and assessment during a seizure, when to contact the physician, and ensuring that appropriate protocols are in place

  
  
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  Educating EEG and monitoring technicians about seizure recognition, testing of seizures, and safe care during seizures

Long-term VEM contributes important information to both our knowledge of how seizures manifest and the diagnostic significance of the behavior.⁹ The opportunity to record a series of seizures over several days provides important insight into a patient’s subjective experience of the seizure, the sequence of events during the seizure, and the accuracy of the patient’s memory before, during, and after the event. Patients may not be able to reliably report their ictal experience. They frequently underestimate lapses of consciousness and the duration of periods of altered awareness, for example. The observations of untrained witnesses may not be reliable for diagnostic purposes. Subtle and brief changes in behavior are easy to miss in everyday life. VEM therefore has a very important place in diagnosing and treating seizure disorders.

An essential function of the bedside nurse is recognizing early behavioral changes that signify the onset of a seizure.^10,11 This should be followed by prompt verbal interaction to assess cognitive and motoric components of the seizure. This testing contributes invaluable information with respect to type and classification of seizure, as well as the brain region that might be involved. Components of cognitive testing are usually organized around assessing level of awareness, memory for the event itself, ability to follow commands, and ability to name objects. The steps that might be taken in testing a seizure are given in Table 7-1. Behavior during a seizure represents complex and varied brain processes, and testing may need to be varied in order to reflect specific changes in brain function, for example, the ability to recognize written words. It is important to maintain consistency in the quality of testing between observers. Missing seizures or failing to respond to the early signs of seizure onset conflicts with the fundamental goals of the admission. This may also seriously jeopardize patient safety.

Nursing staff and other personnel (EEG technicians, monitoring technicians, and physicians) responsible for clinical care of patients in the monitoring unit need to be trained in recognizing the early clinical signs of a seizure, as patients may not always be able to report the onset of an event. Observable signs might include changes in level of activity, either sudden arousal from sleep or a cessation of activity, staring, sitting up, and purposeless fidgeting or other automatic behaviors, such as lip smacking. Failure to respond may be due to an altered level of awareness or due to disruption of language areas in the brain. Careful testing can help to discriminate between the two. In essence, seizure testing gives us a more refined way to classify seizures and to understand the mechanisms underlying the seizure. Observing the video (and EEG) in the absence of an adequate ictal assessment may not be diagnostically helpful. This may also result in a prolonged hospital stay in order to capture further events to support diagnostic confidence.

Missed seizures are an acknowledged problem on VEM units.⁸ The reasons for this range from poor camera work and equipment malfunction,⁸ to simply not recognizing the onset of a seizure, to patients leaving the monitoring unit for tests or smoke breaks.¹² In a recent study,¹² patients leaving the unit in order to smoke accounted for 5.2% of missed seizures. Habitual smokers in this study also required a longer hospital stay to complete their evaluations. Any time patients leave the VEM there is a possibility of unrecorded seizures and increased safety risks.

When AEDs are lowered, there are risks of provoking prolonged seizures and different seizure behaviors. To the nurse untrained in reading an EEG, a patient’s failure to return to baseline alertness may be the only sign that seizure activity is ongoing and that medical intervention is needed. A careful postictal assessment of cognition is therefore important. Although video records of the events are kept and can be reviewed at a later date, it is important for the nursing record to reflect a return to baseline cognitive level after every seizure, as well as the duration of the postictal period.