Developing and Implementing a Standardized Ictal Examination in the Epilepsy Monitoring Unit

Abstract

BackgroundThe ictal examination is crucial for neuroanatomic localization of seizure onset, which informs medical and neurosurgical treatment of epilepsy. Substantial variation exists in ictal examination performance in epilepsy monitoring units (EMUs). We developed and implemented a standardized examination to facilitate rapid, reliable execution of all testing domains and adherence to patient safety maneuvers.MethodsFollowing observation of examination performance, root cause analysis of barriers, and review of consensus guidelines, an ictal examination was developed and disseminated. In accordance with quality improvement methodology, revisions were enacted following the initial intervention, including differentiation between pathways for convulsive and nonconvulsive seizures. We evaluated ictal examination fidelity, efficiency, and EMU staff satisfaction before and after the intervention.ResultsWe identified barriers to ictal examination performance as confusion regarding ictal examination protocol, inadequate education of the rationale for the examination and its components, and lack of awareness of patient-specific goals. Over an 18-month period, 100 ictal examinations were reviewed, 50 convulsive and 50 nonconvulsive. Ictal examination performance varied during the study period without sustained improvement for convulsive or nonconvulsive seizure examination. The new examination was faster to perform (0.8 vs 1.5 minutes). Postintervention, EMU staff expressed satisfaction with the examination, but many still did not understand why certain components were performed.ConclusionWe identified key barriers to EMU ictal assessment and completed real-world testing of a standardized, streamlined ictal examination. We found it challenging to reliably change ictal examination performance in our EMU; further study of implementation is warranted.

Automatic Responsiveness Testing in Epilepsy with Wearable Technology: The ARTiE Watch

“…The current ARTiE Watch behavioral responsiveness testing sequence consists of 18 command prompts (Table 1; Figure 2; Supplementary Video 1). The ARTiE Watch test length is 6 minutes and 56 seconds, which is longer than the average seizure duration of 1-2 minutes, to allow for capture of ictal and postictal behavioral responsiveness (Afra et al, 2008; O’Kula et al, 2021).…”

“…The current ARTiE Watch behavioral responsiveness testing sequence consists of 18 command prompts (Table 1; Figure 2; Supplementary Video 1). The ARTiE Watch test length is 6 minutes and 56 seconds, which is longer than the average seizure duration of 1-2 minutes, to allow for capture of ictal and postictal behavioral responsiveness (Afra et al, 2008;O'Kula et al, 2021). At ARTiE Watch test onset, an auditory signal tone plays on the smartwatch to alert the participant that the ARTiE Watch behavioral testing sequence and audio recording is beginning on the smartwatch.…”

Implementation of a New Clinical Testing Tool to Assess Patients During Ictal and Postictal Periods

“…In recent years, clinicians have emphasized improving clinical testing procedures. 7,16,17 Existing procedures are complex and require the use of objects and small instruction cards to perform assessments. Experienced staff are needed to perform such tests.…”