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April 2021; 11 (2) Research

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

Susanna S. O'Kula, Lisa Faillace, View ORCID ProfileCatherine V. Kulick-Soper, Sahily Reyes-Esteves, Jackie Raab, View ORCID ProfileKathryn A. Davis, Ammar Kheder, Chloe E. Hill
First published February 6, 2020, DOI: https://doi.org/10.1212/CPJ.0000000000000815
Susanna S. O'Kula
Department of Neurology (SSO'K), New York University; Department of Neurology (LF, CVK-S, SR-E, KAD), University of Pennsylvania; Department of Neurology (JR), Jefferson Hospital, Philadelphia, PA; Department of Neurology (AK), Emory University, Atlanta, GA; and Department of Neurology (CEH), University of Michigan, Ann Arbor.
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Lisa Faillace
Department of Neurology (SSO'K), New York University; Department of Neurology (LF, CVK-S, SR-E, KAD), University of Pennsylvania; Department of Neurology (JR), Jefferson Hospital, Philadelphia, PA; Department of Neurology (AK), Emory University, Atlanta, GA; and Department of Neurology (CEH), University of Michigan, Ann Arbor.
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Catherine V. Kulick-Soper
Department of Neurology (SSO'K), New York University; Department of Neurology (LF, CVK-S, SR-E, KAD), University of Pennsylvania; Department of Neurology (JR), Jefferson Hospital, Philadelphia, PA; Department of Neurology (AK), Emory University, Atlanta, GA; and Department of Neurology (CEH), University of Michigan, Ann Arbor.
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  • ORCID record for Catherine V. Kulick-Soper
Sahily Reyes-Esteves
Department of Neurology (SSO'K), New York University; Department of Neurology (LF, CVK-S, SR-E, KAD), University of Pennsylvania; Department of Neurology (JR), Jefferson Hospital, Philadelphia, PA; Department of Neurology (AK), Emory University, Atlanta, GA; and Department of Neurology (CEH), University of Michigan, Ann Arbor.
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Jackie Raab
Department of Neurology (SSO'K), New York University; Department of Neurology (LF, CVK-S, SR-E, KAD), University of Pennsylvania; Department of Neurology (JR), Jefferson Hospital, Philadelphia, PA; Department of Neurology (AK), Emory University, Atlanta, GA; and Department of Neurology (CEH), University of Michigan, Ann Arbor.
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Kathryn A. Davis
Department of Neurology (SSO'K), New York University; Department of Neurology (LF, CVK-S, SR-E, KAD), University of Pennsylvania; Department of Neurology (JR), Jefferson Hospital, Philadelphia, PA; Department of Neurology (AK), Emory University, Atlanta, GA; and Department of Neurology (CEH), University of Michigan, Ann Arbor.
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Ammar Kheder
Department of Neurology (SSO'K), New York University; Department of Neurology (LF, CVK-S, SR-E, KAD), University of Pennsylvania; Department of Neurology (JR), Jefferson Hospital, Philadelphia, PA; Department of Neurology (AK), Emory University, Atlanta, GA; and Department of Neurology (CEH), University of Michigan, Ann Arbor.
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Chloe E. Hill
Department of Neurology (SSO'K), New York University; Department of Neurology (LF, CVK-S, SR-E, KAD), University of Pennsylvania; Department of Neurology (JR), Jefferson Hospital, Philadelphia, PA; Department of Neurology (AK), Emory University, Atlanta, GA; and Department of Neurology (CEH), University of Michigan, Ann Arbor.
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Citation
Developing and Implementing a Standardized Ictal Examination in the Epilepsy Monitoring Unit
Susanna S. O'Kula, Lisa Faillace, Catherine V. Kulick-Soper, Sahily Reyes-Esteves, Jackie Raab, Kathryn A. Davis, Ammar Kheder, Chloe E. Hill
Neurol Clin Pract Apr 2021, 11 (2) 127-133; DOI: 10.1212/CPJ.0000000000000815

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Abstract

Background The 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.

Methods Following 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.

Results We 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.

Conclusion We 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.

Footnotes

  • Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.

  • Editorial, page 95

  • Received August 29, 2019.
  • Accepted November 23, 2019.
  • © 2020 American Academy of Neurology
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The Nerve!: Rapid online correspondence

  • Author response: Developing and implementing a standardized ictal examination in the epilepsy monitoring unit
    • Susanna S. O'Kula, Epilepsy Fellow, NYU
    Submitted April 08, 2020
  • Reader response: Developing and implementing a standardized ictal examination in the epilepsy monitoring unit
    • Nitin K. Sethi, Associate Professor of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center (New York City)
    Submitted February 17, 2020
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