PT  - JOURNAL ARTICLE
AU  - Susanna S. O'Kula
AU  - Lisa Faillace
AU  - Catherine V. Kulick-Soper
AU  - Sahily Reyes-Esteves
AU  - Jackie Raab
AU  - Kathryn A. Davis
AU  - Ammar Kheder
AU  - Chloe E. Hill
TI  - Developing and Implementing a Standardized Ictal Examination in the Epilepsy Monitoring Unit
AID  - 10.1212/CPJ.0000000000000815
DP  - 2021 Apr 01
TA  - Neurology: Clinical Practice
PG  - 127--133
VI  - 11
IP  - 2
4099  - http://cp.neurology.org/content/11/2/127.short
4100  - http://cp.neurology.org/content/11/2/127.full
AB  - 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.