Table 3.

Recommendations: Inpatient Services/EMU

1. Recommendation: All epilepsy centers should have an EMU, which is a dedicated inpatient location for performing 24-h continuous video-EEG monitoring for seizure classification or localization. CB   Remark: The EMU should be staffed with epilepsy-trained nurses and nursing assistants. The nurse-to-patient ratio should be adequate to ensure safety   and rapid response to seizures. CB   Remark: Patient rooms in the EMU should have remote control video cameras with 24/7 recording available that are movable by observers to keep the   patient on video continuously. CB   Remark: Video and EEG data should be captured and sent to a central location and be readily available to the physician reviewer in real time. CB   Remark: All EMU rooms should have a patient-activated event button and alarm. CB   Remark: Centers should have registered EEG technologists on staff. CB

2. Recommendation: All epilepsy centers should have 24/7, continuous, real-time supervision of ongoing VEEG studies in the EMU. CB   Remark: Supervision should be performed by a trained observer watching VEEG studies with no other concurrent responsibilities. The trained observer   may be an EEG technologist. CB   Remark: Trained observers must have direct access to nurses and physicians caring for the patient. If the observer is not an EEG technologist, trained   observers must have direct access to a supervising EEG technologist. CB   Remark: Trained observers should be provided patient-specific seizure descriptions and considerations to assist them in seizure recognition. CB   Remark: The ratio of trained observers to VEEG studies being monitored should be adequate for timely recognition of seizures and patient-related events. CB

3. Recommendation: All epilepsy centers should have physicians with sufficient training and expertise to provide optimal care. CB   Remark: Center physicians should have board certification in epilepsy or clinical neurophysiology. CB   Remark: Centers treating children should have at least 1 pediatric epilepsy specialist on staff with board certification in epilepsy or clinical neurophysiology as well as neurology with special qualifications in child neurology. CB

4. Recommendation: All epilepsy centers should have sufficient volume of patients admitted to the EMU to maintain the expertise of the epilepsy care team. CB

5 Recommendation: All epilepsy centers should have EMUs that are equipped to handle epilepsy-related emergencies. CB   Remark: Emergency medications and equipment (such as supplemental oxygen, suction) for seizures or status epilepticus should be available in   the EMU. CB   Remark: All centers should implement a written protocol for managing status epilepticus and acute repetitive or prolonged seizures. CB   Remark: Qualified providers or a rapid response team must be available in-house to manage seizure emergencies at all times. CB

6. Recommendation: All epilepsy centers should implement written protocols regarding response to events that occur in the EMU. CB   Remark: A trained observer must be present to identify seizures and initiate a medical response promptly. CB   Remark: Centers should have a written protocol for testing speech, memory, level of consciousness, and motor function during and following a   seizure. CB   Remark: All epilepsy centers should take efforts to minimize risk due to injury and falls. CB   Remark: All epilepsy centers should have a protocol for responding to postictal agitation, including education for responders on how to work with these   patients. CB

7. Recommendation: All epilepsy centers should have a standard set of admission orders and protocols for patients admitted to the EMU. CB   Remark: Centers should have a written protocol that addresses the number or duration of seizures over a given period that require physician notification   and include measures to be taken if number, duration, or severity of seizures observed is excessive. These instructions should also be included in the   admission orders. CB   Remark: All centers should have a written protocol that addresses safe medication reduction to increase seizure yield. CB   Remark: All EMU patients should have a documented plan for seizure response including rescue medications. CB

8. Recommendation: All epilepsy centers caring for children should have pediatric-specific protocols and resources. CB   Remark: Child life specialists play an important role in caring for children in the EMU and should be part of the epilepsy care team. CB   Remark: Centers with pediatric patients should modify all EMU protocols including, but not limited to, age-appropriate safety measures and medication   dosage. CB

9. Recommendation: All epilepsy centers should provide EMU reports that meet ACNS standards. CB   Remark: Reports should use standard classification of seizure and epilepsy type. CB   Remark: Reports should be generated in a timely fashion. CB

10. Recommendation: Centers should provide patient and caregiver education in preparation for EMU admission. CB

11. Recommendation: Centers should regularly inform EMU patients and/or caregivers of important findings in their evaluation and changes in the care plan. CB   Remark: Patients and/or caregivers should be updated daily with interval results from VEEG and other diagnostic tests and changes in treatment. CB   Remark: Information in EMU reports should be shared with patients and caregivers, including a verbal conference with patient and caregiver to discuss   preliminary findings before discharge. CB

12. Recommendation: Centers should provide EMU discharge planning and education that is shared with patients and caregivers, including safe medication resumption or guidance on new medication, follow-up care, and contact information. CB

Abbreviations: ACNS = American Clinical Neurophysiology Society; CB = consensus based; EMU = epilepsy monitoring unit; VEEG = video-EEG.