Donald Rumsfeld, Secretary of Defense,
Press Conference at NATO Headquarters, Brussels, Belgium,
June 6, 2002
“There are things we now know that we know."
"There are known unknowns. That is to say there are things that we now know we don't know."
"But there are also unknown unknowns. These are things we do not know we don't know.”
Hospital Risk Management
How does the Lack of Continuous EEG Impact Risk Management?
Risk Management, as defined by Yale University Hospital, “is a planned and systematic process to reduce and/or eliminate the probability that losses will occur in a specific setting, and includes risk identification and loss prevention, loss reduction and risk financing” of potential incidents.
The goal is the identification, evaluation, and correction of potential risks that could lead to either unintended or unnecessary harm to a patient including near misses, adverse events, sentinel events and unsafe acts.
When you focus on hospital neurocritical care patients you must consider the premise that untreated seizures, specifically status epilepticus, cause worse neurological outcomes. If seizures do cause progressive brain dysfunction, then early intervention for seizure control is indicated in order to prevent further brain injury.
Of the 300 neurologic lawsuits requiring a pay out in 2004, mismanagement of seizure ranked 4th on the list of most common causes. (Top 8 diagnoses: disc disorder, stroke, headaches/migraine, seizure, cancer, meningitis, paralysis and aneurysm) [1]
There is a body of mounting evidence that untreated seizures, and specifically status epilepticus, cause worse neurological outcomes.[2], [3] In addition well over 50% of the patients that are having seizures exhibit no clinical signs, or their seizures are non-convulsive and can only be detected using electroencephographic (EEG) monitoring. [4]
If this is true - when does this clinical situation raise to the level of risk management to make sure that patient populations predisposed to seizures are monitored prior to permanent injury? What is the best way to minimize unsuspected neurocritical care risk?
However... We now know
NCSZs are most frequently diagnosed in the intensive care unit (ICU).
In fact, approximately 90% of critically ill patients with seizures recorded have purely nonconvulsive seizures that are unrecognized at the bedside and can only be diagnosed with cEEG.
Claassen J, et. al., Detection of electrographic seizures with continuous EEG monitoring in critically ill patients. Neurology 2004;62:1743–8.
Pandian JD, et.al Digital videoelectroencephalographic
monitoring in the neurological–neurosurgical intensive care unit: clinical features and outcome. Arch Neurol, 2004;61:1090–4.
One Answer is simply...monitor critical care patients with EEG
It is often expounded that EEG monitoring is too expensive. When considering the cost of cEEG UCLA presented a non-peer reviewed financial projections on the costs of cEEG monitoring. They estimated that “performing cEEG saved money by shortening intensive care unit length of stay particularly in patients found to have nonconvulsive seizures. This savings more than offset the overall cost of performing cEEG.” [5]
CortiCare has the goal to provide hospitals an outsourced neurotelemetry service that offers their patients constant cerebral monitoring to protect against neuronal damage using registered technologists and neurophysiologists without incurring the higher cost of maintaining an in-house, round the clock neurodiagnostic monitoring staff.
We have succeeded in providing reliable neurophysiologic monitoring services to hospitals across the country, eliminating the worrisome problem for critical care physicians and hospital staff who have to arrange for continuous EEG monitoring on short notice which often results in settling for unattended EEG recording by untrained monitoring staff and unsatisfactory service for your reading neurologists. There is limited value in a continuous EEG “recording” if no one is looking at the real-time information and intervening in care of the critical patient care.
Although malpractice cases seldom reach public record and are often settled out of court, there are a few noteworthy case that show a failure to make a timely diagnosis of nonconvulsive status epilepticus led to a $1.25 to $1.5 million judgment against a hospital because of long-term cognitive impairment in the patient. [6], [7]
In addition to having cases settled against them, these hospitals now have another trait in common – they all have a continuous EEG monitoring program staffed 24/7 and 365 days a year.
If your hospital is in need of reliable on-call neurodiagnostic monitoring staff, CortiCare can help. Contact CortiCare to open a dialogue about your specific needs and requirements.
1 American Academy of Neurology, 2012, " Patient Safety 101 for Neurologists", Downloaded PPT Internet presentation, 8/2/2013
2 Bronen RA, The status of status: seizures are bad for your brain's health.AJNR Am J Neuroradiol. 2000 Nov-Dec;21(10):1782-3.
3 Topijan AA, et. al, Electrographic Status epilepticus is associated with mortality and worse short-term outcome in critically ill children. Crit Care Med. 2013 Jan;41(1):215-23.
4 Friedman D, Claassen J, Hirsch LJ. Continuous electroencephalogram monitoring in the ntensive care unit. Anesth Analg. 2009 Aug;109(2):506-23
5 Vespa P. EEG cost analysis. Presented at the Noncritical Care Society Annual Meeting, Las Vegas, October 31–November 3, 2007.
6 Jordan KG. Continuous EEG monitoring in the neuroscience intensive care unit and emergency department.J Clin Neurophysiol 1999;16:14–39.
7 msnbc.com, updated 4/8/2008 8:28:26 AM ET, Before Code Blue: Who’s minding the patient? http://www.nbcnews.com/id/24002334/#.UgLoQWRASIV