Exploring COVID-19 census burdens by US hospital characteristics: Implications of quality reporting at rural and critical access hospitals.

PURPOSE: By assessing longitudinal associations between COVID-19 census burdens and hospital characteristics, such as bed size and critical access status, we can explore whether pandemic-era hospital quality benchmarking requires risk-adjustment or stratification for hospital-level characteristics. METHODS: We used hospital-level data from the US Department of Health and Human Services including weekly total hospital and COVID-19 censuses from August 2020 to August 2023 and the 2021 American Hospital Association survey. We calculated weekly percentages of total adult hospital beds containing COVID-19 patients. We then calculated the number of weeks each hospital spent at Extreme (≥20% of beds occupied by COVID-19 patients), High (10%-19%), Moderate (5%-9%), and Low (<5%) COVID-19 stress. We assessed longitudinal hospital-level COVID-19 stress, stratified by 15 hospital characteristics including joint commission accreditation, bed size, teaching status, critical access hospital status, and core-based statistical area (CBSA) rurality. FINDINGS: Among n = 2582 US hospitals, the median(IQR) weekly percentage of hospital capacity occupied by COVID-19 patients was 6.7%(3.6%-13.0%). 80,268/213,383 (38%) hospital-weeks experienced Low COVID-19 census stress, 28% Moderate stress, 22% High stress, and 12% Extreme stress. COVID-19 census burdens were similar across most hospital characteristics, but were significantly greater for critical access hospitals. CONCLUSIONS: US hospitals experienced similar COVID-19 census burdens across multiple institutional characteristics. Evidence-based inclusion of pandemic-era outcomes in hospital quality reporting may not require significant hospital-level risk-adjustment or stratification, with the exception of rural or critical access hospitals, which experienced differentially greater COVID-19 census burdens and may merit hospital-level risk-adjustment considerations.

A Multisite Assessment of Inpatient Safety Event Rates During the Coronavirus Disease 2019 Pandemic.

To date, there has been a notable lack of peer-reviewed or publicly available data documenting rates of hospital quality outcomes and patient safety events during the coronavirus disease 2019 pandemic era. The dearth of evidence is perhaps related to the US health care system triaging resources toward patient care and away from reporting and research and also reflects that data used in publicly reported hospital quality rankings and ratings typically lag 2-5 years. At our institution, a learning health system assessment is underway to evaluate how patient safety was affected by the pandemic. Here we share and discuss early findings, noting the limitations of self-reported safety event reporting, and suggest the need for further widespread investigations at other US hospitals. During the 2-year study period from January 1, 2020, through December 31, 2021 across 3 large US academic medical centers at our institution, we documented an overall rate of 25.8 safety events per 1000 inpatient days. The rate of events meeting "harm" criteria was 12.4 per 1000 inpatient days, the rate of nonharm events was 11.1 per 1000 inpatient days, and the fall rate was 2.3 per 1000 inpatient days. This descriptive exploratory analysis suggests that patient safety event rates at our institution did not increase over the course of the pandemic. However, increasing health care worker absences were nonlinearly and strongly associated with patient safety event rates, which raises questions regarding the mechanisms by which patient safety event rates may be affected by staff absences during pandemic peaks.

Subclinical seizures on stereotactic EEG: characteristics and prognostic value.

OBJECTIVE: Although stereotactic EEG (sEEG) has become a widely used intracranial EEG technique, the significance of subclinical seizures (SCS) recorded on sEEG is unclear and studies examining this finding on sEEG are limited. We investigated (1) the prevalence of SCS in patients undergoing sEEG and clinical factors associated with their presence, (2) how often the subclinical seizure onset zone (SOZ) colocalizes with clinical SOZ, (3) the association of SCS and surgical outcomes, and (4) the influence of resection of the subclinical SOZ on surgical outcome. METHODS: We reviewed all patients who underwent intracranial monitoring with sEEG at our institution from 2015 through 2020 (n=169). Patient and seizure characteristics were recorded, as was concordance of subclinical and clinical seizures and post-surgical outcomes. RESULTS: SCS were observed during sEEG monitoring in 84 of 169 patients (50%). There was no difference in the prevalence of SCS based on imaging abnormalities, temporal vs extratemporal SOZ, number of electrodes, or pathology. SCS were more common in females than males (62% vs 40%, p=0.0054). SCS had complete concordance with clinical SOZ in 40% of patients, partial concordance in 29%, overlapping in 19%, and discordant in 12%. Eighty-three patients had surgery, 44 of whom had SCS. There was no difference in excellent outcome (ILAE 12 or 2) based on the presence of SCS or SCS concordance with clinical SOZ; however, there were improved outcomes in patients with complete resection of the subclinical SOZ compared with patients with incomplete resection (p =0.013). SIGNIFICANCE: These findings demonstrate that SCS are common during sEEG and colocalize with the clinical SOZ in most patients. Discordance with clinical SOZ does not necessarily predict poor surgical outcome; rather, complete surgical treatment of the subclinical SOZ correlates with excellent outcome. For unclear reasons, subclinical seizures occurred more commonly in females than males.

A Learning Health System Approach to Hospital Quality Performance Benchmarking: The Composite Hospital Quality Index.

US hospital quality rankings and ratings use disparate methodologies and are weakly correlated. This causes confusion for patients and hospital quality staff. At the authors' institution, a Composite Hospital Quality Index (CHQI) was developed to combine hospital quality ratings. This approach is described and a calculator is shared here for other health systems to explore their performance. Among the US News and World Report Top 50 Hospitals, hospital-specific numeric summary scores were aggregated from the 2021 Centers for Medicare and Medicaid Services (CMS) Hospital Overall Star Rating, the Spring 2021 Leapfrog Safety Grade, and the April 2021 Hospital Consumer Assessment of Healthcare Providers and Systems Star Rating. The CHQI is the hospital-specific sum of the national percentile-rankings across these 3 ratings. In this example, mean (SD) percentiles were as follows: CMS Stars 74 (19), Hospital Consumer Assessment of Healthcare Providers and Systems 63 (19), Leapfrog 65 (24), with mean (SD) CHQI of 202 (49). The CHQI is used at the authors' institution to identify improvement opportunities and ensure that high-quality care is delivered across the health system.

The association of acute COVID-19 infection with Patient Safety Indicator-12 events in a multisite healthcare system.

BACKGROUND: Patient Safety Indicator (PSI)-12, a hospital quality measure designed by Agency for Healthcare Research and Quality (AHRQ) to capture potentially preventable adverse events, captures perioperative venous thromboembolism (VTE). It is unclear how COVID-19 has affected PSI-12 performance. OBJECTIVE: We sought to compare the cumulative incidence of PSI-12 in patients with and without acute COVID-19 infection. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study including PSI-12-eligible events at three Mayo Clinic medical centers (4/1/2020-10/5/2021). EXPOSURE, MAIN OUTCOMES, AND MEASURES: We compared the unadjusted rate and adjusted risk ratio (aRR) for PSI-12 events among patients with and without COVID-19 infection using Fisher's exact χ2  test and the AHRQ risk-adjustment software, respectively. We summarized the clinical outcomes of COVID-19 patients with a PSI-12 event. RESULTS: Our cohort included 50,400 consecutive hospitalizations. Rates of PSI-12 events were significantly higher among patients with acute COVID-19 infection (8/257 [3.11%; 95% confidence interval {CI}, 1.35%-6.04%]) compared to patients without COVID-19 (210/50,143 [0.42%; 95% CI, 0.36%-0.48%]) with a PSI-12 event during the encounter (p < .001). The risk-adjusted rate of PSI-12 was significantly higher in patients with acute COVID-19 infection (1.50% vs. 0.38%; aRR, 3.90; 95% CI, 2.12-7.17; p < .001). All COVID-19 patients with PSI-12 events had severe disease and 4 died. The most common procedure was tracheostomy (75%); the mean (SD) days from surgical procedure to VTE were 0.12 (7.32) days. CONCLUSION: Patients with acute COVID-19 infection are at higher risk for PSI-12. The present definition of PSI-12 does not account for COVID-19. This may impact hospitals' quality performance if COVID-19 infection is not accounted for by exclusion or risk adjustment.

A Stroke Alert With Unexpected Outcome.

INTRODUCTION: Observational studies have suggested that intravenous (IV) thrombolysis may be unfavorable in patients with high-grade gliomas. However, current literature on thrombolysis outcomes in patients with primary brain tumors is largely limited to case reports and may be influenced by publication bias. CASE REPORT: A 69-year-old male presented with acute left hemiplegia, left hemisensory loss, neglect, dysarthria and right gaze preference (National Institutes of Health Stroke Scale 22). An emergent noncontrast head computerized tomography showed hypoattenuation in the right parietal lobe of unclear chronicity and IV thrombolysis with tissue plasminogen activator was administered within the 4.5 hour window. Following IV thrombolysis, a computerized tomography angiogram of the head and neck revealed no large vessel occlusion. However, a marginally enhancing, and centrally nonenhancing mass within the right parietal lobe associated with vasogenic edema was elucidated. Subsequently, the patient developed abnormal left hemibody tonic-clonic motor activity, left gaze preference and left-beating nystagmus concerning for focal motor status epilepticus. An emergent electroencephalogram, following administration of IV levetiracetam, showed right hemispheric electrographic seizures and right hemispheric periodic lateralized epileptiform discharges. Brain magnetic resonance imaging with gadolinium revealed 2.5 cm ring-enhancing mass in the right parietal lobe. The patient underwent right sided craniotomy with resection of the mass and pathology revealed Glioblastoma. CONCLUSION: We report a case of thrombolysis administered in a patient with high-grade glioma with no apparent complications.

Quantifying the Importance of COVID-19 Vaccination to Our Future Outlook.

Predictive models have played a critical role in local, national, and international response to the COVID-19 pandemic. In the United States, health care systems and governmental agencies have relied on several models, such as the Institute for Health Metrics and Evaluation, Youyang Gu (YYG), Massachusetts Institute of Technology, and Centers for Disease Control and Prevention ensemble, to predict short- and long-term trends in disease activity. The Mayo Clinic Bayesian SIR model, recently made publicly available, has informed Mayo Clinic practice leadership at all sites across the United States and has been shared with Minnesota governmental leadership to help inform critical decisions during the past year. One key to the accuracy of the Mayo Clinic model is its ability to adapt to the constantly changing dynamics of the pandemic and uncertainties of human behavior, such as changes in the rate of contact among the population over time and by geographic location and now new virus variants. The Mayo Clinic model can also be used to forecast COVID-19 trends in different hypothetical worlds in which no vaccine is available, vaccinations are no longer being accepted from this point forward, and 75% of the population is already vaccinated. Surveys indicate that half of American adults are hesitant to receive a COVID-19 vaccine, and lack of understanding of the benefits of vaccination is an important barrier to use. The focus of this paper is to illustrate the stark contrast between these 3 scenarios and to demonstrate, mathematically, the benefit of high vaccine uptake on the future course of the pandemic.

Refractory Left Focal Motor Status Epilepticus as Initial Clinical Presentation of Acute Basilar Artery Thrombosis.

Seizures are uncommon with posterior circulation strokes. They are more often associated with anterior circulation strokes, with only a limited number of cases of status epilepticus reported to be related to brain stem ischemia. The literature includes case reports of generalized tonic-clonic seizures and associated status epilepticus as an initial presentation of acute basilar artery thrombosis. However, there are only rare cases reporting focal motor seizure as status epilepticus in the setting of acute basilar artery thrombosis, an important clinical presentation that should prompt evaluation for acute brain stem ischemia.

Deployment of an Interdisciplinary Predictive Analytics Task Force to Inform Hospital Operational Decision-Making During the COVID-19 Pandemic.

In March 2020, our institution developed an interdisciplinary predictive analytics task force to provide coronavirus disease 2019 (COVID-19) hospital census forecasting to help clinical leaders understand the potential impacts on hospital operations. As the situation unfolded into a pandemic, our task force provided predictive insights through a structured set of visualizations and key messages that have helped the practice to anticipate and react to changing operational needs and opportunities. The framework shared here for the deployment of a COVID-19 predictive analytics task force could be adapted for effective implementation at other institutions to provide evidence-based messaging for operational decision-making. For hospitals without such a structure, immediate consideration may be warranted in light of the devastating COVID-19 third-wave which has arrived for winter 2020-2021.

Nine-year prospective efficacy and safety of brain-responsive neurostimulation for focal epilepsy.

OBJECTIVE: To prospectively evaluate safety and efficacy of brain-responsive neurostimulation in adults with medically intractable focal onset seizures (FOS) over 9 years. METHODS: Adults treated with brain-responsive neurostimulation in 2-year feasibility or randomized controlled trials were enrolled in a long-term prospective open label trial (LTT) to assess safety, efficacy, and quality of life (QOL) over an additional 7 years. Safety was assessed as adverse events (AEs), efficacy as median percent change in seizure frequency and responder rate, and QOL with the Quality of Life in Epilepsy (QOLIE-89) inventory. RESULTS: Of 256 patients treated in the initial trials, 230 participated in the LTT. At 9 years, the median percent reduction in seizure frequency was 75% (p < 0.0001, Wilcoxon signed rank), responder rate was 73%, and 35% had a ≥90% reduction in seizure frequency. We found that 18.4% (47 of 256) experienced ≥1 year of seizure freedom, with 62% (29 of 47) seizure-free at the last follow-up and an average seizure-free period of 3.2 years (range 1.04-9.6 years). Overall QOL and epilepsy-targeted and cognitive domains of QOLIE-89 remained significantly improved (p < 0.05). There were no serious AEs related to stimulation, and the sudden unexplained death in epilepsy (SUDEP) rate was significantly lower than predefined comparators (p < 0.05, 1-tailed χ2). CONCLUSIONS: Adjunctive brain-responsive neurostimulation provides significant and sustained reductions in the frequency of FOS with improved QOL. Stimulation was well tolerated; implantation-related AEs were typical of other neurostimulation devices; and SUDEP rates were low. CLINICALTRIALSGOV IDENTIFIER: NCT00572195. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that brain-responsive neurostimulation significantly reduces focal seizures with acceptable safety over 9 years.

Diagnostic utility of the Minnesota Multiphasic Personality Inventory-2 Restructured Form in the epilepsy monitoring unit: Considering sex differences.

Psychological assessment measures are frequently used to evaluate patients in epilepsy monitoring units. One goal of that assessment is to contribute information that may help with differential diagnosis between epilepsy and psychogenic nonepileptic seizures (PNES). The Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF) is one such measure. Del Bene et al. (2017) recently published an analysis that was the first to compare MMPI-2-RF scale elevations between diagnostic groups stratified by sex. The purpose of the present study was to replicate that analysis in a larger sample. Similar to previous work, we found that both men and women with PNES were more likely than men and women with epilepsy to report high levels of somatic complaints (2 to 5 times greater odds of somatic symptom reporting) and a variety of types of complaints. Mood disturbance scales were not significantly elevated in our PNES sample. Results contribute to the small body of research on sex differences in patients with PNES and suggest that somatization is a key characterization across sexes.

Usage of EpiFinder clinical decision support in the assessment of epilepsy.

BACKGROUND: The diagnosis of epilepsy is at times elusive for both neurologists and nonneurologists, resulting in delays in diagnosis and therapy. The development of screening methods has been identified as a priority in response to this diagnostic and therapeutic gap. EpiFinder is a novel clinical decision support tool designed to enhance the process of information gathering and integration of patient/proxy respondent data. It is designed specifically to take key terms from a patient's history and incorporate them into a heuristic algorithm that dynamically produces differential diagnoses of epilepsy syndromes. OBJECTIVE: The objective of this study was to test the usability and diagnostic accuracy of the clinical decision support application EpiFinder in an adult population. METHODS: Fifty-seven patients were prospectively identified upon admission to the Epilepsy Monitoring Unit (EMU) for episode classification from January through June of 2017. Based on semiologic input, the application generates a list of epilepsy syndromes. The EpiFinder-generated diagnosis for each subject was compared to the final diagnosis obtained via continuous video electroencephalogram (cVEEG) monitoring. RESULTS: Fifty-three patients had habitual events recorded during their EMU stay. A diagnosis of epilepsy was confirmed (with cVEEG monitoring) in 26 patients while 27 patients were found to have a diagnosis other than epilepsy. The algorithm appropriately predicted differentiation between the presence of an epilepsy syndrome and an alternative diagnosis with 86.8% (46/53 participants) accuracy. EpiFinder correctly identified the presence of epilepsy with a sensitivity of 86.4% (95% confidence interval [CI]: 65.0-97.1) and specificity of 85.1% (95% CI: 70.2-96.4). CONCLUSION: The initial testing of the EpiFinder algorithm suggests possible utility in differentiating between an epilepsy syndrome and an alternative diagnosis in adult patients.

Detection of generalized tonic-clonic seizures using surface electromyographic monitoring.

OBJECTIVE: A prospective multicenter phase III trial was undertaken to evaluate the performance and tolerability in the epilepsy monitoring unit (EMU) of an investigational wearable surface electromyographic (sEMG) monitoring system for the detection of generalized tonic-clonic seizures (GTCSs). METHODS: One hundred ninety-nine patients with a history of GTCSs who were admitted to the EMU in 11 level IV epilepsy centers for clinically indicated video-electroencephalographic monitoring also received sEMG monitoring with a wearable device that was worn on the arm over the biceps muscle. All recorded sEMG data were processed at a central site using a previously developed detection algorithm. Detected GTCSs were compared to events verified by a majority of three expert reviewers. RESULTS: For all subjects, the detection algorithm detected 35 of 46 (76%, 95% confidence interval [CI] = 0.61-0.87) of the GTCSs, with a positive predictive value (PPV) of 0.03 and a mean false alarm rate (FAR) of 2.52 per 24 h. For data recorded while the device was placed over the midline of the biceps muscle, the system detected 29 of 29 GTCSs (100%, 95% CI = 0.88-1.00), with a detection delay averaging 7.70 s, a PPV of 6.2%, and a mean FAR of 1.44 per 24 h. Mild to moderate adverse events were reported in 28% (55 of 199) of subjects and led to study withdrawal in 9% (17 of 199). These adverse events consisted mostly of skin irritation caused by the electrode patch that resolved without treatment. No serious adverse events were reported. SIGNIFICANCE: Detection of GTCSs using an sEMG monitoring device on the biceps is feasible. Proper positioning of this device is important for accuracy, and for some patients, minimizing the number of false positives may be challenging.

Awake Surgery for Brain Vascular Malformations and Moyamoya Disease.

OBJECTIVE: Although a significant amount of experience has accumulated for awake procedures for brain tumor, epilepsy, and carotid surgery, its utility for intracranial neurovascular indications remains largely undefined. Awake surgery for select neurovascular cases offers the advantage of precise brain mapping and robust neurologic monitoring during surgery for lesions in eloquent areas, avoidance of potential hemodynamic instability, and possible faster recovery. It also opens the window for perilesional epileptogenic tissue resection with potentially less risk for iatrogenic injury. METHODS: Institutional review board approval was obtained for a retrospective review of awake surgeries for intracranial neurovascular indications over the past 36 months from a prospectively maintained quality database. We reviewed patients' clinical indications, clinical and imaging parameters, and postoperative outcomes. RESULTS: Eight consecutive patients underwent 9 intracranial neurovascular awake procedures conducted by the senior author. A standardized "sedated-awake-sedated" protocol was used in all 8 patients. For the 2 patients with arteriovenous malformations and the 3 patients with cavernoma, awake brain surface and white matter mapping was performed before and during microsurgical resection. A neurological examination was obtained periodically throughout all 5 procedures. There were no intraoperative or perioperative complications. Hypotension was avoided during the 2 Moyamoya revascularization procedures in the patient with a history of labile blood pressure. Postoperative imaging confirmed complete arteriovenous malformation and cavernoma resections. No new neurologic deficits or new-onset seizures were noted on 3-month follow-up. CONCLUSIONS: Awake surgery appears to be safe for select patients with intracranial neurovascular pathologies. Potential advantages include greater safety, shorter length of stay, and reduced cost.

Brain-responsive neurostimulation in patients with medically intractable mesial temporal lobe epilepsy.

OBJECTIVE: Evaluate the seizure-reduction response and safety of mesial temporal lobe (MTL) brain-responsive stimulation in adults with medically intractable partial-onset seizures of mesial temporal lobe origin. METHODS: Subjects with mesial temporal lobe epilepsy (MTLE) were identified from prospective clinical trials of a brain-responsive neurostimulator (RNS System, NeuroPace). The seizure reduction over years 2-6 postimplantation was calculated by assessing the seizure frequency compared to a preimplantation baseline. Safety was assessed based on reported adverse events. RESULTS: There were 111 subjects with MTLE; 72% of subjects had bilateral MTL onsets and 28% had unilateral onsets. Subjects had one to four leads placed; only two leads could be connected to the device. Seventy-six subjects had depth leads only, 29 had both depth and strip leads, and 6 had only strip leads. The mean follow-up was 6.1 ± (standard deviation) 2.2 years. The median percent seizure reduction was 70% (last observation carried forward). Twenty-nine percent of subjects experienced at least one seizure-free period of 6 months or longer, and 15% experienced at least one seizure-free period of 1 year or longer. There was no difference in seizure reduction in subjects with and without mesial temporal sclerosis (MTS), bilateral MTL onsets, prior resection, prior intracranial monitoring, and prior vagus nerve stimulation. In addition, seizure reduction was not dependent on the location of depth leads relative to the hippocampus. The most frequent serious device-related adverse event was soft tissue implant-site infection (overall rate, including events categorized as device-related, uncertain, or not device-related: 0.03 per implant year, which is not greater than with other neurostimulation devices). SIGNIFICANCE: Brain-responsive stimulation represents a safe and effective treatment option for patients with medically intractable epilepsy, including patients with unilateral or bilateral MTLE who are not candidates for temporal lobectomy or who have failed a prior MTL resection.

Brain-responsive neurostimulation in patients with medically intractable seizures arising from eloquent and other neocortical areas.

OBJECTIVE: Evaluate the seizure-reduction response and safety of brain-responsive stimulation in adults with medically intractable partial-onset seizures of neocortical origin. METHODS: Patients with partial seizures of neocortical origin were identified from prospective clinical trials of a brain-responsive neurostimulator (RNS System, NeuroPace). The seizure reduction over years 2-6 postimplantation was calculated by assessing the seizure frequency compared to a preimplantation baseline. Safety was assessed based on reported adverse events. Additional analyses considered safety and seizure reduction according to lobe and functional area (e.g., eloquent cortex) of seizure onset. RESULTS: There were 126 patients with seizures of neocortical onset. The average follow-up was 6.1 implant years. The median percent seizure reduction was 70% in patients with frontal and parietal seizure onsets, 58% in those with temporal neocortical onsets, and 51% in those with multilobar onsets (last observation carried forward [LOCF] analysis). Twenty-six percent of patients experienced at least one seizure-free period of 6 months or longer and 14% experienced at least one seizure-free period of 1 year or longer. Patients with lesions on magnetic resonance imaging (MRI; 77% reduction, LOCF) and those with normal MRI findings (45% reduction, LOCF) benefitted, although the treatment response was more robust in patients with an MRI lesion (p = 0.02, generalized estimating equation [GEE]). There were no differences in the seizure reduction in patients with and without prior epilepsy surgery or vagus nerve stimulation. Stimulation parameters used for treatment did not cause acute or chronic neurologic deficits, even in eloquent cortical areas. The rates of infection (0.017 per patient implant year) and perioperative hemorrhage (0.8%) were not greater than with other neurostimulation devices. SIGNIFICANCE: Brain-responsive stimulation represents a safe and effective treatment option for patients with medically intractable epilepsy, including adults with seizures of neocortical onset, and those with onsets from eloquent cortex.

Fall prevention and bathroom safety in the epilepsy monitoring unit.

Falls are one of the most common adverse events occurring in the epilepsy monitoring unit (EMU) and can result in significant injury. Protocols and procedures to reduce falls vary significantly between institutions as it is not yet known what interventions are effective in the EMU setting. This study retrospectively examined the frequency of falls and the impact of serial changes in fall prevention strategies utilized in the EMU between 2001 and 2014 at a single institution. Overall fall rate was 2.81 per 1000 patient days and varied annually from 0 to 9.02 per 1000 patient days. Both seizures and psychogenic nonepileptic events occurring in the bathroom were more likely to result in falls compared with events occurring elsewhere in the room. With initiation of increased patient education, hourly nurse rounding, nocturnal bed alarms, having two persons assisting for high fall risk patients when out of bed, and immediate postfall team review between 2001 and 2013, there was a trend of decreasing fall frequency; however, no specific intervention could be identified as having a particular high impact. In late 2013, a ceiling lift system extending into the bathroom was put in place for use in all EMU patients when out of bed. In the subsequent 15 months, there have been zero falls. The results reinforce both the need for diligent safety standards to prevent falls in the EMU as well as the challenges in identifying the most effective practices to achieve this goal.

Quality of life in psychogenic nonepileptic seizures and epilepsy: the role of somatization and alexithymia.

It is clear that many individuals with psychogenic nonepileptic seizures (PNESs) often present with poorer quality of life compared with those with epileptic seizures (ESs). However, the mechanisms linking seizure diagnosis to quality-of-life outcomes are much less clear. Alexithymia and somatization are emotional markers of psychological functioning that may explain these differences in quality of life. In the current study, patients from an epilepsy monitoring unit with vEEG-confirmed diagnosis of PNESs or ESs were compared on measures of alexithymia, somatization, quality of life, and a variety of demographic and medical variables. Two models using alexithymia and somatization individually as mediators of the relations between diagnosis and quality of life were tested. Results indicated that patients with PNESs had significantly poorer quality of life compared with those with ESs. Alexithymia was associated with poor quality of life in both groups but did not differentiate between diagnostic groups. Further, alexithymia did not mediate the relationship between diagnosis and quality of life. Somatization was associated with poor quality of life, and patients with PNESs reported greater somatization compared with patients with ESs. Somatization also significantly mediated the relationship between diagnosis and quality of life. In conclusion, somatization may be one mechanism affecting poor quality of life among patients with PNESs compared with ESs and should be a target of comprehensive treatments for PNESs. Alexithymia proved to be an important factor impacting quality of life in both groups and should also be targeted in treatment for patients with PNESs and patients with ESs.

The influence of staffing on diagnostic yield of EMU admissions: a comparison study between two institutions.

Patients with recurrent, stereotyped neurological events of unclear etiology often warrant admission for continuous video-EEG monitoring in an epilepsy monitoring unit (EMU) for diagnosis. Epilepsy monitoring unit admission duration has been reported to range from days to weeks. To date, there are limited data on the average duration of admission for patients admitted to the EMU for spell classification. Many EMUs are forced to limit the overall duration of admission for numerous reasons including limited resources. It is unclear if a time-limited EMU stay reduces the event capture rate and, therefore, diagnostic yield of event classification admissions. The goal of this study was to determine how a time-limited length of stay strategy impacted event capture in patients admitted for spell classification. A retrospective chart review was performed at two comparable adult epilepsy monitoring units, Mayo Clinic Hospital (MCH) in Phoenix, Arizona, and Banner Good Samaritan Medical Center (BGSMC) in Phoenix, Arizona. Banner Good Samaritan Medical Center is only staffed Monday through Friday, thereby limiting the total possible duration of admission to five days. The goal was to determine if the rate of event capture differed between two institutions employing a time-limited EMU admission (BGSMC) when compared with the nonlimited admission (MCH). A total of 300 patient admissions at MCH and 260 patient admissions at BGSMC were reviewed over a comparable time period. The event capture rates at MCH and BGSMC were 74% and 72%, respectively. There was a greater percentage of patients with nonepileptic events (NEEs) at MCH than at BGSMC (62.7% vs. 47.3%). The mean duration until first event was 31h at MCH and 38 h at BGSMC. The mean length of stay was greater at MCH (4.5 days) when compared with BGSMC (3.3 days). The overall diagnostic yield of a time-limited EMU admission was similar to that of a nonlimited admission for the purpose of spell classification. There was a statistically significant difference when comparing the time until first event at both institutions; however, this still fell within the 5-day duration that the time-restricted admission was limited to. These results may be important in optimizing an EMU practice in patients requiring admission for spell classification.