COVID-19 Resources

Technologist Safety

1. Most institutions recommend droplet precautions for COVID+/PUI (patients under invesitgation) except for during aerosolizing procedures when airborne precautions are recommended. However, given data that COVID 19 can survive up to 3 hours aerosolized (van Doremalen et al., NEJM, March 2020, https://www.nejm.org/doi/full/10.1056/NEJMc2004973), many centers are recommending airborne precautions (N95) for all ventilated COVID+/PUI undergoing neurodiagnostic (NDT) procedures.
2. Inquire about COVID/ PUI status and whether patient is ventilated or receiving regular nebulizer treatments before arriving bedside to perform a NDT procedure
   1. For PUI - Ask clinical team if the procedure can be postponed until test results are available (with introduction of rapid test kits, it will become likely that most NDT procedures could be performed after results are available without significant impact on patient care)
   2. If determined N95 is needed (COVID+/PUI and ventilated or receiving nebulizer treatments), inquire about N95 availability on the unit
   3. If N95 is needed and not immediately available on the unit, establish other means to obtain (CDC has recommended appointment of a PPE coordinators to oversee PPE accountability and appropriate use)
   4. If N95 is not available on the unit or by other means, consider securing one N95 mask per tech to have on their carts as a final back up
   5. A question has been raised as to whether use of an air hose for application of collodion constitutes an aerosolizing procedure. At the current time there is not enough data to make an informed decision regarding this issue. However, N95 use should be considered for COVID+/PUI patients when air hose is being used.
   6. As of 3/22/20, CDC recommends conservation of PPE given short supply. Therefore PPE may be re used but in accordance to institutional protocols (see U Washington protocol on re use of N95 as an example)
   7. Consider having techs keep a surgical mask, face shield, gown and gloves on their cart as backup. Remember, droplet precautions is appropriate for most COVID+/PUI patients
   8. Finally, if technologists are not comfortable entering a patient room, encourage them to contact the EEG attending or NDT lab director for consultation (education and reassurance can go a long way, not all patients require use of N95)

NOTE: Policies and procedures regarding N95 use are rapidly evolving and vary considerably between institutions and units so keep current with national and institutional updates

Technologist Staffing

1. Many hospitals are experiencing staffing difficulties due to illness, lack of child care and self-quarantine directives. In addition, many NDT staff experience considerable anxiety about frequent and prolonged exposures to potentially infectious patients, and the impact that their illness could have on themselves and their family. Furthermore, most institutions have been operating with minimal NDT staffing even prior to COVID 19 due to a national technologist shortage. Therefore, efforts should be made to limit technician exposure to potentially infectious patients
2. Consider reduction of inpatient tech hours of coverage.
   1. Even if you currently have full staff, this could change very rapidly.
   2. To reduce burn out and ensure well-being of techs, consider eliminating overnight call backs and shorter daytime hours of operation
3. For continuous EEGs/ prolonged studies: Limit number of different techs going into each patient room, particularly for COVID+/PUI
4. Consider rapid application EEG with caps/ templates for if/when tech staffing is limited. Nursing staff could apply which reduces number of different staff in the room and conserves PPE

1. Use antiseptic wipe to clean all surfaces of the NDT equipment that has entered any COVID+/PUI patient room
2. Consider clear plastic bags to cover EEG equipment in COVID+/PUI rooms
3. See U Maryland equipment cleaning protocol

Inpatient Testing

1. Inpatient EEG
   1. Neurology or Neurophysiology attending should establish medical necessity and appropriate timing of all NDT studies on COVID +/PUI
   2. If NDT staffing is limited then consider Neurology or Neurophysiology approval of ALL NDT procedures, regardless of COVID status
   3. Give careful consideration to whether EEGs ordered routine (20 minute) should be converted to continuous EEG prior to the start of the procedure to reduce the chance of re-hooks and time in the room
2. Elective EEG monitoring/ EMU
   1. In keeping with national directives to limit elective admissions to optimize bed availability for potential COVID-19 patients, many institutions have cancelled elective EMU admissions
   2. Consider alternatives to elective EEG monitoring (particularly for diagnostic evaluations)
      1. Acquire home video of events
      2. Assess index of suspicion and consider empiric treatment with ASD vs. CBT/ psychotherapy (explore online resources including FNDHope.org, neurosymptoms.org and telehealth for psychotherapy)
      3. Ambulatory EEG (see below)
      4. Benefit may outweigh the risk of “semi elective” admission. For example- a patient with very frequent events and/or recent ED visits and the options above have been exhausted
   3. Consider current bed availability and number of COVID+ cases at your institution. It may be safer and more appropriate to proceed with urgent EMU admissions if COVID+ cases are low and beds are available
   4. For patients presenting to the ED with frequent events, consider admission for non elective video EEG monitoring to get rapid diagnosis and avoid subsequent ED visits (if resources allow)
   5. When assessing risk of elective EMU admission, consider location of the EMU (proximity to COVID/isolation units)
   6. See NAEC guidelines for triage of pre surgical and surgical patients

Outpatient Testing

1. Ambulatory EEG (with video if available)
   1. As above, balance risk vs. benefit; Ambulatory EEG data may inform treatment to avoid ED visits
   2. Cleaning – as above, clean all surfaces with antiseptic wipe
   3. If possible have the same tech perform hook up and take down
   4. If not already being done, consider having hookup/ take down done at the outpatient lab and not the hospital to limit exposure and hospital traffic
2. Outpatient “Routine” EEG
   1. Due to the potential risk of infectious exposure to both patients and healthcare providers, hospitals are encouraged to postpone non-urgent elective outpatient procedures such as EEG and EMG whenever possible
   2. However, urgency should always be considered
      • Could information gained from a routine OP EEG potentially avoid ED visits?
      • Will EMG results immediately alter the treatment plan?
      • Based on your geographical location, is the current risk/ infection rate relatively low but likely to be higher in the future? (ie safer to do the procedure now rather than postpone a few weeks)
3. Sleep Studies
   1. Very good information available on AASM website: https://aasm.org/clinical-resources/covid-19-faq/
   2. One specific area of concern is exposure of health-care workers by aerosolized particles during positive-airway ventilation. Many institutions are rescheduling or foregoing CPAP titration studies, instead relying or autotitration.
   3. Home sleep testing remains an option. As above, balance risk vs. benefit and importance of cleaning all equipment between uses.

1. Work remotely whenever possible
2. Given in person clinic visits will likely be reduced, consider staffing outpatient clinic on alternate or rotating days to limit provider exposure
3. Follow institutional and ACGME recommendations regarding scheduling of residents and fellows (www.acgme.org/covid-19)