ACNS is committed to providing you with resources to navigate this unprecedented situation and to keep you, your staff and your patients safe.
The situation is evolving at a rapid pace, and ACNS first recommends that members follow the policies and guidelines set by their institutions and state/federal authorities.
Although best practices are not entirely clear and the situation is too fluid and variable among different facilities to offer specific recommendations, ACNS has provided the list of considerations and approaches below for members to consider when developing policies and protocols for their own facilities.
Suzette LaRoche, MD, FACNS provides an overview of how the COVID-19 pandemic has changed the practice of EEG. This lecture was part of ACNS's Virtual Fall Courses, presented in October 2020.
If you have a specific question or would like to weigh in on any of the items listed, please click below. ACNS leaders will respond to individual questions and hope to develop additional resources to address frequently asked questions.
Please continue to check back for new information as it becomes available! Last updated: June 1, 2020
COVID-19 Resources for Clinical Neurophysiology
Technologist Safety & Staffing
Technologist Safety
Current CDC guidelines recommend all staff wear surgical masks at all times while in clinical care areas or unable to maintain safe social distancing. Masks are typically being used for the entire shift unless they become soiled.
Current CDC guidelines also recommend all people (patients, family members, etc) wear face covering when not able to social distance.
Institutional policies should guide visitation, however, a maximum of 1 family member/caregiver should accompany patients for inpatient or outpatient procedures.
Most institutions are screening patients as well as staff for symptoms of infection each day using questionnaires and/or temperature screening.
CDC recommends N95 respirator, face shield or goggles, nonsterile gloves and gown for all COVID+/PUI (patients under investigation). If N95 respirator is not available, a surgical face mask is considered an appropriate alternative. Data has shown that COVID 19 can survive up to 3 hours following aerosolizing procedures. https://www.nejm.org/doi/full/10.1056/NEJMc2004973
Inquire about COVID/ PUI status prior the procedure
For PUI - Ask clinical team if the procedure can be postponed until test results are available.
CDC recommends conservation of PPE given short supply. Therefore, PPE may be reused in accordance with institutional protocols.
Activation procedures, especially hyperventilation, should not be performed on a COVID positive patients or PUI.
In patients with low concern for COVID, consider performing hyperventilation ONLY on patients where it is likely to have high diagnostic yield, for example, a patient with suspicion of absence or other primary generalized epilepsies.
Due to the concern that use of an air hose for application of collodion may constitute an aerosolizing procedure, in COVID+/PUI patients alternative approaches should be considered, such as using paste, taping down the electrodes and/or using head wrapping.
If technologists are not comfortable entering a patient room, encourage them to contact the EEG attending or NDT lab director for consultation
NOTE: Policies and procedures are rapidly evolving and vary considerably between institutions and units. So, keep current with national, state and institutional updates.
Technologist Staffing
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, many institutions were 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 and to provide resources for counseling.
Consider reduction of inpatient tech hours of coverage.
Even if you currently have full staff, this could change very rapidly.
To reduce burn out and ensure well-being of techs, consider eliminating overnight call backs and shorter daytime hours of operation.
For continuous EEGs/ prolonged studies: Limit number of different techs going into each patient room, particularly for COVID+/PUI.
Consider rapid application EEG with disposable, single use caps/ templates particularly if tech staffing is limited.
Equipment Maintenance & Cleaning
Use antiseptic wipe to clean all surfaces of the NDT equipment that has entered any COVID+/PUI patient room.
Consider clear plastic bags to cover EEG equipment in COVID+/PUI rooms
Consider keeping the machine outside the patient’s room (via long wiring). This minimizes equipment contamination and the amount of time the EEG tech needs to stay in the room.
Disposable electrodes should be utilized whenever possible.
If disposable electrodes are not available, then consider soaking electrodes in a disinfecting solution for minimum of 1 minute. Although not specific for EEG electrodes, CDC recommends 70% isopropyl alcohol or dilute bleach solution for disinfection of solid surfaces.
Neurology or Neurophysiology attending should establish medical necessity and appropriate timing of all NDT studies on COVID +/PUI, in conjunction with the involved neurology team.
If NDT staffing is limited then consider Neurology or Neurophysiology approval of ALL NDT procedures, regardless of COVID status
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
Activation procedures, especially hyperventilation, should not be performed on COVID positive patients or PUI.
In patients with low concern for COVID, consider performing hyperventilation ONLY on patients where it is likely to have high diagnostic yield, for example, a patient with suspicion of absence or other primary generalized epilepsies.
Due to the concern that use of an air hose for application of collodion may constitute an aerosolizing procedure, in COVID+/PUI patients alternative approaches should be considered, such as using paste, taping down the electrodes and/or using head wrapping.
In keeping with national directives to limit elective admissions to optimize bed availability for potential COVID-19 patients, beginning in March, 2020, many institutions cancelled elective EMU admissions. While many institutions have now resumed elective admissions and procedures, some are still forced to limit admissions. Consider alternatives to elective EEG monitoring (particularly for diagnostic evaluations)
Acquire home video of events
Assess index of suspicion and consider empiric treatment or Ambulatory EEG (see below)
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
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), or consider home (ambulatory) video/EEG if readily and rapidly available.
Considerations for re-opening elective EMU procedures
Joint statement from AAN, ACNS, AES, ASET and NAEC
Some specific items to consider:
Safety of patients and staff
Ensure adequate staffing levels – NDT staff may have been reassigned to other duties
Consider institutional policies on visitors/family members
Are family members essential for safety and diagnostic accuracy?
Availability of masks for patients (if allowed to leave room) and visitors (when outside of patient room)
Masking of patient during EEG hookup and electrode maintenance
Availability of COVID testing, including POC testing
Consider COVID testing for patients prior to admission, particularly in institutions and geographic regions with high COVID volumes
Consider physical location of the EMU and proximity to COVID patient care areas
Assess availability of ICU beds – for status epilepticus, post-operative care
Ensure availability of rescue medications (IV benzodiazepines)
Review logistics related to specific surgical procedures (e.g., SEEG, implants, etc.)
Be prepared to postpone admissions if conditions change
Outpatient Testing
Ambulatory EEG (with video if available)
As above, balance risk vs. benefit; Ambulatory EEG data may inform treatment to avoid ED visits
Cleaning – as above, clean all surfaces with antiseptic wipes
If possible, have the same tech perform hook up and take down
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
If using a third party for home video EEG, make sure they are following CDC guidelines related to COVID-19.
Outpatient “Routine” EEG
Determine risk vs. benefit and relative urgency of outpatient NDT procedures
Could information gained from a routine OP EEG potentially avoid ED visits or other morbidity?
Will EEG results immediately alter the treatment plan?
Activation procedures, especially hyperventilation, should not be performed on a COVID positive patient or PUI. In patients with low concern for COVID, rather than routinely performing hyperventilation and photic stimulation on all patients, patients should be selected for high diagnostic yield. For example, a patient with concern/suspicion for absence epilepsy or other primary generalized epilepsies is most likely to benefit from hyperventilation.
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 on autotitration.
Home sleep testing remains an option. As above, balance risk vs. benefit and importance of cleaning all equipment between uses
In areas with significant ongoing COVID-19 activity, it is prudent to work remotely whenever possible. This is especially true for educational and clinical conferences and interpretation of neurophysiologic studies. If resources and rules permit, a significant proportion of clinic visits may still be conducted in virtual environments.
Follow institutional and ACGME recommendations regarding scheduling of residents and fellows (www.acgme.org/covid-19).