To the Editor: We thank Dr. Benbadis for his comments regarding the American Clinical Neurophysiology Society’s consensus statement on continuous EEG monitoring in critically ill adults and children (Herman et al., 2015). Dr. Benbadis proposes that many critical care continuous EEG (CCEEG) studies should be performed as stat studies because the results can have immediate implications for patient management, rather than “as soon as possible” (ASAP), as proposed in the consensus statement. We appreciate his important point, and we agree that many CCEEG indications meet the reasonable criterion he proposes for a stat study: “the result is of critical importance and will affect immediate management.” In drafting the consensus statement, the Task Force avoided designating a specific time frame for initiation of CCEEG. In general, stat studies are “now” studies, can be initiated at all times, and provide results within 1 or possibly 2 hours. Because of the importance of stat results, many hospitals have medical policies that define turnaround times and communication of the results of stat studies. Currently, most EEG laboratories do not have in-hospital EEG technologists 24 hours per day and 7 days per week. When a stat EEG order is placed during normal working hours, it often can be initiated and sometimes even reported within the stat 1 hour time frame. During some hours, an EEG technologist may be in the hospital but may not be immediately available to perform a stat study because of other job tasks. Even in rare hospitals with continuous in-house EEG technologist coverage, multiple critically ill patients may have CCEEG ordered simultaneously, thereby precluding immediate initiation. Even more problematic, at many institutions, an EEG technologist may need to be called into the hospital from home. Furthermore, the interpreting physician is usually not in-house during evening hours so additional time is required for remote access, review, and reporting of the results to the requesting team. A 2001 survey of emergency EEG services reported that emergency EEG was offered by 80% of 46 responding hospitals (Quigg et al., 2001). The median response time from request to interpretation was 36 4 hours, with a range of 1 to 24 hours. There was substantial variability in the indications that were believed to warrant emergency EEG, including nonconvulsive status epilepticus, treatment of status epilepticus, cerebral death, diagnosis of convulsive status epilepticus, and diagnosis of coma or encephalopathy. Similarly, 2 recent surveys of CCEEG practice showed that most hospitals do not have EEG technologists available 24/7 (Abend et al., 2010; Quigg et al., 2001). In the first survey (Abend et al., 2010), nearly 20% of respondents would perform an EEG for the diagnosis of NCS the next time an EEG technologist was available for regular working hours. In the second survey (Gavvala et al., 2014), 26% of respondents had an in-house EEG technologist available 24/7, 60% could call a technologist in from home, and 14% had no availability for emergent off-hours EEG. Given this substantial variability in practice and resource availability, the Task Force concluded that designating CCEEG as stat studies was not feasible and would place centers at potential legal risk if they could not complete the study within the designated time frame. Use of the admittedly less defined terms “urgent” and “as soon as possible” was intended to convey urgency but also avoid strict temporal definitions that some or many centers would not be able to provide. Furthermore, as Dr. Benbadis points out, the optimal timing may be dependent on the overall clinical scenario and not solely the CCEEG indication. Hopefully, if rapid diagnosis and management of nonconvulsive seizures is demonstrated to improve neurologic outcome, EEG laboratories will be able to justify increased staffing and 24/7 coverage. At a minimum, CCEEG laboratories should have written policies describing the time frame for initiation, recording, and reporting of CCEEG studies for each indication, with the recognition that care must also be individualized. The policy should include standards for both routine and off-hours EEGs. If an oncall technologist is used, the policy should describe the criteria for calling in the technologist. Finally, to ensure that orders and results are transmitted efficiently between the clinical care and EEG teams, the policy should describe the workflow and personnel responsible for ordering, performing, interpreting, and communicating the results of urgent/ASAP (and sometimes stat) CCEEG studies.
S. Herman, N. Abend
Journal of clinical neurophysiology : official publication of the American Electroencephalographic Society