LETTERS

Reducing the Cost of Continuous EEG Monitoring To the Editor: I read with interest the study by Kolls et al. (2014) on the use of a template system to achieve cost reduction in continuous video-EEG (cEEG) monitoring service. Working in the comprehensive epilepsy center of a large academic center in New York City, I have certain observations that I would like to share. The use of cEEG has grown exponentially in our center with the majority of studies requested from the critical care units especially neurological ICU. In addition to patients admitted to the epilepsy monitoring unit, bedside EEG monitoring with the help of portable EEG machines are carried out on patients admitted to the medical and surgical services. The epilepsy monitoring unit and neurological ICU beds are hard-wired to record cEEG with the EEG machine mounted on the wall in the patient’s room and EEG data available to review both at the bedside and remotely in real time both from within and outside the hospital by logging into the EEG server. The other studies although first need to be downloaded on to a portable drive and then uploaded on to the server for the epileptologist to review. Therefore, our technologist does not simply paste the electrodes, he wheels the machine to the patient’s bedside, determines if the full 10-20 montage can be applied or a restricted montage is needed on account of patient’s craniotomy, carries out bedside activation procedures such as photic stimulation and hyperventilation, downloads and uploads studies on to the server, and finally reviews the cEEG studies and alerts epileptologist on call if seizures or worrisome patterns are documented. Therefore, although suggestion by Kolls et al. (2014) of using a template system is laudable, I doubt its practicality. The way to reduce cEEG monitoring costs is by better physician and resident education on the indications of cEEG monitoring for frequently studies are requested where a routine EEG shall suffice. As I see it, the only 3

TO THE

EDITOR

indications for cEEG monitoring is to rule out nonconvulsive seizures in the critically ill patient, characterize events when a question of nonepileptic events is raised, and for characterization and localization of seizure focus in the potential epilepsy surgery patient.

Nitin K. Sethi Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, U.S.A. e-mail: [email protected]

REFERENCE Kolls BJ, Lai AH, Srinivas AA, Reid RR. Integration of EEG lead placement templates into Traditional technologist-based staffing models reduces costs in continuous video-EEG monitoring service. J Clin Neurophysiol 2014;31:187e193.

Response to: Reducing the Cost of Continuous EEG Monitoring In Reply: I appreciate the feedback from Dr Sethi. At our center, like most academic centers, the continuous video-EEG monitoring service is busy, and neurocritical care unit centric. Without a doubt, the technologists are indispensable to these centers and perform many roles including, in many cases, management of the laboratory staff and operations. It was not the intent of the cost analysis to suggest that technologists be replaced by the templates. We suggest instead that the task of lead placement be done by others who are already at the bedside so that the key skill sets of the technologists, which you enumerated, can be applied in many other areas for which they are responsible. The purpose of the study was to find ways to reduce costs for the service that could allow for implementation outside of the academic centers. There are numerous

intensive care units in community hospitals that lack EEG technologist support in any form. It is not possible for a technologist to be at every hospital, and it is not possible for all these patients to be transferred to major centers just for EEG monitoring. Some alternative approach needs to be established that allows these community centers to provide patients with the same quality of care in terms of brain monitoring as that received at academic centers’ intensive care units. Technologists are required to run a template-based service as well, but their role is to manage the service and focus on data quality and not to spend hours hooking patients up for recording. This new role, leveraging the unique expertise of EEG technologists, could allow for monitoring to be performed at smaller centers. As with any proposed change from the established standard, there is always a concern about impact on study quality and technologist jobs. However, the implementation of templates increases the demand for expert oversight and reduces the demand on application of leads which, as you admitted, can be limited in many neurocritical care patients. Although I appreciate the sentiment that one can simply be more selective in which patients to monitor, the reality is that EEG is finding a role beyond seizure detection. Prognosis, diagnostic utility in coma and encephalopathy, and potentially formal brain monitoring of critically ill and acute brain injured patients as quantitative approaches mature over time. As the role for EEG monitoring in the intensive care unit expands, it is unlikely that limiting its application will be a practical way to address growth and demand. Instead, new approaches to making the application and the use of EEG need to be created and rigorously evaluated for accuracy, signal quality, and ease of use. This report was simply the first step in that rigorous evaluation of one possible solution to the ever growing demand for EEG services in the intensive care unit.

Brad J. Kolls Department of Neurology, Brain Injury Translational Research Center, Duke University School of Medicine, Durham, North Carolina, U.S.A. e-mail: [email protected]

Copyright Ó 2014 by the American Clinical Neurophysiology Society

ISSN: 0736-0258/14/3105-0505

Journal of Clinical Neurophysiology  Volume 31, Number 5, October 2014

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