Overnight monitoring of continuous video EEG

[SenescentNeuron]

Hello,

I am a neurology resident at a very large academic program. I wanted to ask how other similarly large academic programs monitor continuous EEG overnight - especially for patients on non-neurological services.

At our institution, we do not have an epilepsy attending, epilepsy fellow, or EEG tech who monitors or reads the continuous EEGs overnight. We do have an on-call epilepsy fellow or attending that is available overnight. However, they will not look at any EEGs overnight; instead, they are only available to approve or deny requests for continuous EEG.

Our overnight consult resident will try to monitor the EEGs for patients on non-neurological services (there are usually 2 - 4 at any given time). However, they often miss seizures due to lack of time, experience, and/or training. They also often over-treat electrographic patterns that do not represent seizures.

We are told that continuous EEG refers to continuous recording rather than continuous monitoring. Is this how most epilepsy departments at large academic institutions approach this?

Thank you for your time. I appreciate any insight or commentary you have on this topic.

---

Members don't see this ad.

 

[GuillainMollaret]

We were responsible for overnight cEEGs as residents (usually 3 to 5 at any given time that we were actively monitoring). I remember lots of ICU patients in non-convulsive status. There was always a fellow you could page with questions.

Good training that I'll never use again as an outpatient, non EEG reading neurologist.

 

[xenotype]

We were responsible for overnight cEEGs as residents (usually 3 to 5 at any given time that we were actively monitoring). I remember lots of ICU patients in non-convulsive status. There was always a fellow you could page with questions.

Good training that I'll never use again as an outpatient, non EEG reading neurologist.

I guess the practice you work for will never get bought up by a hospital system that will then force you to cover inpatient on the weekends thus making that skill set immediately valuable again.

'Continuous' EEG is a joke unless there is at least tech 24/7 monitoring. It is a farce that anyone is allowed to get away with less but it seems fairly routine to not check it after bedtime. It should pay a lot better than 24hr unmonitored with real, stringent requirements, but here we are. If anyone decides to go into status at midnight it'll be found at about 7am, slightly better than an unmonitored study. Relying on an overnight resident who is also seeing 13 stroke alerts is ridiculous, as is expecting an epilepsy fellow to magically be awake 24/7 with hawk eyes.

 

[Postictal Raiden]

I guess the practice you work for will never get bought up by a hospital system that will then force you to cover inpatient on the weekends thus making that skill set immediately valuable again.

'Continuous' EEG is a joke unless there is at least tech 24/7 monitoring. It is a farce that anyone is allowed to get away with less but it seems fairly routine to not check it after bedtime. It should pay a lot better than 24hr unmonitored with real, stringent requirements, but here we are. If anyone decides to go into status at midnight it'll be found at about 7am, slightly better than an unmonitored study. Relying on an overnight resident who is also seeing 13 stroke alerts is ridiculous, as is expecting an epilepsy fellow to magically be awake 24/7 with hawk eyes.

If someone is on cEEG monitoring for concern of NCSE, they should already be treated for seizure. Most are already on some sort of anesthetic, be it propofol, midazolam or pentobarb which can serve as an AED.

When I interviewed for fellowships, one particular institution (big name) didn't have overnight monitoring. They didn't have STAT EEGs at all. Their rationale is that if you are suspecting a seizure, you should treat it. I was very surprised by this coming from a less prestigious program, but one where every encephalopathic and consciously altered patient is being hooked to a trend.

Seizure remains mainly a clinical diagnosis. However, we are becoming increasingly reliant on EEGs, but mainly to rule people in rather than ruling them out.

 

[GuillainMollaret]

I guess the practice you work for will never get bought up by a hospital system that will then force you to cover inpatient on the weekends thus making that skill set immediately valuable again.

'Continuous' EEG is a joke unless there is at least tech 24/7 monitoring. It is a farce that anyone is allowed to get away with less but it seems fairly routine to not check it after bedtime. It should pay a lot better than 24hr unmonitored with real, stringent requirements, but here we are. If anyone decides to go into status at midnight it'll be found at about 7am, slightly better than an unmonitored study. Relying on an overnight resident who is also seeing 13 stroke alerts is ridiculous, as is expecting an epilepsy fellow to magically be awake 24/7 with hawk eyes.

I already work for a hospital system. We have dedicated neurohospitalists and 100% outpatient neurologists. I will find a different job if I ever have to cover inpatient.

My experience with overnight cEEG in an academic setting: the day residents gave sign out on who to pay attention to and what AED to load them with if they went back into NCSE. I'd go through those every couple of hours or so. We had Persyst which was nice. For other patients depending on the sign out, we'd only look if the nurses paged about a clinical event. Definitely wouldn't call it a joke and thought it was pretty useful and certainly better than no monitoring at all.

 

[xenotype]

If someone is on cEEG monitoring for concern of NCSE, they should already be treated for seizure. Most are already on some sort of anesthetic, be it propofol, midazolam or pentobarb which can serve as an AED.

When I interviewed for fellowships, one particular institution (big name) didn't have overnight monitoring. They didn't have STAT EEGs at all. Their rationale is that if you are suspecting a seizure, you should treat it. I was very surprised by this coming from a less prestigious program, but one where every encephalopathic and consciously altered patient is being hooked to a trend.

Seizure remains mainly a clinical diagnosis. However, we are becoming increasingly reliant on EEGs, but mainly to rule people in rather than ruling them out.

Of course they are already treated for seizure, possibly intubated on multiple ASM sometimes even burst suppressed but that doesn't matter if brief electrographic seizures start appearing when everyone is asleep and no one is looking, and continue every few minutes for hours by the time anyone catches it.

Ask yourself if anyone has done a study on the adequacy of burst suppression between the hours of 10pm and 8am in these institutions with no real overnight monitoring. I guarantee it averages to be inconsistent/somewhat poor and much worse than the daytime hours when people are looking. It isn't optimal patient care, it is saving some bucks. I'm speaking from personal experience here from my days in training. Nobody looks at the EEG after midnight in a lot of big places, and it doesn't always result in the best patient care. Persyst is not a substitute either.

As for that one institution not doing stat EEGs- I'm sure they are great at clinically detecting 3 Hz GPDs at bedside in every stuporous/obtunded patient, and have never unnecessarily sedated patients and/or started multiple ASMs just because EEG wasn't available for hours.

 

[Neurogeneral]

Overnight continuous EEG reads are usually only possible at big power house centers where there are a bunch of willing fellows that can share that responsibility. Moreover, you have to hire a tech who is willing to take call and hook people up STAT.

It’s just not feasible otherwise IMO. Expecting a very busy on-call in house PGY2 resident to reliably read EEGs overnight is crazy. At less known and smaller programs, you willhave great difficulty attracting applicants if you make them do overnight EEG reads.

 

[xenotype]

Overnight continuous EEG reads are usually only possible at big power house centers where there are a bunch of willing fellows that can share that responsibility. Moreover, you have to hire a tech who is willing to take call and hook people up STAT.

It’s just not feasible otherwise IMO. Expecting a very busy on-call in house PGY2 resident to reliably read EEGs overnight is crazy. At less known and smaller programs, you willhave great difficulty attracting applicants if you make them do overnight EEG reads.

Don't have to have reads from fellow all night. Paying for an in house tech screening overnight would be adequate. That also takes care of any stat hook up requests that inevitably come as well. However, continuous EEG doesn't reimburse well enough to offset that cost and most of these 'powerhouse' centers won't pay for a tech overnight. There is no 'intermittent monitoring' at a lot of places from 12am to 7am.

 

[GuillainMollaret]

It’s just not feasible otherwise IMO. Expecting a very busy on-call in house PGY2 resident to reliably read EEGs overnight is crazy. At less known and smaller programs, you willhave great difficulty attracting applicants if you make them do overnight EEG reads.

To clarify, we always had one senior and one junior in house overnight where I trained (busy, brand name academic center).

We'd alternate consults until 10 or 11 and then the junior would be the consult monkey while the senior would only be responsible for monitoring cEEG and going to stroke alerts with the junior.

We also had an EEG tech in house overnight for stat hookups.

Always an epilepsy attending or fellow on call you could contact with questions.

The system worked well and usually not too much was missed overnight.

 

[deathmerchant]

Hello,

I am a neurology resident at a very large academic program. I wanted to ask how other similarly large academic programs monitor continuous EEG overnight - especially for patients on non-neurological services.

At our institution, we do not have an epilepsy attending, epilepsy fellow, or EEG tech who monitors or reads the continuous EEGs overnight. We do have an on-call epilepsy fellow or attending that is available overnight. However, they will not look at any EEGs overnight; instead, they are only available to approve or deny requests for continuous EEG.

Our overnight consult resident will try to monitor the EEGs for patients on non-neurological services (there are usually 2 - 4 at any given time). However, they often miss seizures due to lack of time, experience, and/or training. They also often over-treat electrographic patterns that do not represent seizures.

We are told that continuous EEG refers to continuous recording rather than continuous monitoring. Is this how most epilepsy departments at large academic institutions approach this?

Thank you for your time. I appreciate any insight or commentary you have on this topic.

Like mentioned above, its impossible to have someone monitor cEEG 24/7 in every hospital, for every patient. Clinical seizures/status should obviously be treated ASAP.
Non convulsive seizures or status has a much better prognosis (depending on underlying cause). Ideally we want to treat them as soon as possible as well but delay in treatment by few hours might not make much difference in prognosis.