Authors (including presenting author) :
Hsu HC (3), Lui ST (1), Yeung WT (1)(2), Lee OK (1)(2), Lei PO (1)(2)
Affiliation :
(1) Medical and Geriatric Department, Ruttonjee Hospital, (2) Intensive Care Unit, Ruttonjee Hospital, (3) School of Nursing, Caritas Medical Centre
Introduction :
Non-convulsive status epilepticus (NCSE) and non-convulsive seizures (NCSs) are common in intensive care unit (ICU) patients with prevalence from 8% to 21%. The Neuro-critical Care Society’s guideline suggests 48 hours cEEG monitoring in patients that are comatose. A latest study from American academy of Neurology (Kaleems et al., 2021) provided a class I evidence that neuro-ICU nurse interpretation of quantitative EEG (qEEG) detects seizures in adults with a sensitivity of 74% and a specificity of 92% compared with traditional cEEG review. Mean nurse time to seizure detection was also significantly shorter than standard of care by 132 minutes.
Objectives :
Ruttonjee Hospital (RH) ICU was the first adult ICU in Hong Kong that introduced the bilateral BIS monitor (Covidien) with 4-channels bilateral cEEG and qEEG panel including Bispectral index (BIS), Asymmetry index (AYSM) and Color Density Spectral Arrays (CDSA) in Feb 2021. ICU nurses expressed hesitation of using the new monitor due to insufficient knowledge and confidence in bedside cEEG and qEEG monitoring. A training program was implemented between Feb 2021 to Mar 2021 to enhance the nurses’ knowledge and confidence in cEEG and qEEG monitoring. In view of the lack of local studies on the clinical applications of qEEG in ICU setting, the program also tried to identify the specific patterns of cEEG, BIS, ASYM and CDSA in different neuro-critical conditions by a prospective observational study.
Methodology :
A 30 minutes training program with return demonstration and bedside coaching was designed based on manufacturer menu and literature finding to educate the RH ICU nurses about the clinical utilities of cEEG, BIS, ASYM and CDSA in Feb & Mar 2021. After the training program, Bilateral BIS monitor (Covidien) has been utilized to the neuro-critical patients requiring cEEG monitoring and patients on Rocuronium infusion since Mar 2021. A prospective observational study was conducted from Mar 2021 to Nov 2022 to identify the specific cEEG and qEEG patterns in different neuro-critical conditions. Abnormal cEEG and qEEG patterns were captured using the HA clinical photo app and interpreted by doctors to provide suitable treatment accordingly. Special cases were selected into case series study. The case series were updated and shared to ICU nurses regularly. An evaluation survey was conducted in Nov 2021 to obtain the feedback from RH ICU nurses on the clinical applications of the bilateral BIS monitor using Likert scale and evaluate their confidence level (from 1 to 10) in cEEG, BIS, ASYM and CDSA monitoring before and after the training program. The data was analyzed by the non-parametric Wilcoxon test to evaluate any significant improvement in the confidence level after the training program.
Result & Outcome :
Total 57 ICU nurses have completed the training. The evaluation survey obtained positive feedback from the ICU nursing staff. Most of them agreed the training program was practical and resourceful; they had better understanding and awareness in cEEG, BIS, ASYM and CDSA monitoring after the training; the new monitor facilitated seizure and hypoxia detection and sedation titration; the color changes of CDSA are alarming and sensitive to clinical events such as convulsion and cerebral hypoxia. Their confidence level in cEEG and qEEG monitoring, seizure detection (convulsive/ non convulsive), and sedation titration also showed significant improvement. (P< 0.01). The Bilateral BIS monitor (Covidien) has been utilized to 38 patients with different neuro-critical illnesses including convulsive / non-convulsive status epilepticus, auto-immune encephalitis, post-cardiac arrest with hypoxic brain damage, myoclonus status epilepticus, massive hemorrhage stroke, ischemic stroke with rTPA and brain death. 10 case series were generated to illustrate the clinical applications of cEEG and qEEG monitoring in different neuro-critical diseases. The finding of the case series provided a foundation for future qEEG study.
