The authors of a new research paper offer an enhanced safety protocol for performing EEGs on patients with COVID-19.

Due to the many unknowns and highly contagious nature of this virus, researchers in the Neurodiagnostic Department at Medical City Dallas Hospital felt they needed to go beyond standard infection control measures. They applied a new EEG workflow in a case study published in Neurodiagnostic Journal in April 2020.

Their patient (a 73-year-old male) was in acute respiratory failure, requiring intubation in the hospital’s COVID-19 ICU unit. The patient experienced a convulsion-like episode with transient left-sided facial droop while being weaned from sedation. The patient was too unstable to undergo head imaging. A neurologist ordered continuous video EEG.

To minimize contact, the team wanted to limit the performance of the study to just one technologist. They chose their EEG laboratory manager to perform the study because of her level of experience.

“Experienced EEG technologists will be preferred to perform procedures on these patients as a high level of judgment and critical thinking skills, and experience in recording and assessing the waveforms are needed,” the authors write. “Also, real-time troubleshooting skills in this critical situation are necessary in providing the optimal balance between quality and efficiency while minimizing collective staff exposure.”

Before the tech performed the EEG, the group adapted its usual workflow — one based on American Clinical Neurophysiology Society guidelines. The new protocol, they write, cuts technologist exposure time by 50 percent from set up to takedown. They gained the most time savings during setup, going from 76 minutes to 33 minutes, largely due to using a reduced array of single-use electrodes.

“Depending on the patient’s clinical presentation, a minimum of 8 electrodes will be used with the following electrodes [see bulleted list below] preferred due to their ease of application and relative high utility in screening for clinically relevant EEG abnormalities,” the authors write.

  • Left: Fp1, F7, T7, P7, O1, C3
  • Right: Fp2, F8, T8, P8, O2, C4
  • Midline: Cz
  • EKG, Ground, and Reference

In addition to reducing the exposure time for the technologist, the authors also recommend stricter airborne isolation practices:

  • Use of face masks, face shields, gloves, and gowns
  • Patient to wear a N95 mask when possible
  • Portable EEG system kept six feet from patient’s bedside
  • Don’t routinely perform hyperventilation and photic stimulation
  • Monitor and review cvEEG remotely
  • COVID-19 dedicated machinery, cleaned following CDC guidelines, and stored in designated storage area

The authors also recommend a more rigorous patient selection process to ensure that the medical necessity of any EEG procedures outweighs the risk of COVID-19 transmission.

They do this in their own facility by having all requesting physicians fill out a “Medical Justification For Procedure” form (a sample is included in their paper).

In March, when the authors saw their case-study patient, their hospital was rationing personal protective equipment (PPE) and few COVID-19 guidelines were available. They knew then that following standard procedures would no longer pass a risk-benefit analysis, so they adapted. Since then, “modifications will likely continue to evolve with experience” as more guidance has been published, the authors write. “We hope that this manuscript stimulates ideas and collaboration.”

You can read their entire protocol and discussion, “Practical Considerations When Performing Neurodiagnostic Studies on Patients with COVID-19 and Other Highly Virulent Diseases,” available with free access online.