ICUcEEG Staffing and Implementation

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ICU/cEEG Staffing and Implementation

• Anita Schneider, R.EEGT/EPT., CNIM
• ASET Webinar
• 2008

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Disclosure

• VP/Marketing Product Development
• of Jordan NeuroScience, Inc., a medical device
  manufacturer in the field of acute EEG monitoring
• Certain JNS proprietary products and methods are
  included in this presentation
• No money or fees from outside sources

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Intensive Care Units

• 1953 Copenhagen - The first intensive care
  unit in the world
• 1962 Baltimore - The first surgical ICU was
  established
• (Internet Research)

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1962 - 2007 ICUs

• General
• Surgical
• Neuro
• Adult
• Pediatric
• Neonatal
• Trauma Units
• Stroke Units

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Staffed with

• General Intensivists
• Neurointensivists
• Critical Care Nurses
• Neurocritical Care Nurses
• Critical Care Nurse Practitioners
• Trauma RT Therapists

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During the past 10 years

• ICU/cEEG is becoming a
• standard of care
• revealing previously undetected pathology

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ICU/cEEG is commonly requested for patients with

• ALOC
• Coma
• Seizures
• Status Epilepticus
• Nonconvulsive Status Epilepticus
• Cerebral Ischemia

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ICU/cEEG is also requested to monitor

• Sedation Titration
• Vasospasm / SAH
• Intracerebral Hemorrhage
• Encephalopathies

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The Facts

• ICU/cEEG adds important diagnostic information
• Early EEG better patient management
• ICU patients need cEEG available 24/7

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The Facts

• 6,000 Intensive Care Units/USA
• (does not include over 1100 Neonatal ICUs)
• 55,000 patients/day admitted to ICUs
• 180 billion (30 of acute care costs)
• American Hospital Association

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The Facts

• 15,000 Neurologists/USA (-)
• 4500 read EEGs (-)
• 1131 are credentialed neurophysiologists
• by the American Board of Clinical
• Neurophysiology (ABCN)
• Very few neurointensivists read EEGs

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The Facts
The Facts

• There is a severe shortage
• of EEGers to serve
• this unmet patient need
• 24/7

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The Facts

• Neurophysiologists and EEG Technologists are
  historically synergistic in nature
• We share an interdependence that has become
  increasingly important for patient care.

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The Facts

• EEG Technologists
• are the only profession, other than the
  EEGer/neurophysiologists, who have the knowledge
  and skills to
• obtain, identify and describe
• normal and abnormal EEG waveforms

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Electroneurodianostic Program Curriculum includes

• Neuroanatomy
• Neurophysiology
• Neuro Imaging
• Technical Application
• Computer Application
• Waveform Recognition
• Clinical Correlation

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4000 R.EEGTs

• A solid technologist base for
• advanced practice level
• neurodiagnostic professionals
• who have the knowledge and skills to share
  responsibility for the technical operation of
  critical care neurodiagnostic programs

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• ASET
• Education for advanced practice level
• ICU/cEEG Task Force
• Developing technologist competencies
• ICU/cEEG course planned for annual meeting in New
  Orleans in August
• On-line education underway

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• ABRET
• Advanced practice level credentialing
• 2008 Advanced Certification exam
• in Long Term Monitoring (CLTM)
• available to the advanced level R. EEG T.
• with a minimum of one year of experience
• in a long term monitoring unit

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Advanced Level Registered EEG Technologistsare
well positioned to

• Be the
• Neurophysiologist
• extender
• Oversee the technical operation of ICU/cEEG
  program
• Interact with the patient/nurse/intensivist

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ICU/cEEG program most successful with
collaboration of all who are involved in the
patients care

• Neurointensivist
• Intensivist
• ICU Nurse
• PA or NP
• Neurophysiologist
• END Technologists
• ICU Respiratory Therapists

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• TEAMWORK

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TEAMWORK
None of us is as smart as ALL of us
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• Lets assume you are an END Lab manager
  - eager to start an
• ICU/cEEG program
• Begin with the end in mind
• Have a well designed plan!

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Getem on Board!!Find a Champion

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1

• Recruit the support of your
• END Lab
• Medical Director
• Collaborate together to form a plan for
  success

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2

• Recruit the support of the
• ICU Medical Director
• Have END Medical Director arrange a meeting

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3

• Recruit the support of the
• ICU Nurse Manager
• Have END/ICU Medical Director arrange a
  meeting that includes you

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4

• Recruit the support of the
• ICU Nurse Educator
• Have ICU Nurse Manager
• arrange a meeting that includes you

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5

• Recruit the support of the
• Other ICU MD players
• Neurointensivists
• Intensivists
• Neurosurgeons
• Other attendings
• Fellows/Residents

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6

• Recruit the support of the
• Other key players
• EEG Technologists
• Tech Assistants/Extenders
• Physician Assistants
• Nurse Practicioners

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Once your core team is onboard,its time to
implement your plan

• Heres How We
• Did It

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• Education

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ICU-CEEG WORKSHOP
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ICU-CEEG WORKSHOP

• Presented 3 times/year
• Attendees MDs, Fellows,Residents, ICU Nurses,
  NPs, Pas, Trauma RTs, (often interested nurses
  from other floors came too)
• CEUs awarded
• Course workbook provided

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ICU-CEEG WORKSHOP

• ICU nurses comfortable with waveform recognition
  from their experience with other monitors in the
  ICU.
• They accept CEEG monitoring as natural extension
  of physiologic monitoring to the brain.
• They embrace CEEG benefit to patient care.

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ICU-CEEG WORKSHOP

• We found it important to plan for the
  objections we may hear and address them up-front,
  during the workshop
• I dont have time
• Who will attach the electrodes at 3am?
• Are we responsible for interpretation
• Who do we call during the day and after hours
• to help with the electrodes, the equipment
• Who do we call if the EEG looks different?

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ICU-CEEG WORKSHOP AGENDA

• Why Is ICU/CEEG Important for patient care?
• Dr. Jordan
• EEG waveform recognition - R.EEGT.
• The Set-Up who, when, how? - R.EEGT.
• The Technologists Role - R.EEGT
• The Nurses Role ICU Nurse
• Written Post Test and Hands-On Competency

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Electrode Placement/nomenclature
FP1
FP2
F7
Leftodd
Righteven
Fz
F8
F4
F3
Cz
C4
T4
C3
T3
Pz
P4
P3
T6
T5
O2
O1
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Electrode Application Method
Needle Electrodes with Collodion
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Electrode Application Method
Disk Electrodes with Collodion
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EEG Electrode Innovation
MRI compatible subdermal wire electrodes
MRI compatible disk electrodes with common plug-in
Courtesy of Dr.John Ives
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Left
Right
Left
Right
5
1
1
2
6
3
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4
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13
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EKG
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Keep it Simple!
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WAVEFORM RECOGNITION TRAINING
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CHARTING CODES FOR CEEG WAVEFORMS
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NURSE ICU-CEEG FLOWCHART
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LT, MA, UE
RT, LA, E
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1215 Verbal response inappropriate at times.
Confused. 1400 A short burst of spikes in
R. Frontal leads no change in
neuro Response 1402 Another longer burst about
20 secs of spikes observed primarily right hemi.
Eyes deviated, increased seizure activity. ICP
18. Neurologist notified ordered additional
Dilantin
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Technology
ICU Nurse entering comments
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Status Epilepticus
SIEZURES
Photo compliments of Viasys
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Clarian Cerner Neurotelemetry Reporting
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Neurotelemetry Technical Report
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Technology
R.EEGT. Viewing cEEG remotely - speaking
with ICU nurse
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Neurophysiologist viewing CEEG remotely from
his office
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Or from a BlackBerry !
Photo compliments of Viasys
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Electrode Set Up

• For the STAT EEG
• whoever does it,
• for the best patient care,
• it needs to be
• FAST
• EASY
• ACCURATE
• SAFE

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FAST

• On-Site Staff is fastest
• 24/7 Trauma EEG Technologist
• Nurse/NP, PA
• Fellow/Resident
• Trauma RT Therapist

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Neuro Tech Assistant setting up ICU/CEEG
This could be a fellow, a resident, a physicians
assistant a nurse or
trauma therapist
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• Assistance with set-up saves valuable
  R.EEGT.time.
• Time to do more advanced
• neuromonitoring
• tasks
• Waveform analysis
• Technical description
• Staff education
• Staff interaction
• Overseeing the process

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BraiNet Prototype
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Space for ICP and adjustable around C-Color
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10/20 BraiNet
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Collodion Substitute for Securing Electrodes
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New Software Innovations
Courtesy of Persyst
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R.EEGT/CLTM
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SAVING BRAINSSAVING MINDSSAVING PEOPLE
ARMC NEURO TEAMWORK AT WORK
ARMC ICU RN and NCSE PATIENT
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• Thank You