Expanding Access to Continuous EEG Monitoring in Neonatal Intensive Care Units

Accurate identification of neonatal seizures is important given the increasing evidence that high seizure burden is associated with unfavorable neurodevelopmental outcomes. However, neonatal seizures are difficult to identify clinically because the majority are subclinical and correct identification of electroclinical seizures based on semiology is unreliable.

Continuous EEG (CEEG) monitoring is recommended as the gold standard for seizure identification in guidelines published by the American Clinical Neurophysiology Society and the World Health Organization. Despite these recommendations, barriers to implementing widespread CEEG exist in neonatal intensive care units (NICUs), including availability of EEG equipment, EEG technologists for study initiation, and experienced personnel (EEG technologists and electroencephalographers) for frequent EEG interpretation.

Children’s Hospital of Philadelphia (CHOP) has a very robust EEG service that consists of 25 EEG technologists, 15 pediatric electroencephalographers with neonatal EEG expertise, and 5 epilepsy/EEG fellows providing CEEG interpretation 24 hours per day and 7 days per week. We perform >2,000 days of CEEG in the neonatal, cardiac, and pediatric ICUs per year. Previously, CEEG monitoring was available only to patients at the Harriet and Ronald Lassin Newborn/Infant Intensive Care Unit (N/IICU) at our Main Hospital. However, in an effort to expand access to CEEG monitoring, we recently initiated a pilot program of remote CEEG monitoring for at-risk neonates at two regional affiliated hospitals that provide neonatology services.

The workflow for CEEG at the two pilot network hospitals is as follows:

1. A neonatologist at the network hospital identifies a neonate who should undergo CEEG monitoring based on clinical concerns and consistent with guideline recommendations.
2. An EEG technologist at the network hospital places the EEG leads, initiates the study, performs troubleshooting for technical issues, and gathers standardized clinical data.
3. The network hospital EEG technologist then notifies the CHOP EEG technologist of the initiated study, and the two technologists communicate directly by phone to resolve any technical issues with the study.
4. If seizures are identified by the CHOP EEG technologist, then they notify the on-call attending electroencephalographer, who reviews the study along with the on-service epilepsy/EEG fellow and communicates directly with the network neonatologist by phone.
5. A report is generated in the electronic medical record and forwarded to the network NICU.

Continuous EEG indications included the following:

• Hypoxic-ischemic encephalopathy (with or without therapeutic hypothermia).
• Differential diagnosis of movements of concern.
• Unexplained encephalopathy/concern for subclinical seizures.
• Seizure burden assessment.

To evaluate the feasibility and impact of this pilot program, we recently reviewed the EEG results and clinical care notes of the neonates monitored during the first 27 months of the program. Status epilepticus was defined as any electrographic seizure in excess of 5 minutes duration or any 1-hour epoch in which 50% or more of the epoch contained electrographic seizure(s).

In a 27-month period from June 2017 through September 2019, 76 neonates underwent CEEG monitoring between the two network NICUs, for an average of 2 to 3 monitoring sessions per month. CEEG monitoring data impacted clinical care in three quarters of neonates (57/76; 75%). CEEG monitoring data impacted decisions to treat with antiseizure medications in approximately one half of patients (28/57; 49%), and CEEG monitoring data impacted prognostic discussions in approximately two thirds of patients (39/57; 68%).

Our findings suggest that:

• Remote CEEG monitoring is technically feasible and effective, allowing neonates to receive care locally.
• Remote CEEG monitoring positively impacts clinical care and prognostic discussions.
• The incidence of electrographic neonatal seizures, including electrographic status epilepticus, at network NICUs is similar to the incidence reported at quaternary care centers.
• Providing remote CEEG monitoring to network NICUs allows neonates to remain hospitalized in centers that could meet their overall medical needs, alleviates the safety risks associated with transferring critically ill neonates between hospitals for the sole purpose of obtaining CEEG, and reduces otherwise unnecessary bed utilization at CHOP.

We intend to expand this model throughout our network, and we believe it may serve as a model for other pediatric networks seeking to expand CEEG in their regional NICUs.