EEG Lessons from the Italians During COVID-19

In early April 2020, two things were clear: The COVID-19 outbreak had reached the level of a pandemic, and it was peaking in Italy. Those on the ground there were inundated, and they knew the lessons they were learning could help those still in front of the virus.

They began sharing their experiences then and continue to do so, even as their case counts wane and those in places like the U.S. are on the rise.

The Italians recently released a set of recommendations regarding the ordering and safe performance of electroencephalograms (EEG) during the different phases of this pandemic. Their paper, published in the journal Neurological Sciences on July 22, 2020, is a collaboration between three major Italian medical associations: the Italian Society of Neurophysiology (SINC), the Italian League Against Epilepsy (LICE), and, notably, the Italian Association of Neurophysiology Technologists (AITN).

Similar to the recommendations by their American counterparts, the authors write: “During the different phases of COVID-19 pandemic, the EEG should be reserved for patients really benefiting from its execution in terms of diagnosis, treatment, prognosis, and avoidance of emergency room access.”

The authors go on to illuminate these criteria, giving detailed guidance according to the phase of the outbreak, COVID positivity, and clinical setting. They provide recommendations in the following five areas:

1. Classification of the urgency of an EEG
2. Protocols for medical personnel, including neurologists, neurophysiopathologists, and child neurologists
3. Protocols for neurodiagnostic technologists (NDTs), whom they call neurophysiology technologists (NPTs).
4. Use of PPE
5. Disinfecting equipment

Dividing their recommendations by outbreak phase is particularly relevant to an American audience. That’s because the pandemic continues to show a pattern of waxing and waning in cities and states here since the pandemic began. Appropriately, EEG protocols change depending on the severity of the outbreak.

For the purposes of their paper, the Italians define two phases of the outbreak:

Phase 1: Restriction of outpatient services to emergencies

During the first phase, EEG tests should only be offered to inpatients and some outpatients only when they can’t clinically be delayed. Each case should be evaluated individually, but their listed conditions include emergencies like suspicion of acute encephalitis, acute changes in consciousness, or differential diagnosis with non-convulsive status epilepticus.

Long-term monitoring “was considered almost always deferrable, unless special clinical conditions established the real unavoidable urgency,” the authors write.

Phase 2: Initial outpatient reopening phase, with partial restrictions on services

During the second phase, the healthcare team should carefully weigh the risks and benefits before performing EEG testing. A standard outpatient EEG can be performed if it is useful for changes in treatment or if the EEG will help prevent a later emergency room visit.

For long-term monitoring, the authors write, “the possibility to perform the connection/removal at the outpatient laboratory and not in the hospital should be considered in order to limit the patient’s exposure and access to the hospital environment.”

No matter the phase, the authors recommend that all neurodiagnostic technologists wear surgical masks throughout their shifts in all areas of clinical care. They should scrupulously follow hand hygiene recommendations, maintain physical distance, and limit the number of people in the laboratory “as much as possible.”

The authors recommend cleaning equipment with antiseptic wipes and disinfectants that contain 70 percent ethyl alcohol. For COVID-positive or uncertain patients, they recommend keeping equipment outside the patient’s room whenever possible (using long cords or transmitting via Wi-Fi or Bluetooth). Also, just like their American counterparts, the authors recommend using single-use EEG electrodes.

Their recommendations, they note, will likely evolve as the pandemic progresses and more data is collected. Unlike other procedures performed during emergency conditions, EEG testing exists in a bit of a gray area, making recommendations like these extremely important.

“In acute life-threatening conditions, there is no doubt about acting,” the authors write. “In other situations, as in the case of neurophysiological procedures such as electroencephalogram (EEG), the choice can be questionable.”

You can read the recommendations in the authors’ full paper available with free access online.

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