Structure and Outcomes of Educational Programs for Training Non-electroencephalographers in Performing and Screening Adult EEG: A Systematic Review

Abstract

Objective

To qualitatively and quantitatively summarize curricula, teaching methods, and effectiveness of educational programs for training bedside care providers (non-experts) in the performance and screening of adult electroencephalography (EEG) for nonconvulsive seizures and other patterns.

Methods

PRISMA methodological standards were followed. MEDLINE, EMBASE, Cochrane, CINAHL, WOS, Scopus, and MedEdPORTAL databases were searched from inception until February 26, 2020 with no restrictions. Abstract and full-text review was completed in duplicate. Studies were included if they were original research; involved non-experts performing, troubleshooting, or screening adult EEG; and provided qualitative descriptions of curricula and teaching methods and/or quantitative assessment of non-experts (vs gold standard EEG performance by neurodiagnostic technologists or interpretation by neurophysiologists). Data were extracted in duplicate. A content analysis and a meta-narrative review were performed.

Results

Of 2430 abstracts, 35 studies were included. Sensitivity and specificity of seizure identification varied from 38 to 100% and 65 to 100% for raw EEG; 40 to 93% and 38 to 95% for quantitative EEG, and 95 to 100% and 65 to 85% for sonified EEG, respectively. Non-expert performance of EEG resulted in statistically significant reduced delay (86 min, p < 0.0001; 196 min, p < 0.0001; 667 min, p < 0.005) in EEG completion and changes in management in approximately 40% of patients. Non-experts who were trained included physicians, nurses, neurodiagnostic technicians, and medical students. Numerous teaching methods were utilized and often combined, with instructional and hands-on training being most common.

Conclusions

Several different bedside providers can be educated to perform and screen adult EEG, particularly for the purpose of diagnosing nonconvulsive seizures. While further rigorous research is warranted, this review demonstrates several potential bridges by which EEG may be integrated into the care of critically ill patients.

Appendices

Appendix 1: Search Strategy and List of Data Extracted From Studies

MEDLINE Search Strategy

1	exp electroencephalography/
2	electroencephalogra*.mp
3	EEG*.mp
4	Spectral array*.mp
5	(brain adj1 activit*).mp
6	brain wave*.mp
7	brainwave*.mp
8	electrocorticograph*.mp
9	ECOG*.mp
10	Alpha rhythm*.mp
11	Beta rhythm*.mp
12	Delta rhythm*.mp
13	Gamma rhythm*.mp
14	Theta rhythm*.mp
15	or/1–14
16	exp Education/
17	educat*.mp
18	teach*.mp
19	train*.mp
20	instruct*.mp
21	workshop*.mp
22	or/16–21
23	15 and 22
24	exp Electroencephalography/ed [Education]
25	23 or 24
26	exp Epilepsy/
27	exp Seizures/
28	epilep*.mp
29	seizure*.mp
30	convulsion*.mp
31	or/26–30
32	interpret*.mp
33	exp Diagnosis/
34	diagnos*.mp
35	di.fs
36	or/32–35
37	adolescent/
38	exp Adult/
39	adolescen*.mp
40	teen*.mp
41	youth*.mp
42	adult*.mp
43	aged.mp
44	elderly.mp
45	senior*.mp
46	or/37–45
47	15 and 25 and 31 and 36 and 46
48	remove duplicates from 47

EMBASE Search Strategy

1	exp electroencephalogram/
2	exp electrocorticography/
3	electroencephalogra*.mp
4	EEG*.mp
5	Spectral array*.mp
6	(brain adj1 activit*).mp
7	brain wave*.mp
8	brainwave*.mp
9	electrocorticograph*.mp
10	ECOG*.mp
11	Alpha rhythm*.mp
12	Beta rhythm*.mp
13	Delta rhythm*.mp
14	Gamma rhythm*.mp
15	Theta rhythm*.mp
16	or/1–15
17	exp Education/
18	educat*.mp
19	teach*.mp
20	train*.mp
21	instruct*.mp
22	workshop*.mp
23	or/17–22
24	exp "seizure, epilepsy and convulsion"/
25	epilep*.mp
26	seizure*.mp
27	convulsion*.mp
28	or/24–27
29	interpret*.mp
30	exp Diagnosis/
31	diagnos*.mp
32	di.fs
33	or/29–32
34	exp adolescent/
35	exp adult/
36	adolescen*.mp
37	teen*.mp
38	youth*.mp
39	adult*.mp
40	aged.mp
41	elderly.mp
42	senior*.mp
43	or/34–42
44	16 and 23 and 28 and 33 and 43
45	remove duplicates from 44

Cochrane Search Strategy

1	electroencephalogra*.mp
2	EEG*.mp
3	Spectral array*.mp
4	(brain adj1 activit*).mp
5	brain wave*.mp
6	brainwave*.mp
7	electrocorticograph*.mp
8	ECOG*.mp
9	Alpha rhythm*.mp
10	Beta rhythm*.mp
11	Delta rhythm*.mp
12	Gamma rhythm*.mp
13	Theta rhythm*.mp
14	or/1–13
15	educat*.mp
16	teach*.mp
17	train*.mp
18	instruct*.mp
19	workshop*.mp
20	or/15–19
21	epilep*.mp
22	seizure*.mp
23	convulsion*.mp
24	or/21–23
25	interpret*.mp
26	diagnos*.mp
27	25 or 26
28	adolescen*.mp
29	teen*.mp
30	youth*.mp
31	adult*.mp
32	aged.mp
33	elderly.mp
34	senior*.mp
35	or/28–34
36	14 and 20 and 24 and 27 and 35

CINAHL Search Strategy

S1	(MH "Electroencephalography")
S2	electroencephalogra*
S3	EEG*
S4	Spectral array*
S5	(MH "Brain Waves")
S6	brain N1 activit*
S7	brain wave*
S8	brainwave*
S9	electrocorticograph*
S10	ECOG*
S11	Alpha rhythm*
S12	Beta rhythm*
S13	Delta rhythm*
S14	Gamma rhythm*
S15	Theta rhythm*
S16	S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13 OR S14 OR S15
S17	(MH "Education + ")
S18	educat*
S19	teach*
S20	train*
S21	instruct*
S22	workshop*
S23	S17 OR S18 OR S19 OR S20 OR S21 OR S22
S24	S16 AND S23
S25	(MH "Electroencephalography/ED")
S26	(MH "Electroneurodiagnostic Technologists/ED")
S27	S24 OR S25 OR S26
S28	exp Epilepsy/
S29	exp Seizures/
S30	epilep*
S31	seizure*
S32	convulsion*
S33	S28 OR S29 OR S30 OR S31 OR S32
S34	interpret*
S35	(MH "Diagnosis + ")
S36	diagnos*
S37	S34 OR S35 OR S36
S38	(MH "Adult + ")
S39	(MH "Adolescence + ")
S40	adolescen*
S41	teen*
S42	youth*
S43	adult*
S44	aged
S45	elderly
S46	senior*
S47	S38 OR S39 OR S40 OR S41 OR S42 OR S43 OR S44 OR S45 OR S46
S58	S16 AND S27 AND S33 AND S37 AND S47

Web of Science Search Strategy

TOPIC: (Electroencephalogra* OR EEG* OR spectral array* OR brain activit* OR brain electric activit* OR brain wave* OR brainwave* OR electrocorticograph* OR ECOG* OR Alpha rhythm* OR Beta rhythm* OR Delta rhythm* OR Gamma rhythm* OR Theta rhythm*)

AND

TOPIC: (educat* OR teach* OR train* OR instruct* OR workshop*)

AND

TOPIC: (epilep* OR seizure* OR convulsion*)

AND

TOPIC: (interpret* OR diagnos*)

AND

TOPIC: (adolescen* OR teen* OR youth* OR adult* OR aged OR elderly OR senior*)

SCOPUS Search Strategy

(TITLE-ABS-KEY (electroencephalogra* OR eeg* OR "spectral array" OR "spectral arrays" OR "brain activity" OR "brain activities" OR "brain electric activity" OR "brain electric activities" OR "brain wave" OR "brain waves" OR brainwave OR brainwaves OR electrocorticograph*)

AND

TITLE-ABS-KEY (educat* OR teach* OR train* OR instruct* OR workshop*)

AND

TITLE-ABS-KEY (epilep* OR seizure* OR convulsion*)

AND

TITLE-ABS-KEY (interpret* OR diagnos*)

MedEdPORTAL Search Strategy

ANYWHERE: (EEG)

OR

ANYWHERE: (Seizure)

OR

ANYWHERE (Epilepsy)

Data Extracted from Studies

The following data were extracted when possible:

• Study information

  • Author

  • Year

  • Country

• Non-expert information

  • Number of non-experts

  • Demographics

    • Age

    • Sex

    • Healthcare profession

      • Nurse

      • Neurodiagnostic technologist

      • Medical student

      • Resident (specialty noted)

      • Fellow (specialty noted)

      • Attending physician (specialty noted)

    • Years of experience in current profession

• EEG Curriculum information

  • Learning Theories

  • Objectives

  • Content

  • Teaching methods

  • Duration

  • Resources provided to learners

  • Learner feedback regarding curriculum

• EEG information

  • Method of selection

  • Number

  • Duration

  • Type of EEG

    • Raw EEG defined as montaged EEG (number of channels noted)

    • Sonified EEG

    • Quantitative EEG—specific trends noted including:

      • Amplitude integrated EEG

      • Color spectral array

      • Color density spectral array

      • Density spectral array

      • Rhythmicity spectrogram

      • Asymmetry spectrogram

      • Seizure/pattern indicators

      • Other

  • Demographics of patients whose EEGs were performed/reviewed by non-experts

    • Age

    • Diagnosis

    • Location including

      • Intensive Care Unit

      • Emergency room

      • Hospital ward

      • Seizure monitoring unit

      • Outpatient setting

      • Other

  • EEG patterns (criteria used and numbers of) to be identified by non-experts

    • Electrographic seizures

    • Periodic discharges

    • Rhythmic delta activity

    • Slowing

    • Burst suppression

    • Artifacts

    • Normal patterns

    • Other

  • Details of gold standard comparison

    • EEG performance/interpreted by neurodiagnostic technologist/neurophysiologist

      • Type of EEG performed/interpreted noted including

        • Raw EEG defined as montaged EEG (number of channels noted)

        • Sonified EEG

        • Quantitative EEG—specific trends noted similar to above

• Non-expert quantitative outcomes

  • Time required to review EEG and comparisons to gold standard

  • Time required to perform EEG and comparisons to gold standard

  • Diagnostic accuracy (for any of the above noted patterns)

    • True positives

    • True negatives

    • False positives

    • False negatives

    • Sensitivity

    • Specificity

    • Kappa values

    • Interrater agreement

    • Percent agreement

    • Pre-curriculum test results

    • Post-curriculum test results

    • Other

  • Measures of changes in patient management

Appendix 2: Summary of EEG education studies

Appendix 3: Sensitivity, Specificity, and Other Markers of Accuracy/Agreement of Non-Experts Identifying Electrographic Seizures