TABLE 1.

Areas of Consensus

Clinical Considerations for the Utility of MNM	Contexts of Use: Case Presentations
1) Level of consciousness 2) Underlying disease or diagnosis 3) Potential risk for secondary brain injuries or neurodeterioration 4) Structural imaging findings 5) Confounding factors clouding the neurologic examination 6) Desire to understand pathophysiology underlying brain dysfunction 7) Guiding individualized management decisions 8) Informing goals or thresholds for targeted management 9) Abstaining from or de-escalating a therapy or treatment that might cause harm	1) Nonsurgical TBI comatose (GCS 8 or less) after initial resuscitation 2) Surgical TBI comatose (GCS 8 or less) after evacuation and/or decompression 3) aSAH comatose (Hunt-Hess 4–5) after initial resuscitation and/or treatment of hydrocephalus 4) aSAH with vasospasm or vasospasm-associated delayed cerebral ischemia, comatose or ventilated on sedation 5) ICH without IVH comatose (GCS 8 or less) after initial resuscitation and/or treatment of hydrocephalus 6) ICH with IVH comatose (GCS 8 or less) after initial resuscitation and/or treatment of hydrocephalus
Minimum Necessary Technology: Access
1) Bedside visualization or display of…  • single, current (live) measurement value  • single measurement trended over time  • multiple, current (live) measurement values together on the same screen  • multiple measurements trended over time and aligned on the same screen  • summary or aggregate data on a device visible in a patient care area 2) Access to data with high temporal resolution (≥ 1 data point/min) 3) Access to data at waveform resolution 4) EHR display (in a table or graph) of multiple different measurement values together on a single panel, tab, or screen	5) Ability to…  • annotate neuromonitoring data at bedside to indicate clinical events or context  • display neuromonitoring data at bedside linked with annotations and/or with EHR information  • manipulate visualization or display at bedside, e.g., zooming, scrolling, or selecting measurements  • visualize or display neuromonitoring data in real-time remotely  • manipulate and review displayed neuromonitoring data in real-time remotely  • display neuromonitoring data remotely linked with bedside annotations and/or with EHR information  • set alarms or thresholds to alert staff at bedside  • access neuromonitoring data in real-time for use in data analytic tools either through a network interface or hardware connection
Minimum Necessary Work of MNM	Operationalizing MNM
1) As part of daily clinical care, most intensivists staffing an ICU…  • are not able to adequately integrate and interpret MNM data  • do not have adequate time to fully review all available MNM data  • do not have all the necessary technology to integrate and interpret MNM data  • do not have technical knowledge sufficient to troubleshoot device errors and to identify artifactual or erroneous MNM data  • would find regularly written reports summarizing MNM data and providing clinical interpretation/correlation to be helpful in making clinical decisions 2) The integration and interpretation of MNM requires…  • access to raw data for data manipulation outside of source devices  • review of a variety of time-scales—from hours to days of data—in order to make clinically meaningful inferences from the information  • specific skill or expertise to synthesize multiple data trends over time  • skill or expertise that is not routinely developed by existing fellowship training  • integration with both brain-specific data and systemic data traditionally measured during critical care (e.g., hemodynamic information)  • clinical context: clinical correlation is a central component of this process 3) MNM work that is time intensive independent of other clinical duties includes:  •a pplication and maintenance of equipment and technologies  • synthesis and interpretation of multiple neuromonitoring data trends 4) Existing billing codes for other neurophysiologic procedures such as continuous video electroencephalography monitoring (e.g., CPT 95720) or intraoperative monitoring (e.g., CPT 95941) do not adequately capture the work of MNM	1) Provide bedside users (e.g., clinical care team) an interface that…  • facilitates an understanding of multiple parameters in the context of specific disease processes  • displays trend data on a single screen that can be used to manipulate and explore data 2) Enhance clinical confidence in monitoring data by using software tools to identify or remove artifacts within real-time monitoring data that limits clinical interpretation 3) Identify necessary Information Technology or Clinical Engineering personnel to overcome technological hurdles that limit access to monitoring data 4) Invest in education for bedside users (e.g., clinical care team) focused on…  • understanding the parameters being measured and why  • learning how to respond to monitoring data 5) Standardize who is monitored and by which technologies 6) Develop clinical management algorithms for bedside users (e.g., clinical care team) 7) Identify physiologic thresholds and other findings that would trigger clinical action or judgement 8) Access to a standardized lexicon of physiologic patterns with biological or clinical relevance 9) Enlist staff and/or trainees to provide technical and clinical expertise at any time 10) Staff member to act as a “clinical champion” to encourage the use of monitoring 11) Directly engage multiple stakeholders involved in day-today care 12) Schedule regularly held multidisciplinary case conferences to discuss monitoring cases
Education Formats	Training Background and Expertise
1) Training and expertise necessary to understand and interpret MNM is best acquired through…  • Hands-on workshops or seminars  • Clinical practice or bedside teaching  • Development of a core curriculum  • Supervised performance and demonstration of procedural competency	1) Specific training or expertise is required to adequately understand and interpret MNM information 2) Clinical training programs in emergency medicine (alone) do not provide adequate knowledge base 3) Clinical training programs in specialty nursing (alone) do not provide adequate knowledge base

aSAH = aneurysmal subarachnoid hemorrhage, CPT = Current Procedural Terminology, EHR = electronic health record, GCS = Glasgow Coma Scale, ICH = intracerebral hemorrhage, IVH = intraventricular hemorrhage, MNM = multimodality neuromonitoring, TBI = traumatic brain injury.

Agreement was defined as a median Likert score of ≥ 7 or ≤ 3 while consensus was defined as > 70% within the lowest or highest tertile and an interquartile range difference ≤ 1.75. Items achieving consensus during discussion-based round 3 must have a) agreement during round 2 plus b) at least 70% voting strong agreement and < 10% voting strong disagreement.