Continuous EEG Monitoring in Canadian Hospitals

Abstract

Background and Objectives

Continuous EEG (cEEG) is the gold standard for diagnosing nonconvulsive seizures (NCSs) and nonconvulsive status epilepticus (NCSE) in critically ill patients, with NCSE occurring in 8%–10% of patients with unexplained coma. Untreated NCSs are associated with secondary brain injury, as well as increased mortality and morbidity. cEEG monitoring allows clinicians to identify more than twice the number of seizures compared with a 30-min routine EEG recording. However, there are limited data on cEEG practices in Canadian hospitals. The aim of this study was to evaluate the availability, indications, and barriers to cEEG access in Canada.

Methods

A national cross-sectional survey was distributed to EEG laboratory directors and physicians who interpret cEEGs to assess cEEG monitoring practices in Canadian adult hospitals. The survey evaluated institutional cEEG availability, clinical applications, and technical infrastructure.

Results

Among 1,267 adult hospitals in Canada, only 92 hospital networks (9%) were identified as having an EEG laboratory. Twenty-four were identified as potentially offering cEEG monitoring, and a survey was sent to a physician at these institutions. Responses were received from 22 institutions (92% response rate), with 19 hospital networks reporting cEEG availability—representing just 2% of Canadian hospitals. Geographic disparities were significant, with 3 provinces and all 3 territories lacking cEEG access. Among tertiary care hospitals, only 68% reported cEEG availability. Barriers included insufficient EEG technologist coverage and prolonged processing periods for 24-hour EEG recordings. Most institutions lacked standardized guidelines, were unable to perform new cEEG hookups after regular work hours, and did not have access to abbreviated montages when cEEG was unavailable.

Discussion

cEEG availability in Canada is highly limited, including at tertiary care centers, with significant geographic inequities and operational barriers. Most Canadian hospitals do not meet guideline standards for cEEG use. These findings highlight the need for systemic changes to improve cEEG access and align Canadian cEEG practices with international standards.

Introduction

The use of continuous EEG (cEEG) monitoring in intensive care units (ICUs) has increased significantly over the past decade.^1-3 cEEG is the gold standard for diagnosis of nonconvulsive seizures (NCSs) and nonconvulsive status epilepticus (NCSE) in the ICU. NCSE occurs in 8%–10% of patients with unexplained coma and in up to 35% of patients admitted to a neurologic ICU.^1,4-7 Untreated NCSs are associated with secondary brain injury, as well as increased mortality and morbidity.^4,8 cEEG monitoring facilitates timely diagnosis and management of NCSs and NCSE and allows clinicians to identify more than double the number of seizures captured during a 30-min routine EEG recording.^3,9-12 The American Clinical Neurophysiology Society (ACNS) has published consensus statements outlining the indications and logistical considerations of cEEG in critically ill patients and recommends that cEEG be initiated as soon as possible when NCSs or NCSE is suspected, and ideally within 1 hour of such suspicion.^13,14

Previous studies have shown significant variability in how cEEG monitoring is performed in ICUs worldwide including differences in indications, availability, and usage.^2,9,15,16 A study involving 27 countries reported that only 44% of institutions had access to 24/7 initiation of cEEG monitoring, although most study respondents were from the United States.² There are currently very limited data outlining cEEG practices in Canadian hospitals. One small Canadian study looked at EEG utilization across 3 academic ICUs over the course of 2 months, and of 127 patients meeting at least 1 indication for EEG monitoring, only 46 patients (37%) received a routine EEG and only 3 underwent cEEG monitoring.^1,17 Given the limited information on cEEG practices across Canadian hospitals, we aimed to understand the availability, indications, and barriers to cEEG access in Canada.

Methods

Study Design

We conducted a national cross-sectional survey of EEG laboratory medical directors, cEEG laboratory directors, and/or physicians who read cEEGs, to obtain information about cEEG monitoring practices in Canadian adult hospitals.

Study Population

An exhaustive list of all adult Canadian hospitals with EEG laboratories was developed from available government websites and resources and cross-referenced with available lists through the Canadian Society of Clinical Neurophysiology (CSCN). Prescreening of medical EEG laboratories was completed through emails and review of websites, and hospitals with exclusively outpatient EEG laboratories and/or a definite lack of cEEG capability, such as due to equipment limitations, were excluded. A list of medical EEG laboratory directors was then obtained for the remaining Canadian hospitals with possible cEEG access.

Participants were eligible for this study if they were either (1) an EEG laboratory medical director, (2) a cEEG laboratory director, or (3) a physician who reads cEEGs and is informed about institutional cEEG practices and were further employed at a Canadian adult hospital with access to cEEG monitoring. cEEG monitoring was defined as a minimum of 4 hours of continuous video EEG recording outside of an Epilepsy Monitoring Unit (EMU) for the purposes of this study. Participants were required to be comfortable completing the survey in either English or French. Potential participants were excluded if their institution only had cEEG capabilities in an EMU setting.

Survey Content and Development

The study questionnaire was developed using standardized and rigorous survey design methodology.¹⁸ The bilingual survey was modified from a previously developed study, which was initially disseminated to institutions in the United States to assess the use of cEEG monitoring.¹⁵ Further item generation, question development, and modification were performed following a literature review and in discussion with 2 content experts (T.F, M.A.). New domains were incorporated into the previously developed survey, and item reduction was then performed to remove any redundant topics.

Pretesting was completed by conducting semistructured interviews with 3 experts in the field (T.F., M.A., Paulina Kyriakopoulos). Pilot and clinical sensibility testing was completed by 5 neurophysiologists and intensivists. Data from pilot and clinical sensibility testing were not included in the final analysis. The final survey consisted of 4 sections: (1) practitioner information; (2) institution information; (3) cEEG monitoring indications; (4) technical aspects. The survey is available in the supplementary materials (eAppendixes 1 and 2). The survey contained embedded questions to confirm eligibility for the study.

Survey Administration

The online survey was distributed through SurveyMonkey in April 2024. The survey was disseminated through email to a single representative at each hospital network, preferentially the EEG laboratory director. This decision was made to avoid introducing bias through individual opinions and to rather focus on hospital policies and data. If the participant was uncertain about a question response, they were asked to reach out to other members of their EEG laboratory, and particularly the head technologist. Participants were sent a reminder notification at 1, 2, and 4 weeks. Survey responses were closed after 6 months, in October 2024.

For the purposes of this study, a hospital network is defined as a parent hospital or institution that may comprise multiple campuses. For example, The Ottawa Hospital is a hospital network or institution, and it includes 3 campuses: the Civic Hospital, the General Hospital, and the Riverside Hospital. A tertiary care hospital is defined as a specialized health care referral facility that provides advanced and highly specialized medical care.

Data Collection Methods and Statistical Analysis

Data were collected through SurveyMonkey, and deidentified data were transferred to an Excel database. Data were presented descriptively using tables and figures where relevant. All responses were included in the final analysis.

Standard Protocol Approvals, Registrations, and Participant Consents

This study falls within the context of a quality initiative, quality improvement, quality assurance, and/or program evaluation. Therefore, as per the Tri-Council Policy Statement 2, Article 2.5, this project received exemption from Research Ethics Board review by our local institution.

Data Availability

Data not published within this article are available from the corresponding author on reasonable request.

Results

Access to EEG in Canada

There are 1,267 adult hospitals in Canada, and of these, there are 92 hospital networks with EEG laboratories. These hospital networks serve 122 hospital campuses, although only 109 of these have access to EEG, representing 9% of Canadian hospitals (Figure 1). There are no EEG laboratories in any of the Canadian territories.

Figure 1. Map of Canadian Hospitals With Access to Routine and Continuous EEG.

Of 92 hospital networks with EEG laboratories in Canada, 24 were identified as possibly having access to cEEG monitoring. The survey was sent to a physician at these 24 institutions, and responses were received from 22 institutions (92% response rate). Nineteen hospital networks reported having access to cEEG monitoring (86% of survey respondents; 21% of hospital networks with EEG laboratories), encompassing a total of 31 campuses. Of these 31 hospital campuses, only 25 were reported to have access to cEEG (Figure 2). This represents only 2% of all Canadian hospitals. Three Canadian provinces, Prince Edward Island, New Brunswick, and MB, do not currently have access to cEEG monitoring.

Figure 2. Survey Flowchart of Continuous EEG Availability in Canadian Hospitals.

There are 22 tertiary care hospital networks in Canada, encompassing 38 campuses. Only 68% of Canadian tertiary care hospital networks and 55% of tertiary care hospital campuses have access to cEEG monitoring (Table 1).

Table 1.

Continuous EEG Access in Canadian Tertiary Care Centers

	Canadian tertiary care hospital networks (N = 22)	Canadian tertiary care hospital campuses (N = 38)
cEEG availability
Yes (%)	15 (68.2)	21 (55.3)
No (%)	6 (27.3)	16 (42.1)
Data unavailable (%)	1 (4.5)	1 (2.6)

Abbreviation: cEEG = continuous EEG.

Survey Respondents and Institutional Demographics

One hundred percent of respondents identified themselves as neurologists who completed additional certification in neurophysiology through either the CSCN, the American Board of Psychiatry and Neurology, or the American Board of Clinical Neurophysiology. Two respondents completed an additional fellowship in critical care medicine and 1 respondent in neurocritical care.

Eighty-two percent of institutions surveyed identified themselves as tertiary referral centers and 18% as university-affiliated community hospitals. Eighty-six percent of respondents reported that their EEG laboratory is associated with ≥1 hospital campus, and 82% reported an affiliation with ≥1 ICU. Only 45% of institutions reported having access to cEEG in all ICUs served by their EEG laboratory. Additional respondent characteristics are given in Table 2.

Table 2.

Characteristics of Respondents (N = 22)

Characteristics	N (%)
Type of hospital
Tertiary referral center	18 (82)
University-affiliated community hospital	4 (18)
Respondent board certification
CSCN EEG diplomate	21 (95)
FRCPC	17 (77)
ABPN, clinical neurophysiology	2 (9)
ABCN	2 (9)
Hospital campuses associated with EEG laboratory
1	3 (14)
2	7 (32)
3	6 (27)
4	3 (14)
≥5	3 (14)
cEEG available
Yes	19 (86)
No	3 (14)
ICUs served by EEG laboratory
1	4 (18)
2	4 (18)
3	6 (27)
4	6 (27)
≥5	2(9)
Number of ICUs with access to cEEG
0	3 (14)
1	10 (45)
2	3 (14)
3	3 (14)
4	2 (9)
≥5	1 (5)
Types of ICUs
General systems ICU	22 (100)
Cardiac ICU	18 (82)
Cardiac surgery ICU	11 (50)
Neurocritical care ICU	8 (36)
Surgical ICU	1 (5)

Abbreviations: ABCN = American Board of Clinical Neurophysiology; ABPN = American Board of Psychiatry and Neurology; cEEG = continuous EEG; CSCN = Canadian Society of Clinical Neurophysiology; FRCPC = Fellowship of the Royal College of Physicians and Surgeons of Canada; ICU = intensive care unit.

Of the 3 institutions without cEEG monitoring, all 3 identified themselves as tertiary referral centers with ≥2 ICUs. All 3 institutions reported having a general systems ICU, and 2 reported having a dedicated neurocritical care unit.

Continuous EEG Monitoring Practices

Only 32% of institutions with cEEG access reported having a hospital guideline outlining the indications for cEEG monitoring. Most respondents use cEEG to evaluate for NCSs in patients with altered mental status (AMS) with risk factors of NCSs, after treatment of seizures without return to baseline, after a routine EEG with NCSs or high-risk patterns, and to evaluate for seizures in post–cardiac arrest patients. All institutions use cEEG for spell characterization, but less than half report using cEEG for indications other than seizure identification including post–cardiac arrest neuroprognostication, depth of anesthesia monitoring, delayed cerebral ischemia (DCI) monitoring, and intracranial pressure (ICP) monitoring (Table 3).

Table 3.

^aUse of Continuous EEG (N = 19)

Characteristics	N (%)
Institutional guideline outlining indications for cEEG
Yes	6 (32)
No	13 (68)
Indications for cEEG to evaluate for NCSs
After treatment of seizures/status epilepticus without return to baseline	18 (95)
NCSs or high-risk patterns on routine EEG	18 (95)
Altered mental status with risk factors of NCSs	17 (89)
Altered mental status of unknown etiology	11 (58)
Post–cardiac arrest seizures/status epilepticus	15 (79)
Indications for cEEG (other than seizure detection/monitoring)
Spell characterization	19 (100)
Post–cardiac arrest neuroprognostication	9 (47)
Depth of anesthesia	8 (42)
Delayed cerebral ischemia monitoring	3 (16)
ICP monitoring	2 (11)
Availability of quantitative EEG
Yes	5 (26)
No	14 (74)

Abbreviations: cEEG = continuous EEG; NCS = nonconvulsive seizure.

^aInstitutions without cEEG excluded from analysis (n = 3).

Only 26% of institutions reported having quantitative EEG (qEEG), with most having access to ≤2 trends and only 1 institution reporting the use of Persyst software. Most of these institutions use qEEG to monitor response to therapy and burst suppression, with only 1 using qEEG for DCI monitoring. Three institutions reported using qEEG in addition to reviewing every page of raw data while the other 2 institutions used qEEG to help pinpoint specific areas of raw EEG for review (eAppendix 3).

Technical Aspects

Sixty-eight percent of institutions have 5–10 video EEG machines, 26% have 6–10, and 5% have 11–15. At most institutions, all available video EEG machines cannot be run simultaneously because of technical barriers, with 47% of institutions performing <5 ICU cEEG studies per month, 32% 6–10 studies, and 21% 10–20 studies. On average, patients undergo cEEG monitoring for less than 48 hours at 32% of institutions, between 48 and 96 hours at 58% of institutions, and more than 96 hours at 11% of institutions.

No institution reported having EEG technologists available on-site 24/7, with only 31% having access to a technologist on-call 24/7 and only 26% of institutions performing new cEEG hookups 24/7 (Table 4). When technologists were unavailable for new hookups, only 26% of institutions reported having access to abbreviated 4-channel EEG or subhairline montages.

Table 4.

^aInstitutional Continuous EEG Availability (N = 19)

Characteristics	Percentage (%)
Number of video EEG machines available
1–5	13 (68)
6–10	5 (26)
11–15	1 (5)
bNumber of cEEG machines that can run simultaneously
1	5 (26)
2	3 (16)
3	3 (16)
4	6 (32)
≥5	2 (11)
bPatients undergoing cEEG/month
<5	9 (47)
6–10	6 (32)
10–20	4 (21)
Technologist availability
Technologist on-site 24/7	0
Technologist on-call 24/7	6 (31)
7 d a wk, extended hours (8:00 am–10:00 pm)	2 (11)
7 d a wk, daytime hours only (8:00 am–3:00 pm)	8 (42)
Weekdays only (8:00 am–3:00 pm)	3 (16)
Time from ordering to cEEG hookup
≤4 h	9 (47)
End of the day (3:00 pm same day)	8 (42)
End of the next day (3:00 pm next day)	2 (11)
Technologist time for hookup
<30 min	6 (31)
30–60 min	11 (58)
>60 min	2 (11)

Abbreviation: cEEG = continuous EEG.

^aInstitutions without cEEG excluded from analysis (n = 3).

Review of cEEG Monitoring

The time required for technologists and physicians to process a 24-hour EEG record is illustrated in Figure 3. Every page of cEEG raw data is reviewed by a physician or technician at 90% of institutions, with 5% reviewing at least 75% of the recording and 5% of institutions reviewing <25% of a 24-hour EEG record. Ninety percent of physicians review the EEG record ≥2 times a day, and 84% of physicians write a distinct EEG report daily. In addition, 79% of institutions use ACNS-standardized critical care EEG terminology. At 84% of institutions, the cEEG reader is expected to give clinical advice, which is directed to the ordering provider at 37% of institutions, to neurology or critical care at 32%, and exclusively to critical care at 11%.

Figure 3. Time Required for Processing of One 24-Hour EEG Record.

ICU EEGs can be read remotely at 63% of institutions. At 26% of institutions, remote access is available for EEG records from some, but not all, hospital locations, whereas at 11% of institutions, no EEG records can be accessed remotely. A neurophysiology physician or fellow is available on-call 24/7 to read cEEG recordings at 63% of institutions.

Discussion

This study provides a comprehensive outline of the availability and use of cEEG monitoring across Canadian hospitals. Our study demonstrates that there is a clear lack of EEG laboratories and cEEG access across Canadian health care institutions, including at major tertiary care centers. Our study also highlights the significant geographic disparities in Canada, with all 3 Canadian territories (Yukon, NT, NU) lacking an EEG laboratory, at least 3 of 10 provinces (PE, New Brunswick, MB) lacking access to cEEG monitoring, and data missing from 1 province (Newfoundland).

The use of cEEG monitoring outside Canada has expanded significantly over the past decade, offering superior sensitivity compared with routine 30-min EEG recordings.^2,10,19 Several studies have also demonstrated that cEEG has been associated with reduced in-hospital mortality in critically ill hospitalized patients.^3,19 Despite this, the results of our study demonstrate that only 9% of Canadian hospitals have access to routine EEGs and just 2% have access to cEEG monitoring. Moreover, just 68% of tertiary care hospital networks and 55% of tertiary care hospital campuses have access to any cEEG monitoring. Of the hospitals with access to cEEG monitoring, only 45% have cEEG access in all ICUs served by their EEG laboratory. Most hospitals with cEEG access lack guidelines outlining indications for its use, and less than half report using cEEG for indications beyond seizure identification, such as post–cardiac arrest neuroprognostication, depth of anesthesia monitoring, DCI monitoring, and ICP monitoring. This lack of institutional standardization may result in underutilization and underapplication of cEEG in hospitals. Increased awareness of the importance of cEEG monitoring, along with dedicated funding, could facilitate the procurement of equipment and the recruitment of trained personnel.

The ACNS, Neurocritical Care Society (NCS), and the European Society of Intensive Care Medicine have published evidence-based recommendations on the use of cEEG monitoring in ICU patients.^1,13,14,20 However, it is important to note that these guidelines have not been updated since 2013, 2012, and 2015, respectively, and, therefore, do not incorporate recent data. In addition, most recommendations are based on minimal and low-quality evidence. Nonetheless, the guidelines recommend cEEG monitoring for detecting NCSs and NCSE in critically ill patients with persistent AMS, those with acute brain injury, or those at risk of NCS. They further recommend initiating cEEG monitoring as soon as possible when NCSs are suspected. Our study highlights that many Canadian hospitals, including tertiary care centers managing high-risk patients, do not meet these standards of care. These data underscore significant gaps in the ability to provide adequate care for critically ill adults in Canada, which may result in delayed diagnoses, overtreatment or undertreatment, suboptimal seizure control, and worse neurologic outcomes, given that NCSs are associated with secondary brain injury, as well as increased morbidity and mortality.^4,8 Addressing these deficiencies is critical to ensuring equitable and high-quality care across Canada.

Although our study focuses on EEG access in Canada, limited access to cEEG seems to be a shared challenge across other Commonwealth countries. In Australia and New Zealand, a survey of epileptologists reported that only 31% had access to cEEG, with lack of funding and trained personnel identified as major barriers.²¹ Similarly, in the United Kingdom, a study assessing the management of convulsive refractory status epilepticus found that only 33% of National Health Services (NHS) trusts had access to cEEG monitoring.²² These findings highlight that constrained access to cEEG is a broader issue in publicly funded health care systems.

EEG and cEEG monitoring are resource-intensive technologies requiring access to an EEG machine, a technologist, and a physician to interpret recordings. Several technical and operational challenges hinder the widespread adoption of cEEG in Canada. No Canadian institutions reported having 24/7 on-site EEG technologist availability, and only 31% had access to an on-call technologist. This lack of around-the-clock coverage delays cEEG initiation during evenings and weekends. The shortage of certified EEG technologists and insufficient hospital funding may contribute to this gap. Expanding technologist coverage through investments in training and hiring is crucial to ensure 24/7 availability. Given the lack of technologist resources, implementing less expensive and resource-intensive abbreviated EEG montages for off-hour setups would seem a logical solution; however, only a quarter of institutions report having access to this technology. In addition, commercially available point-of-care EEG devices such as Ceribell (CA), Zeto (CA), and Emotiv (CA) could provide a cost-effective approach to implementing screening EEG monitoring outside typical clinical hours. The only point-of-care device currently available in Canada is VEEGix (Montreal, Canada), which is a more limited device with only 3 prefrontal electrodes. However, none of these devices is currently available in Canada. The deployment of point-of-care EEG devices could enable rapid cEEG initiation in resource-limited settings and improve access in remote areas. Another approach is to train nonexperts and nontechnologists, such as nonepileptologist physicians, fellows, residents, and nurses, to apply both full and abbreviated EEG montages and to screen EEG recordings. Evidence suggests that training providers to both place electrodes and recognize basic high-yield EEG abnormalities is feasible, potentially serving as a bridge when EEG technologists are unavailable to initiate cEEG and epileptologists are unavailable to review recordings.^23,24

Another challenge with implementing cEEG monitoring is the amount of time it takes for a physician to review and report a 24-hour cEEG recording. Fifty percent of institutions reported that processing 1 24-hour epoch takes more than 60 minutes. Depending on the number of patients on cEEG monitoring, increased access could place a considerable burden on physicians. qEEG may mitigate this challenge by compressing hours of data into a single-screen summary, allowing physicians to focus on areas of interest.²⁵ This approach streamlines interpretation and reduces the labor intensity of reviewing prolonged recordings.²⁶ qEEG is also necessary for using cEEG for other indications such as DCI monitoring.^27,28 Despite its potential, qEEG remains minimally implemented in Canada, with few institutions reporting access and most having access to only 1 or 2 trends. Incorporating qEEG tools could reduce the interpretative burden and improve real-time decision making. However, further research is needed to determine how best to integrate qEEG into daily clinical practice, and evidence-based guidelines are needed to standardize its use.

This study has several strengths. It is currently the only study to provide an overview of cEEG access across Canadian hospitals. We used rigorous and systematic methodology in designing and implementing our survey, and our survey was distributed to all relevant hospitals in Canada. The inclusion of both English and French hospitals, combined with a 92% response rate, ensures a representative overview of current practices. However, our study is not without limitations. Reliance on single respondents per hospital may introduce reporting bias and overestimate or underestimate capabilities. In addition, 1 province was not represented in the data set because of nonresponse, and it is possible that this hospital has access to cEEG monitoring.

This study highlights critical deficiencies in cEEG monitoring availability across Canada. Addressing these gaps is important to improve outcomes for critically ill patients and to ensure equitable care for all critically ill patients in need regardless of geographic location. To address these gaps, several strategies are recommended, including expanding technologist coverage, incorporating qEEG tools, and expanding access to point-of-care EEG devices in resource-limited settings. By leveraging innovative technologies and fostering collaboration among stakeholders, Canada can achieve more equitable and effective neurologic care.

Author Contributions

N. Niznick: drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design; analysis or interpretation of data. H. Tang: drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design; analysis or interpretation of data. J. Kromm: drafting/revision of the manuscript for content, including medical writing for content; study concept or design; analysis or interpretation of data. V.A. McCredie: drafting/revision of the manuscript for content, including medical writing for content; study concept or design. M.A. Arevalo Astrada: drafting/revision of the manuscript for content, including medical writing for content; study concept or design. J.R. Gavvala: drafting/revision of the manuscript for content, including medical writing for content; study concept or design. M.C. Ng: drafting/revision of the manuscript for content, including medical writing for content; analysis or interpretation of data. T.A. Fantaneanu: drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design; analysis or interpretation of data.

Study Funding

The authors report no targeted funding.

Disclosure

T. Fantaneanu received an honorarium from Knight Pharmaceuticals and Paladin Labs. The other authors report no relevant disclosures. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.

TAKE-HOME POINTS

• → Limited availability: cEEG monitoring is only available in 2% of Canadian hospitals and 68% of tertiary care centers, demonstrating widespread underutilization across health care institutions.

• → Geographic variability: Access to cEEG is geographically inequitable, with 3 provinces and all 3 Canadian territories lacking any access.

• → Restricted access: Even in hospitals with cEEG capability, access is often limited to specific ICUs, with inadequate off-hour availability and insufficient EEG technologist coverage.

• → Technological limitations: Only 26% of hospitals with cEEG report access to qEEG and abbreviated montages/point-of-care devices. These technologies could reduce the burden of reviewing prolonged recordings and improve off-hour access.

• → National implications: These findings highlight critical gaps in neurophysiology infrastructure and underscore the need for national strategies to improve equitable access to cEEG across Canada.