Inequities in Critical Care Continuous EEG Coverage in Canada

Before the advent of digital EEG, the availability of critical care continuous EEG (cEEG) was limited, largely due to logistical constraints. The arrival of digital EEG led to a steady expansion of its use. With greater use came greater knowledge, leading to consensus-based recommendations that support the use of cEEG in critically ill patients.^1-3 This period saw a phenomenal growth in the use of cEEG in the United States, with one study finding a greater-than-tenfold increase between 2004 and 2013.⁴

Our experience as epileptologists at an academic hospital is that cEEG use has also increased in Canada, although not to the same extent as in the United States. This growing demand presents many challenges, including managing equipment shortages, the scarcity of EEG technicians, and finding the time to review and interpret these prolonged examinations. Without knowledge on practices across Canada, it is difficult to establish standards of care, an important step to obtaining the necessary resources to meet this growing demand.

In this issue of Neurology® Clinical Practice, Niznick et al.⁵ take an important step in filling this knowledge gap in Canada. They report the results of a cross-sectional survey of 22 Canadian hospitals. Nineteen hospitals reported that cEEG was available at their center (86% of survey respondents, 2% of all Canadian hospitals). Most of these centers do not begin new cEEG recordings after regular work hours. Many centers only perform cEEG for seizure detection and not other recognized indications such as prognostication after cardiac arrest or early detection of ischemia after subarachnoid hemorrhage. The authors also highlight major inequities in the availability of cEEG across Canada, with cEEG available in only 6 of 13 provinces and territories.

Niznick et al. recognize that this situation requires a re-evaluation of the Canadian cEEG landscape. With reference to consensus-based recommendations on the use of cEEG,^1-3 the authors conclude that “many Canadian hospitals…do not meet these standards of care.” We agree with many of the proposed solutions to these diagnostic and treatment gaps. With resources already scarce in our public health care system, however, we must ensure that additional initiatives will lead to the greatest possible benefit.

Current cEEG recommendations are generally based on the likelihood of recording epileptic seizures.^1-3 There remains controversy, however, about the impact of cEEG on clinical outcomes in some scenarios. Nonconvulsive seizures in critically ill patients may be an epiphenomenon reflecting the severity of the underlying insult rather than an independent determinant of outcome. It is uncertain that an electrographic seizure that is only detected after 12 or more hours of cEEG contributes importantly to a person's persistently altered mental status. The CERTA (Continuous EEG Randomized Trial in Adults) trial randomized 364 critically ill participants to routine EEG vs cEEG.⁶ Those with cEEG were more likely to have recorded seizures and undergone treatment modifications, but there was no association with clinical outcome. The TELSTAR (Treatment of Electroencephalographic Status Epilepticus after Cardiopulmonary Resuscitation) trial of 172 comatose survivors of cardiac arrest failed to demonstrate a clinical benefit to suppressing rhythmic or periodic EEG patterns in these patients.⁷ Recent reviews conclude that whether to use routine EEG or cEEG for a person with nonconvulsive status epilepticus remains a patient-specific decision.⁸

It is important to note that Niznick et al. shed light on the inequitable availability of cEEG, even in a high-income country such as Canada. Studies conducted in the United Kingdom,⁹ Australia, and New Zealand¹⁰ report similarly limited access to cEEG. In a public health care system, not all 1,267 Canadian hospitals can possess the facilities necessary for cEEG. The lack of system-wide strategies, however, should be of concern to the provincial authorities who are responsible for the allocation of resources and the coordination of care across hospitals. The ethical principle of justice is threatened when a person is provided medical care that does not meet modern standards because they live in an area without ready access to cEEG.

Between 2007 and 2016, Canada's most populous province Ontario developed a provincial strategy to support the quality and equitable access to epilepsy care.¹¹ The Ontario Provincial Strategy for Epilepsy Care included adding 21 epilepsy monitoring unit beds, providing dedicated epilepsy surgery funding, and establishing a permanent task force.¹² The impact of this provincial strategy has been remarkable. It has led to a 48% increase in the number of epilepsy surgeries, while decreasing the number of neurologic consultations, emergency department visits, and hospital admissions by 7%–10%.¹² There has been work to implement similar strategies in other Canadian provinces, but progress has been slow. None of these strategies, including that in Ontario, have addressed cEEG for critically ill patients.

cEEG has gained a foothold in Canada, thanks to dedicated clinicians who have built programs in the face of limited resources. Health administrators in Canada and other countries must learn from the Ontario Provincial Strategy for Epilepsy Care. It is imperative that we develop system-wide strategies to improve the care of critically ill patients with confirmed or suspected nonconvulsive status epilepticus. These strategies would ensure that all patients in need can quickly access cEEG locally or be promptly transferred to an appropriate quaternary health care center. We have seen with the Ontario experience that such large-scale strategies are feasible and can tremendously benefit both patients and the overall health care system.

Study Funding

The authors report no targeted funding.

Disclosure

The 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.