BackgroundTimely management of non-convulsive status epilepticus (NCSE) is critical to improving patient outcomes. However, NCSE can only be confirmed using electroencephalography (EEG), which is either significantly delayed or entirely unavailable in emergency departments (EDs). We piloted the use of a new bedside EEG device, Rapid Response EEG (Rapid-EEG, Ceribell), in the ED and evaluated its impact on seizure management when used by emergency physicians.MethodsPatients who underwent Rapid-EEG to rule out NCSE were prospectively enrolled in a pilot project conducted at two ED sites (an academic hospital and a community hospital). Physicians were surveyed on the perceived impact of the device on seizure treatment and patient disposition, and we calculated physicians’ sensitivity and specificity (with 95% CI) for diagnosing NCSE using Rapid-EEG’s Brain Stethoscope function.ResultsOf the 38 patients enrolled, the one patient with NCSE was successfully diagnosed and treated within minutes of evaluation. Physicians reported that Rapid-EEG changed clinical management for 20 patients (53%, 95% CI 37% to 68%), primarily by ruling out seizures and avoiding antiseizure treatment escalation, and expedited disposition for 8 patients (21%, 95% CI 11% to 36%). At the community site, physicians diagnosed seizures by their sound using Brain Stethoscope with 100% sensitivity (95% CI 5% to 100%) and 92% specificity (95% CI 62% to 100%).ConclusionRapid-EEG was successfully deployed by emergency physicians at academic and community hospitals, and the device changed management in a majority of cases. Widespread adoption of Rapid-EEG may lead to earlier diagnosis of NCSE, reduced unnecessary treatment and expedited disposition of seizure mimics.

Objective. Patients with suspected non‐convulsive seizures are optimally evaluated with EEG. However, limited EEG infrastructure at community hospitals often necessitates transfer for long‐term EEG monitoring (LTM). Novel point‐of‐care EEG systems could expedite management of nonconvulsive seizures and reduce unnecessary transfers. We aimed to describe the impact of rapid access to EEG using a novel EEG device with remote expert interpretation (tele‐EEG) on rates of transfer for LTM. Methods. We retrospectively identified a cohort of patients who underwent Rapid‐EEG (Ceribell Inc., Mountain View, CA) monitoring as part of a new standard‐of‐care at a community hospital. Rapid‐EEGs were initially reviewed on‐site by a community hospital neurologist before transitioning to tele‐EEG review by epileptologists at an affiliated academic hospital. We compared the rate of transfer for LTM after Rapid‐EEG/tele‐EEG implementation to the expected rate if rapid access to EEG was unavailable. Results. Seventy‐four patients underwent a total of 118 Rapid‐EEG studies (10 with seizure, 18 with highly epileptiform patterns, 90 with slow/normal activity). Eighty‐one studies (69%), including 9 of 10 studies that detected seizures, occurred after‐hours when EEG was previously unavailable. Based on historical practice patterns, we estimated that Rapid‐EEG potentially obviated transfer for LTM in 31 of 33 patients (94%); both completed transfers occurred before the transition to tele‐EEG review. Significance. Rapid access to EEG led to the detection of seizures that would otherwise have been missed and reduced inter‐hospital transfers for LTM. We estimate that the reduction in inter‐hospital transportation costs alone would be in excess of $39,000 ($1,274 per patient). Point‐of‐care EEG systems may support a hub‐and‐spoke model for managing non‐convulsive seizures (similar to that utilized in this study and analogous to existing acute stroke infrastructures), with increased EEG capacity at community hospitals and tele‐EEG interpretation by specialists at academic hospitals that can accept transfers for LTM.

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Meningitis and encephalitis are neurologic emergencies that require immediate management and current guidelines recommend empiric treatment with broad-spectrum antimicrobials. Cerebrospinal fluid (CSF) testing algorithms are heterogeneous and largely institution-specific, reflecting a lack of consensus on how to effectively identify CSF pathogens while conserving resources and avoiding false positives. Moreover, many lumbar punctures (LPs) performed in the inpatient setting are done for noninfectious workups, such as evaluation for leptomeningeal metastasis. As such, tailoring CSF testing to clinical context has been a focus of multiple prior reports and several healthcare systems have focused on efforts to limit low-yield diagnostic testing when a positive result is unlikely. To curb ordering viral PCRs when pre-test probability is low, some peer institutions have implemented pleocytosis criteria for virus-specific polymerase chain reaction (PCR) tests from CSF. In this report, we retrospectively analyzed the diagnostic testing of CSF from patients who had an LP while admitted to a single, large academic medical center and found that many cases of Herpes Simplex Virus (HSV) meningoencephalitis were diagnosed by non-neurologists. The rate of positive virus-specific PCR tests was very low, and tests were frequently ordered in duplicate with a multiplexed meningitis/encephalitis PCR panel (M/E panel, BioFire, Salt Lake City, UT). We designed and implemented a systems-level intervention to promote a revised stepwise testing algorithm that minimizes unnecessary tests. This intervention led to a significant reduction in the number of low-yield virus-specific PCR tests ordered without implementing a policy of cancelling virus-specific PCRs.