REVIEW ARTICLE/BRIEF REVIEW Educational initiatives for electroencephalography in the critical care setting: a systematic review and meta-analysis Programmes e ´ducatifs d’enseignement de l’e ´lectroence ´phalographie en milieu de soins intensifs : revue syste ´matique et me ´ta-analyse Shaurya Taran, MD . Wael Ahmed, MD . Ruxandra Pinto, PhD . Esther Bui, MD . Lara Prisco, MD, MSc, AFRCA, AFFICM . Cecil D. Hahn, MD, MPH . Marina Englesakis, HBA, MLIS . Victoria A. McCredie, MBChB, PhD Received: 29 October 2020 / Revised: 18 January 2021 / Accepted: 18 January 2021 / Published online: 11 March 2021 Ó Canadian Anesthesiologists’ Society 2021 Abstract Purpose We systematically reviewed existing critical care electroencephalography (EEG) educational programs for non-neurologists, with the primary goal of reporting the content covered, methods of instruction, overall duration, and participant experience. Our secondary goals were to assess the impact of EEG programs on participants’ core knowledge, and the agreement between non-experts and experts for seizure identification. Source Major databases were searched from inception to 30 August 2020. Randomized controlled trials, cohort studies, and descriptive studies were all considered if they reported an EEG curriculum for non-neurologists in a critical care setting. Data were presented thematically for the qualitative primary outcome and a meta-analysis using a random effects model was performed for the quantitative secondary outcomes. Principal findings Twenty-nine studies were included after reviewing 7,486 citations. Twenty-two studies were single centre, 17 were from North America, and 16 were published after 2016. Most EEG studies were targeted to critical care nurses (17 studies), focused on processed Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s12630- 021-01962-y. S. Taran, MD (&) Interdepartmental Division of Critical Care Medicine, Department of Medicine, Li Ka Shing Knowledge Institute, University of Toronto, 204 Victoria Street, 4th Floor Room 411, Toronto, ON M5B 1T8, Canada e-mail: [email protected]W. Ahmed, MD Á R. Pinto, PhD Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, ON, Canada E. Bui, MD Division of Neurology, University Health Network, Toronto, ON, Canada L. Prisco, MD, MSc, AFRCA, AFFICM Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford, UK Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK C. D. Hahn, MD, MPH Division of Neurology, The Hospital for Sick Children, and Department of Pediatrics, University of Toronto, Toronto, ON, Canada M. Englesakis, HBA, MLIS Library and Information Services, University Health Network, Toronto, ON, Canada V. A. McCredie, MBChB, PhD Interdepartmental Division of Critical Care Medicine, Department of Medicine, Li Ka Shing Knowledge Institute, University of Toronto, 204 Victoria Street, 4th Floor Room 411, Toronto, ON M5B 1T8, Canada Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, ON, Canada Division of Critical Care Medicine, Department of Medicine, University Health Network, Toronto, ON, Canada Krembil Research Institute, University Health Network, Toronto, ON, Canada 123 Can J Anesth/J Can Anesth (2021) 68:1214–1230 https://doi.org/10.1007/s12630-021-01962-y
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REVIEW ARTICLE/BRIEF REVIEW
Educational initiatives for electroencephalography in the criticalcare setting: a systematic review and meta-analysis
Programmes educatifs d’enseignement del’electroencephalographie en milieu de soins intensifs : revuesystematique et meta-analyse
Marina Englesakis, HBA, MLIS . Victoria A. McCredie, MBChB, PhD
Received: 29 October 2020 / Revised: 18 January 2021 / Accepted: 18 January 2021 / Published online: 11 March 2021
� Canadian Anesthesiologists’ Society 2021
Abstract
Purpose We systematically reviewed existing critical care
electroencephalography (EEG) educational programs for
non-neurologists, with the primary goal of reporting the
content covered, methods of instruction, overall duration,
and participant experience. Our secondary goals were to
assess the impact of EEG programs on participants’ core
knowledge, and the agreement between non-experts and
experts for seizure identification.
Source Major databases were searched from inception to
30 August 2020. Randomized controlled trials, cohort
studies, and descriptive studies were all considered if they
reported an EEG curriculum for non-neurologists in a
critical care setting. Data were presented thematically for
the qualitative primary outcome and a meta-analysis using
a random effects model was performed for the quantitative
secondary outcomes.
Principal findings Twenty-nine studies were included
after reviewing 7,486 citations. Twenty-two studies were
single centre, 17 were from North America, and 16 were
published after 2016. Most EEG studies were targeted to
critical care nurses (17 studies), focused on processedSupplementary Information The online version containssupplementary material available at https://doi.org/10.1007/s12630-021-01962-y.
S. Taran, MD (&)
Interdepartmental Division of Critical Care Medicine,
Department of Medicine, Li Ka Shing Knowledge Institute,
University of Toronto, 204 Victoria Street, 4th Floor Room 411,
As discussed in our protocol, we anticipated difficulty
providing Grading of Recommendations Assessment,
Development and Evaluation (GRADE) summary
statements for our chosen outcomes because of
heterogeneity between studies. Our final review of the
included studies confirmed this to be the case, so we did
not generate GRADE recommendations for this systematic
review.
Data analysis
The qualitative primary outcome was broken down by
theme and described in the form of written summaries,
graphs, and tables. Synthesized data for each of the two
secondary outcomes were presented as written summaries
and forest plots. A meta-analysis of studies contributing to
our secondary outcomes was not initially planned because
of anticipated clinical heterogeneity between studies.17
However, after finalizing our study list and reviewing their
clinical methods, we felt there was sufficient similarity
between studies to undertake a standard meta-analysis
following the Cochrane Handbook’s recommendations.19
We used the standardized mean change for comparing
evaluation scores pre-post EEG training program using
patient-level data when available22–24 or the mean
(standard deviation [SD]) of the overall cohort assuming
a correlation of 0.5 between pre-post scores25–27 to
calculate the SD of the mean change. The standardized
mean change is a measure that allows meta-analysis of data
across pre-post studies that have different scores reported
across studies.28 Standardized mean changes were then
pooled using the inverse variance method with
DerSimonian–Laird random effects. We performed two
sensitivity analyses to estimate the SD of the change using
correlations of 0.3 and 0.7 between pre-post scores.
Cohen’s kappa coefficients were pooled using similar
methods. Cohen’s kappa assumes that subjects being rated
are independent of each other, the categories of ratings are
independent and mutually exclusive, and the two raters
operate independently.29 The data available in some papers
had the same patients’ EEGs evaluated by multiple non-
experts (i.e., the subject independence assumption was
Records identified through database searching (n = 7,099)
Additional records identified through other sources (n=387)
Records after duplicates removed (n=6,035)
Records screened (n=6,035)
Records excluded(n=5,804)
Studies included in qualitative synthesis(n=29)
Studies included in quantitative synthesis(n=12)
Data not suited for quantitative synthesis(n=17)
Iden
tific
atio
nSc
reen
ing
Elig
ibili
tyIn
clud
ed
Records excluded(n=202)
Automated algorithm: 10 Prior training in cEEG: Duplicate: 57 cEEG: 15Letter/commentary: 6 Research protocol: 4Limited description Review article: 7of training program: 9 Training not for cEEGNo training program: 72 Interpretation: 19Not in ICU, ED or PACU: 3
Full text articles assessed for eligibility(n=231)
Figure 2 Study selection
1218 S. Taran et al.
123
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A Systematic Review of Electroencephalography Teaching Initiatives in Critical Care 1219
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1220 S. Taran et al.
123
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37
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tten
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iz7
hr–
1
day
A Systematic Review of Electroencephalography Teaching Initiatives in Critical Care 1221
123
incompletely met), leading to estimates of kappa’s
confidence intervals that were potentially narrower than
they should have been.
Results
Literature search
The search yielded 7,486 studies, of which 6,035 were
screened and 29 were included (Fig. 2). Table 1 presents
the characteristics of included studies. Studies were all
published in English and included 26 cohort
studies,14–16,22–27,30–46 two descriptive studies,47,48 and
one randomized-controlled trial.49
Study characteristics
All studies described a program for educating non-experts
in EEG in the acute care environment. Twenty-two studies
were single centre in design, 17 originated in North
America, and 16 were published after 2016. Sample sizes
ranged from four educational participants in the smallest
studies16,32,41 to 250 in the largest.46 Only seven studies
had more than 50 participants.14,25,31,33,35,36,46 One study
was performed in the ED,49 18 in adult ICUs (either
general medical-surgical ICU or neuro-
ICU),14,22–26,30,32,33,38–46 four in pediatric ICUs,15,31,34,37
and six in neonatal ICUs.16,27,35,36,47,48 In three studies,
participants learned intraoperative EEG from trained
experts during various neurosurgical procedures,
although this was in the context of a broader educational
curriculum that largely occurred within the neuro-
ICU.22,23,33 None of the studies were conducted in the
postanesthesia care unit. Additional study characteristics
are presented as ESM (eAppendix 5).
Four studies were conducted by the same primary
author,22–24,33 but because the educational program and
participants were different between the studies (confirmed
by correspondence with the study author), all four were
included and analyzed separately. Two studies outlined
programs for EEG training of non-experts but did not pilot
them in a group of participants.47,48 Both were classified as
descriptive studies and included only in the assessment of
the qualitative primary outcome.
Ta
ble
1co
nti
nu
ed
Au
tho
r(y
ear)
Nu
mb
er
of
cen
tres
Stu
dy
sett
ing
Par
tici
pan
t
bac
kg
rou
nd
Nu
mb
ero
f
par
tici
pan
ts
EE
Gp
rog
ram
char
acte
rist
ics
Rec
ord
ing
Dat
au
sed
for
EE
Gte
ach
ing
Pri
mar
yg
oal
of
trai
nin
g
Tea
chin
gm
eth
od
sA
sses
smen
t
met
ho
d
Len
gth
of
pro
gra
m
Wh
itel
aw48
(20
06
)
1N
eon
atal
ICU
ICU
ph
ysi
cian
sN
/AC
on
tin
uo
us
EE
G
Raw
EE
GE
EG
theo
ryan
d
wav
efo
rm
inte
rpre
tati
on
Bed
sid
e/in
tera
ctiv
e,
case
-bas
edle
arn
ing
,
did
acti
cle
ctu
res,
qu
esti
on
and
answ
er,
sim
ula
tio
n
Wri
tten
qu
iz7
hr–
1
day
aEE
G=
amp
litu
de-
inte
gra
ted
elec
tro
ence
ph
alo
gra
m;
CD
SA
=co
lou
rd
ensi
tysp
ectr
alar
ray
;cE
EG
=co
nti
nu
ou
sel
ectr
oen
cep
hal
og
ram
;E
EG
=el
ectr
oen
cep
hal
og
ram
;IC
U=
inte
nsi
ve
care
un
it;
N/A
=n
ot
app
lica
ble
;N
R=
no
tre
po
rted
;R
CT
=ra
nd
om
ized
con
tro
lled
tria
l
1222 S. Taran et al.
123
Outcome analysis
Primary outcome
Clinical background of participants
Most EEG training programs were geared towards nurses.
Overall, critical care nurses were the most common