Abstracts

Rationale: Ictal Response Testing (IRT) is an essential component in the evaluation of patients in the epilepsy monitoring unit (EMU). It provides corroboration of seizure semiology with ictal electroencephalography (EEG) patterns and is valuable in guiding surgical planning as well as implementing patient safety measures. Despite this, there have been very few studies in current literature about standardized ictal response testing protocols, especially in children. In most centers, ictal testing is performed by the neurodiagnostic technicians monitoring the EEG In the few studies that were done the main limiting factors identified were: 1) a lack of experience among the testing personnel and 2) a lack of standardization. The study aimed to recognize existing limitations and address them by providing targeted training to EEG technicians and implementation of a standardized testing tool. Methods: EEG technicians were trained on seizure identification and standardized ictal response testing in phased manner over 3 months using custom testing tool based on the ILAE task force-guided questionnaire. A total of 13 technicians participated in this project (n=13). A pre-implementation IRT survey was conducted to understand their baseline knowledge and comfort level. Based on the results, we created an intensive training program incorporating the rationale and methods of testing and guide to early seizure identification on EEG. There were weekly training and didactic sessions covering seizure semiology and EEG basics conducted by epileptologists and epilepsy fellows. Following initial training, all technicians were instructed to perform baseline inter ictal testing for all patients during EEG lead placement. This served as baseline and was typed and handed over to the next shift of technicians in the technician report section. Every technician was required to maintain a log of inter ictal and ictal testing performed by them. A post-implementation IRT survey was conducted at the end of 3 months to evaluate comfort and efficiency of testing. This was combined with individual feedback to the technician based on their testing performance as noted on video EEGs. Results: The pre-implementation of IRT anonymous survey results showed that although ictal response testing was being performed in the EMU, 38.5% (5/13) of techs were very comfortable in administering the testing and when asked how to improve testing, 76% (10/13) indicated that the testing needed to be standardized and 53% (7/13) indicated they needed more training. Post-implementation of IRT phased training, 84% (11/13) had completed more than 10 standardized inter-ictal testing and 92% (12/13) had performed ictal testing. 76% (10/13) now indicated they were very comfortable administering the testing which was a significant increase from the initial survey. In addition, improved identification of neurological deficits, seizure detection, EEG notations and shorter ictal SPECT injection times were also noted. Conclusions: Ictal response testing is a crucial component in patient epilepsy evaluation in EMU. After implementation of the ictal response testing protocol in the EMU, the majority of technicians implemented the IRT more often, felt completely comfortable delivering the IRT, and recognized ictal patterns rapidly. The technicians played an integral role in the evaluation of seizures. By recognizing the nuances of seizures during EEG, we improved diagnostic evaluation for epilepsy patients. Funding: No funding