Eeg Book

Guidelines for Clinical Practice
& Facility Standards
Electroencephalography
Facilitated by the College of Physicians and Surgeons of Ontario

September 2000
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The College of Physicians and Surgeons of Ontario
Mission Statement
GOALS OF THE COLLEGE ACCOUNTABILITY AND THE COLLEGE

The College’s goals are to: The College’s prime responsibility is to the people of
Ontario. To assure the effectiveness of its
• promote high quality care by the physicians of
commitment to the public, the College acts to:
Ontario
• ensure that the public is informed of the
• ensure a high standard of personal conduct
College’s services
among physicians
• consult with public groups and respond in a
• protect the public from abuse of trust in the
timely fashion to their concerns
doctor-patient relationship
• ensure that the College is accessible and fair to
• demonstrate responsible, professional self-
all members of the public throughout Ontario
governance with the active participation of the
public and the profession. • ensure that the work of the College is publicly
visible.
To fulfil its goals, the College endeavours to: While the College exists to serve the public interest,
it is also responsive to the medical profession. To
• establish and apply standards which ensure that
accomplish this, the College sets out to:
only qualified physicians are licenced to practise
in Ontario • maintain the confidence and trust of the
profession by ensuring that it is, and is seen to
• provide pertinent information about physicians
be, fair and accessible to physicians
to the public and health care organizations
• consult with other medical organizations on
• investigate and resolve complaints about
initiatives of common interest
physicians
• recognize its obligation to members of the
• maintain a disciplinary process for dealing with
profession for the sound fiscal management of
allegations of misconduct and incompetence
the cost of self-governance.
• monitor the quality of medical practice through The mandate of the College, defined in legislation
programs such as peer assessment and regulations established by the Government of
• promote professional development activities Ontario, is administered independent of Government
such as continuing medical education direction. The College aims to:
• facilitate the establishment and application of • assure government that it is fulfilling its
practice parameters mandate
• consult the public and profession on issues of • consider undertaking specific initiatives at the
concern request of government
• provide advice on current and emerging needs in • act as an advocate for the people of Ontario in
medical education addresing issues of public protection and quality
of medical care with government.
• participate in the accreditation of training
programs for physicians
• provide advice to government on health issues.
& Facility Standards
Facilitated by the College of Physicians and Surgeons of Ontario

September 2000
THE
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First Edition, September 2000:
Members of the Electroencephalography Task Force:
Dr. Donald G. Brunet, Co-Chair Kingston, Ontario
Dr. G. Bryan Young, Co-Chair London, Ontario
Dr. Warren T. Blume London, Ontario
Dr. Joseph Bruni Toronto, Ontario
Dr. Rosalind M. Curtis North York, Ontario
Dr. J.C. Martin del Campo North York, Ontario
Dr. Hiren B. Desai Windsor, Ontario
Dr. Qais Ghanem Ottawa, Ontario
Dr. Richard M. Gladstone North York, Ontario
Dr. Warren C. Goldstein Richmond Hill, Ontario
Dr. Paul A. Hwang North York, Ontario
Dr. Daniel L. Keene Ottawa, Ontario
Ms Brenda Mason, RET Mississauga, Ontario
Dr. Arline McLean North York, Ontario
Mr. Kent McNeill, RET London, Ontario
Dr. Keith L. Meloff Toronto, Ontario
Ms Maria Moncada, RET Toronto, Ontario
Dr. Colin Shapiro Toronto, Ontario
Ms Patricia Tremaine, RET Ottawa, Ontario
Dr. Marvin B. Weber North York, Ontario
Dr. Sharon Whiting Ottawa, Ontario
Dr. Michael J. Winger Windsor, Ontario
Published and distributed by the College of Physicians and Surgeons of

Ontario. For more information:
Daniel J. Klass M D, FRCP (C)

Associate Registrar
Director, Quality M anagement
The College of Physicians and Surgeons of Ontario
80 College Street
Toronto, Ontario
M 5G 2E2
Toll free (800) 268-7096

(416) 967-2600 ext. 403
email: dklass@cpso.on.ca
Contents Guidelines for Clinical Practice and
Facility Standards:
Preface
Role of the College of Physicians and Surgeons . . . . . . . . . . i
Task Force Objectives and Principals . . . . . . . . . . . . . . . . . . . ii
Purpose of Clinical Practice Guidelines . . . . . . . . . . . . . . . . . ii
Definition of Electroencephalography (EEG) . . . . . . . . . . . . . iii
Guideline Development Process for Electroencephalography iii
Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
External Review Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Dissemination and Implementation . . . . . . . . . . . . . . . . . . . . vi
Updating this Document . . . . . . . . . . . . . . . . . . . . . . . . . vi
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
Volume 1 Facility Standards

Chapter 1 Staffing a Facility
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Electroencephalographers . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Physicians Currently Practicing Electroencephalography . 3
Physicians Entering Electroencephalography
After January 1, 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Locum Tenens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Laboratory Director . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Continuing Medical Education . . . . . . . . . . . . . . . . . . . . . . . . . 5
Qualifications of Electroencephalography Technologists . . . . 5
Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Continuing Education for Technologists . . . . . . . . . . . . . . 6
Chapter 2 EEG Equipment and Recording Techniques

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
EEG Equipment and Recording Techniques . . . . . . . . . . . . . . 7
Digital/Quantitative EEG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Sampling Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Displaying Recordings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Screen Resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Topographic Mapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Electrical Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Needle Electrodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Electrode Caps or Similiar Commerical Products . . . . . . . . . 10
Cleaning Electrode Caps or Similar Commercial Products . .10
Guidelines for Clinical Practice and Facility Standards for Electroencephalography i

Chapter 3 Policies and Procedures
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Developing Policies and Procedures . . . . . . . . . . . . . . . . . . . 13
Chapter 4 EEG Requisition Records and Reports

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
EEG Requisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Legal Aspects of EEG Records and Reports . . . . . . . . . . . . 15
Records Retention and Storage . . . . . . . . . . . . . . . . . . . 16
Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
EEG Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Feedback to Referring Physician . . . . . . . . . . . . . . . . . . . 17
Timelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Chapter 5 Quality Improvement

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Goals of a Quality Improvement/Management Program . . . .19
Quality Management Activities . . . . . . . . . . . . . . . . . . . . . . . 20
Chapter 6 Long Term EEG Recordings in Intensive Care

Units
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Infection Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Long-Term EEG Recordings in Intensive Care Units . . . . . .21
Digital EEG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Electrical Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Recording . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Recording Comatose Patients . . . . . . . . . . . . . . . . . . . . . 23
Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Chapter 7 Long-Term EEG Monitoring for Epilepsy

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Electrodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Beveled Disk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Sphenoidal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Intracranial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
EEG Amplifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Pre-Amplifier Location . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
EEG Recording and Storage . . . . . . . . . . . . . . . . . . . . . . . . . 26
Recording Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Minimum Standards for Specific Indications . . . . . . . . . . . . .27
Presurgical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
ii The College of Physicians and Surgeons of Ontario

Chapter 8 Ambulatory Monitoring
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Recording Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Electrodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Patient Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Recording Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Technologist Qualifications and Duties . . . . . . . . . . . . . . . . . 30
Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Chapter 9 EEG Recordings in Neonates and Infants up to

8 Weeks Post-Term
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Electrodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Patient Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Recording and Review Procedures . . . . . . . . . . . . . . . . . . . . 32
Length of Recording . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Response Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Extra-Cerebral Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Activation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Photic Stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Technologist Qualifications . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Volume 2 Clinical Practice Guidelines

Chapter 10 Clinical Indications for
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Applications of EEG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
General Guidelines for EEG . . . . . . . . . . . . . . . . . . . . . . . . . 38
Chapter 11 Administering Sedation to Adults and Children

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Administering Sedation to Adults and Children . . . . . . . . . . . 39
Guidelines for Clinical Practice and Facility Standards for Electroencephalography iii
Chapter 12 Adult and Adolescent Neurological Disorders
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Reasonable Probability of Useful Clinical Information . . . . . .41
First Seizure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Intractable Symptoms to Assess
Possible Non-Epileptic Events . . . . . . . . . . . . . . . . . . . . . 42
Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Stopping Anticonvulsant Therapy . . . . . . . . . . . . . . . . . . 42
Seizure Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Myoclonus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Stupor and Coma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Brain Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Head Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Neurodegenerative Disorders-Dementia . . . . . . . . . . . . .43
Creutzfeldt-Jakob Disease . . . . . . . . . . . . . . . . . . . . . . . 44
Herpes Simplex Virus Encephalitis . . . . . . . . . . . . . . . . . 44
Atypical Transient Ischemic Attack to
Evaluate Partial Seizures . . . . . . . . . . . . . . . . . . . . . . . . 44
Third-Party Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Low Probability of Useful Clinical Information . . . . . . . . . . . .44
Follow-up in Asymptomatic Patients . . . . . . . . . . . . . . . . 44
Family Studies Except in a Research Environment . . . . .45
Syncope, Presyncope and Dizziness . . . . . . . . . . . . . . .45
Assessing Cerebrovascular Disease
Unless Complicated by Seizures . . . . . . . . . . . . . . . . . . . 45
Classifying Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Tremor, Spasms, and Tic Disorders . . . . . . . . . . . . . . . . 46
Brain Injury after Mild Head Trauma or “Whiplash” Injury 46
Chronic Fatigue Syndrome and Daytime Sleepiness . . .46
Chapter 13 Paediatric Neurological Disorders

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Reasonable Probability of Useful Clinical Information . . . . . .47
Neonatal Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Acute Neonatal Encephalopathy . . . . . . . . . . . . . . . . . . . 47
Neonatal Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Complicated Febrile Seizures . . . . . . . . . . . . . . . . . . . . . 47
Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Diagnosis of Subacute Sclerosing
Panencephalitis (SSPE) . . . . . . . . . . . . . . . . . . . . . . . . . 48
iv The College of Physicians and Surgeons of Ontario

Low Probability of Useful Clinical Information . . . . . . . . . . . . 48
Classifying Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Typical Febrile Seizures . . . . . . . . . . . . . . . . . . . . . . . . . 48
Learning Disability Unless Complicated by Seizures . . . 48
Autistic Behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Attention-Deficit Hyperactivity Disorder . . . . . . . . . . . . . . 49
Behavioural Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Breath-holding Attacks . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Assessing Degenerative or Developmental Disorders
Complicated by Seizures . . . . . . . . . . . . . . . . 49
Brain Death in Patients under Three Months of Age . . . . 49
Chapter 14 Psychiatric Disorders

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
EEG Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Role of EEG In Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
EEG Referral Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Reasonable Probability of Useful Clinical Information . . . . . . 52
Possible Organic Etiology . . . . . . . . . . . . . . . . . . . . . . . . 52
Hallucinatory States and Delirium . . . . . . . . . . . . . . . . . . 52
Assessing Medication Toxicity . . . . . . . . . . . . . . . . . . . . 53
Possible Partial Seizures . . . . . . . . . . . . . . . . . . . . . . . . . 53
Low Probability of Useful Clinical Information . . . . . . . . . . . . 53
Certain Screening Procedures . . . . . . . . . . . . . . . . . . . . 53
Schizophrenia, Depression, Obsessive-Compulsive
Disorder, Personality Disorder . . . . . . . . . . . . . . . . . . . . 53
Chapter 15 Ambulatory EEG

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Chapter 16 Quantitative EEG

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Advantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Chapter 17 Intensive EEG/Video Monitoring for Epilepsy

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Indications for Intensive EEG/Video Monitoring for Epilepsy 59
Endnotes
Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
References
Guidelines for Clinical Practice and Facility Standards for Electroencephalography v

Appendix I College of Physicians and Surgeons of Ontario
Infection Control Guidelines for Facilities Performing
Electrophysiologic Studies - March 1996 . . . . . . . . . . . . . . .67
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Infection Control Strategy . . . . . . . . . . . . . . . . . . . . . . . . 68
Appendix II Classifying Medical Instruments

Classifying Medical Instruments . . . . . . . . . . . . . . . . . . . . . . 73
Appendix III Decontamination Procedures

Decontamination Procedures . . . . . . . . . . . . . . . . . . . . . . . . 75
Appendix IV References
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
vi The College of Physicians and Surgeons of Ontario

Preface
Role of the College of Physicians and Surgeons

The College of Physicians and Surgeons of Ontario (The College)
adopted the role of a facilitator when developing this document. The
College, through Members’ Dialogue, solicited interested and qualified
Electroencephalographers to volunteer as members of the EEG Guideline
Development Task Force.
Note: Members of the Task Force were not compensated for their work. The College did not have a role in the
collection, analysis, or interpretation of the data. The College did provide administrative support to the
Task Force. It also printed and distributed the clinical practice guidelines and facility standards. The
College did not solicit external funding.
The Task Force adhered to the following principles:

• clinical practice guidelines must be based on the appropriate mix of current,
scientifically-reliable information from research literature, clinical
experience, and professional consensus.
• any guideline-setting exercises must be done exclusively from the quality
perspective. That may mean that some conclusions could add to medical
care costs.
• guidelines had to be flexible enough to allow for a range of appropriate
options and to take into account variations in practice realities from urban to
rural areas.
• guidelines had to be developed by consensus and consultation with the
profession at large.
• guidelines should provide support and assistance to physicians without
boxing them in with “cookbook formulas”.
• guidelines will need to be regularly updated by the Task Force based on
appropriate research studies.
• guidelines should reduce uncertainty for physicians and improve their
clinical decision-making.
• information on practice guidelines must be widely distributed to ensure that
all physicians benefit from this knowledge.
An important goal of The College is to promote activities which will
improve the level of the quality of care by the majority of physicians.
Guidelines for Clinical Practice and Facility Standards for Electroencephalography vii
Task Force Objectives and Principals
The purpose of the EEG Guideline Development Task Force was to
develop clinical practice guidelines for the practice of
electroencephalography (EEG) for all populations including neonates,
children, and adults. The document covers medical conditions referred to
out-of-hospital and hospital-based EEG labs and addressed the role in
psychiatric disorders as a special area.
The Task Force had the following directives:
• this continuous quality improvement endeavour gives primacy to the
revered medical principle, “first, do no harm”. That is, EEG testing should
be performed in a safe manner. Thus, there should be no risk from
infectious or electrical hazards or other potential dangers.
• EEG should be useful in patient care. Electroencephalograms should only
be done for appropriate indications. Volume II outlines the clinical
conditions for which there is reasonable or low probability of useful clinical
information resulting from an EEG.
• electroencephalograms should be performed in an accurate, careful and
responsible manner by technologists who are competent, using adequate
equipment.
• electroencephalograms should be interpreted carefully and reported
promptly by competent electroencephalographers. The report should
contain a description of the characteristics of the recording. The clinical
interpretation or the conclusion should correlate the clinical features with
the findings on the EEG tracing.
Purpose of Clinical Practice Guidelines

Guidelines for Clinical Pracitce and Facility Standards are designed to
assist physicians in their clinical decision-making by providing a
framework for assessing and treating clinical conditions commonly cared
for by a variety of specialities and areas of practice. The primary purpose
of this document is to assist physicians in continually improving the
quality of services they provide to patients and to act as a guide for
assessing the quality of care provided to patients.
• These guidelines and standards are not intended to either replace a
physician’s clinical judgement or to establish a protocol for all patients with
a particular condition. Guidelines may be adopted, modified, or rejected
according to clinical needs and constraints.
- Guidelines for Clinical Practice and Facility Standards for
Electroencephalography: We understand that some patients will not fit
the clinical conditions contemplated by certain guidelines and that a
particular guideline will rarely be the only appropriate approach to a
viii The College of Physicians and Surgeons of Ontario

patient’s condition. Practice guidelines are not intended as absolute
requirements. The use of practice guidelines cannot guarantee any
specific outcome.
In developing these clinical practice guidelines, our objective was to

create a range of appropriate options for given clinical situations, based
on the available research data and the best professional consensus. This
document should not be thought of as being “cast in stone”, but rather
subject to individual, clinically significant patient differences.
Definition of Electroencephalography (EEG)

Electroencephalography (EEG) testing provides a window on the
electrical activity of the brain. An electroencephalogram provides
information about the physiological state of the brain in health and
disease. An electroencephalogram does not make diagnoses. EEG
laboratories can be found across Ontario in both general and psychiatric
hospitals as well as in office settings.
Guideline Development Process for

In December 1994, representatives from the Canadian Society of Clinical
Neurophysiologists (CSCN) made a presentation concerning the quality
of care of electroencephalography services in Ontario to the Clinical
Quality Improvement Committee (then, the Quality Management
Committee of the Council of the College). They presented their analysis
and recommendations from the EEG services survey which was
coordinated by The College and the Provider Services Branch of the
Ministry of Health.
- The survey was sent to 200 EEG laboratories and 72 responses were
received. The survey results noted the following:
•63 laboratories (88%) had a specialist reading the EEGs
•62 readers had 6 months or more of EEG training
•22 laboratories had one or more non-registered technologists
•14 laboratories had no registered technologists
•EEG/tech/year: mean 563 (160-1600)
•12 laboratories used needle electrodes.
As a result of this survey and the continued concern with the
qualifications of laboratory staff, equipment standards, appropriate
referrals and patient management, the Clinical Quality Improvement
Guidelines for Clinical Practice and Facility Standards for Electroencephalography ix

Committee recommended that clinical practice guidelines be developed.
A Notice to the Profession was included in the May 1995 issue of
Members’ Dialogue to recruit volunteers for the EEG Guideline
Development Task Force.
The Task Force met for the first time in January 1996 and included all the
physicians who responded to the Notice to the Profession in Members’
Dialogue.
Of the 17 physicians, six were community-based practitioners and 11
were academic-based practitioners, and all were neurologists (four were
paediatric neurologists). Geographically, ten physicians were from the
Greater Toronto Area, two were from London, two were from Windsor,
three were from Ottawa, and one was from Kingston.
The Task Force requested representation from the
Neuroelectrophysiological Technologists of Ontario (three
technologists), the Ontario Psychiatric Association (one psychiatrist), and
the Ontario Medical Association.
Drs. Bryan Young and Donald Brunet were selected by the Task Force to
be Co-Chairs. At the January 1996 meeting, the Task Force recognized
the importance of educating not only physicians performing EEGs, but
also physicians who order EEGs to ensure that ordering of these tests is
only done for medically appropriate reasons.
The Task Force divided into three subgroups to address the following:
Subgroup 1
The assessment of patients for possible testing, the clinical indications for
EEG testing and the role of general practitioners/family physicians,
specialists, and laboratory medical directors in the ordering process.
Subgroup 2
The standards for EEG laboratories to interpret and report results.
Subgroup 3
EEG outcome assessment and the utility of EEGs to the ordering
physician in care management.
x The College of Physicians and Surgeons of Ontario

Methodology
As a first step, the Task Force members reviewed the results of
computerized MEDLINE literature searches1, existing published
guidelines, and facility standards by the following organizations:
• International Federation of Clinical Neurophysiology (IFCN)
• American Clinical Neurophysiology Society (ACNS)
• Canadian Society of Clinical Neurophysiologists (CSCN)
• American EEG Society
• Canadian EEG Technologists (CAET)
• American Academy of Neurology (headache, digital EEG).
The MEDLINE search also identified many articles which were then
reviewed by the Task Force. The Task Force members found that these
articles did not meet standards for Level one evidence. Faced with a lack
of Level one evidence, the Task Force agreed to use the best available
information including expert opinion based on consultation with experts
from other provinces and the United States. The Ontario Psychiatric
Association polled its membership about common usage of EEG. A
focussed literature review on various psychiatric disorders was
conducted.
Where evidence was available it was used to formulate recommendations.
In the instances where there was no good evidence, the recommendations
were based on best practice determined by the Task Force members and
external experts. The Task Force agreed, without dissenters, on each
point in the document.
Eight meetings were held at which the Task Force members discussed the
quality of existing evidence and the content of these guidelines and
facility standards. A consensus 2 as to the content of this document was
reached by the Task Force.
External Review Process

This document was sent to 475 external referees for their comments. The
external referees included:
• qualified electroencephalographers and technologists in academic and
private practice as well as hospital based practitioners
• all relevant professional groups (including the Association of Ontario
Neurologists, Ontario Medical Association) in Canada and United States
• selected Canadian and foreign experts in EEG.
Guidelines for Clinical Practice and Facility Standards for Electroencephalography xi

The process of clinical practice guideline development initiated
considerable discussion in the Province about appropriate standards and
excellent written responses from many neurologists were received. The
Task Force believes they have been successful in incorporating
essentially all of the suggestions that meet the guiding principles of the
Task Force. A major revision was made in Chapter 1, Staffing a Facility.
The guidelines were not pilot tested.
Dissemination and Implementation

The College will advise the profession of the availability of the guidelines
for clinical practice and facility standards. Physicians will be notified of
the guidelines through Members’ Dialogue and through the College’s
Web Site. Additional implementation strategies are being explored such
as workshops and academic detailing.
The aim is to continually improve the quality of services physicians
provide to patients. The College will measure outcomes of patient
services provided and monitor the impact of the guidelines through
quality assessments by a team of assessors.
Updating this Document

It is projected that the updating of these guidelines will occur
approximately three to five years after the release of the current version.
The frequency will be based on the availability of new information. The
external review process will be repeated to validate the revised
guidelines.
Acknowledgements
The College acknowledges the efforts of the EEG Task Force in
preparing this document for the profession. The members of this Task
Force are listed on the edition page on the opposite side of the Front Title
Page.
The EEG Task Force acknowledges Drs. Don Low, Elizabeth
Richardson, and Bryan Young for preparing the Infection Control
Guidelines for Facilities Performing Electrophysiologic Studies. These
guidelines were distributed to all providers of EMG, EEG, and Sleep
Medicine facilities in March 1996 and supplement the Infection Control
in the Physician’s Office (January 1999) document published by The
College.
xii The College of Physicians and Surgeons of Ontario

and Facility Standards:
Volume 1
Facility Standards
2 The College of Physicians and Surgeons of Ontario
Chapter 1 Staffing a Facility
Overview
This chapter addresses the minimum qualification standards of the
electroencephalographer and electroencephalography technologist. The
objectives are to ensure that these individuals:
• possess a minimum standard of performance, ensuring accuracy, and
clinical usefulness of recording and reporting
• are knowledgeable regarding measures that ensure safety of the patient.
Electroencephalographers
Physicians Currently Practicing Electroencephalography

Each electroencephalographer meets the following criteria.
The physician:
• has a valid Certificate of Registration in Ontario
and
• is a Certificant or Fellow in Neurology, Neurosurgery, Pediatrics,
Psychiatry or Pediatric Neurology from the Royal College of Physicians and
Surgeons of Canada or holds a PhD in a science involving human
electroencephalography
and
• has a minimum of three continuous months of full-time supervised training
or equivalent in electroencephalography in a laboratory within a university
teaching centre.
Physicians with the above qualifications are eligible to interpret
electroencephalograms without having to pass the Canadian Society of
Clinical Neurophysiologists (CSCN) examination.
Physicians Entering Electroencephalography After January 1, 2000

Physicians who propose to begin interpreting electroencephalograms
after January 1, 2000 must pass the CSCN examination in
electroencephalography. At present, the qualifications for this
examination are as follows:
Guidelines for Clinical Practice and Facility Standards for Electroencephalography 3

• a fellowship or an equivalent diploma from the Royal College of Physicians
and Surgeons of Canada or a Ph.D. in a basic science related to the field of
testing performed
and
• a minimum of six months full-time supervised training in
electroencephalography in a laboratory headed by a member or a person
eligible to be a member of the Electroencephalography Section of the CSCN
or the American Clinical Neurophysiology Society.
Note: Trainees are urged to consult CSCN guidelines for requirements for this examination.
Locum Tenens
A locum tenens is defined as a physician who undertakes the professional
duties of another physician during the latter's absence.
Note: A locum tenens who functions in an acute hospital setting or out-of-hospital clinic should possess the
same qualifications required for electroencephalographers.
Laboratory Director
The laboratory has appointed a physician to be the Laboratory Director.
The Laboratory Director meets the criteria for an
electroencephalographer and is ultimately responsible for advising the
health facility on the professional aspects of services provided in the
laboratory. These responsibilities include, but are not limited to, the
following:
• appropriate design, staffing, and equipping the health facility to ensure
patient comfort, safety, and the proper performance and reporting of
electroencephalographic services
• qualifications and the work of other physicians and technologists employed
in the facility
• performance of electroencephalographic services to ensure that these
services are performed safely, accurately, and reliably
• accuracy and reliability of the equipment used for electroencephalographic
services
• proper design of electroencephalographic services requisitions and reports

• maintenance of all necessary records
• monitoring the results of electroencephalographic services to ensure that
these services are properly interpreted and communicated to the referring
physician in a timely manner
• communication with referring physicians on the appropriateness of test
indications and ordering patterns
• development and maintenance of a quality assurance program for the health
facility.
Continuing Medical Education

Continuing educational activities are in keeping with current specialty
guidelines. Individuals should regularly review journals and attend local
conferences. The electroencephalographer regularly meets with the
technologists for joint EEG interpretation sessions and, if possible, other
electroencephalographers in the area.
The electroencephalographer regularly attends national or international
scientific meetings such as:
• Canadian Congress of Neurological Sciences (CCNS)
• American Clinical Neurophysiology Society (ACNS)
• American Epilepsy Society (AES)
• American Academy of Neurology (AAN)
The electroencephalographer attends courses on EEG and epilepsy at
these and other meetings.
Qualifications of Electroencephalography Technologists

Each laboratory site has a minimum of one Canadian Board of
Registration of Electroneurophysiological Technologists (CBRET). The
goal of the Task Force is to have all technologists registered with
CBRET. Trainees functioning under the supervision of a registered
technologist obtain CBRET certification with CBRET’s current
specification.
Note: CBRET provides the only qualifying examination that is available to technologists in Ontario.

Technologists performing electroencephalographic services in any health
facility are "grandfathered" with the provision that they pass the CBRET
examination within five years of the date the facility standards come into
effect.
Note: Technologists who have not undergone the recommended training programs but who have been in
practice for at least 5 years may take the examination until 2004.
Technologists beginning to perform electroencephalographic services

independently or in a supervisory role after the facility standards come
into effect must have passed the CBRET qualifying examination.
Technologists are registered in cardiopulmonary resuscitation and
recertify every two years.
Training
Electroneurodiagnostic training occurs in laboratories directed by a
qualified electroencephalographer in association with at least one CBRET
registered technologist.
Note: Entry into training occurs according to CBRET specifications.
Continuing Education for Technologists

Laboratory Directors of clinical EEG laboratories promote and support
continuing education for their laboratory staff and assist them in
completing their Board examinations. In addition, reading sessions with
the electroencephalographer and attendance at provincial, Canadian, and
international meetings are recommended.
Note: It is recommended that EEG technologists become members of the Neuroelectrodiagnostic

Technologists of Ontario (NETO) and the Canadian Association of Electroneurodiagnostic
Technologists (CAET).

Chapter 2 EEG Equipment and Recording
Techniques
Overview
This chapter addresses the EEG recording including techniques,
equipment, electrical control, and safety.
The recommendations of the CSCN and the CAET document Minimal
Technical Standards EEG/EMG 1991-1993 are followed, with the
addition of the following facility standards.
EEG Equipment and Recording Techniques

Any new equipment entered into service between the release of these
facility standards five years after implementation of these standards must
be capable of recording 16 or more simultaneous channels of EEG.
There are rare exceptions to this, e.g., scalp lesions or limited recordings
such as burns or neonatal recordings. Until sixteen channel recordings
are implemented, at least eight channels should be devoted to recording
electroencephalographic information. None of these eight channels is to
be sacrificed for recording of other guidelines (e.g., electrocardiogram,
eye movement, etc.). Additional channels for monitoring those
guidelines can be used as clinically indicated.
The recordings are at least for 20 minutes. Any changes in patient state
are noted by the technologist. Longitudinal bipolar, transverse bipolar,
and referential montages are used outside of the neonatal age group.
Montages are designed for adequate spatial sampling.
Telephone transmission of real time EEG is rapidly being replaced by
digital store and newer technology. Currently, the Task Force endorses
the guidelines of the American Electroencephalographic Society
Guidelines in Electroencephalography, Evoked Potentials, and
Polysomnography.
Note: We recommend that most montages include over 70% of the electrodes of the International 10-20
System of Electrode Placement. A single montage that includes all the electrodes is acceptable in the
neonatal period.

Digital/Quantitative EEG
Optical disk or compact disk read-only-memory (CD-ROM) technology
is an acceptable medium for storing digital EEG recordings. It is the
technologist’s responsibility to be aware of possible deteriorating
legibility or impending technical obsolescence and make suitable
arrangements for copying the information onto the appropriate storage
medium or paper to meet storage requirements.
Sampling Rate
To ensure an adequate waveform recording, a minimum sampling rate of
200 samples per second for each channel is used, but higher rates are
preferred. The sampling rate should be even multiples of 50 or 64 Hz.
When sampling at 200 Hz, an anti-aliasing filter of 70 Hz should be used,
with a roll-off of at least 12 dB/octave. Higher sampling rates require a
proportionately higher anti-aliasing filter setting.
A low frequency filter of 0.16 Hz should be available; as should a 60 Hz
notch filter, for use when required. Digitization at voltage level of 12 bits
or greater with the ability to resolve voltage to 0.5µV is recommended.
Common mode rejection is 100 dB or greater at each amplifier input.
Interchannel cross-talk must be less than 1%, i.e., 40 db down or less.
Displaying Recordings
Technology is capable of displaying the recording on a video screen as
well as on paper. With horizontal scaling, one second of time occupies
25-35 mm and contains at least 120 data points/channel; scaling at 0.5, 2,
and 4 times should be feasible. On the vertical display, a minimum
spacing of 10 mm between channels for a display of 16 or 18 channels is
recommended.
Screen Resolution
Adequate screen resolution is at least 4 pixel resolution per vertical
millimetre. We recommend that the screen have at least 1024 x 768
pixels. Playback systems should show the montage, filter, and sensitivity
settings, vertical voltage scale and horizontal time marking scale,
technologist comments, event markers (e.g., for hyperventilation), and
page number or time. The playback unit should also allow for montage
selection changes and post-hoc alterations in sensitivity and filter
settings.

Topographic Mapping
Topographic mapping, frequency, or power spectral analyses and other
quantitative assessments of digital EEG data are not considered an
alternative to traditional (standard) EEG display in either digital or analog
systems. Interpretating the quantitative EEG should involve analysis of
the simultaneously recorded standard EEG. When used in isolation, a
quantitative EEG can yield misleading information.
Electrical Safety
Electroencephalographic equipment meets the minimal standards of
Canadian Standards Association (CSA).
Equipment is purchased from nationally recognized manufacturers of
electroencephalographs. If all components for a machine are not from the
same manufacturer, the machine is tested and approved by a qualified
biomedical engineer before it is used. If this is not feasible, facilities
should not use a multi-component machine and must purchase their
equipment from a single recognized electroencephalograph manufacturer.
Needle Electrodes
Needle electrodes are not used routinely and are never used in out-of-
hospital laboratories. If exceptional clinical circumstances require their
use, (e.g., burns to the head or certain intra-operative procedures)
sterilized, single-use needle electrodes are used and disposed of after the
recording.
In patient preparation, the use of blunt tip needles is not recommended.
To reduce skin impedance, the use of abrasive gels applied with a cotton-
tipped applicator is preferred. However, if the clinical situation, e.g.,
there is difficulty in adequately reducing the impedance, warrants the use
of such needles for lowering impedances, sterilized disposable blunt tip
needles are used for each patient and discarded after each use. 3
Note: Please refer to Appendix I, Infection Control Guidelines for Facilities Performing Electrophysiological
Studies, March 1996.

Electrode Caps or Similiar Commerical Products
Electrode caps, premeasured elastic caps with embedded electrodes, are
discouraged for EEG recordings because of problems with cleansing and
disinfecting. In addition, inaccuracies in electrode placement may arise
when there are gross skull or scalp asymmetries. Prolonged use, e.g.,
over several hours may lead to skin breakdown from pressure from the
electrodes.
Note: Electrode caps or similar commercial products should be avoided when the patient has scalp lesions or
potentially transmissible viral disorders (Acquired Immune Deficiency Syndrome (AIDS), serum
hepatitis, Creutzfeldt-Jakob disease, or any systemic infection.)
If the cap is used on a patient with a communicable disease, the cap is

promptly disinfected with Metri-Cide®. Infection control standards meet
the guidelines established for the performance of EEG, as listed in
Appendix I- Infection Control Guidelines for Facilities Performing EEG
Studies.
Because of the potential problems related to cleaning and disinfecting, the
use of this and similar products is discouraged.
Cleaning Electrode Caps or Similar Commercial

Products
Appropriate cleaning, disinfecting and/or sterilizing of electrodes and
accessories is carried out between patients.4
Note: These guidelines meet the standards defined by the College of Physicians and Surgeons of Ontario in
Infection Control Guidelines for Facilities Performing Electrophysiological Studies, March 1996.
For ill in-patients, the technologist consult with the nursing staff
concerning any special infection control requirements for the patient.
Fastidious, frequent cleaning of the electrodes and cap between patients is
recommended. The manufacturer recommends that only liquid
dishwashing detergent be used for cleaning after routine use to remove
electrode gel. Gel buildup causes excessively high impedances and
electrode artifacts. The gel and debris may also need to be mechanically
removed with an “orange stick” or cotton swab.

Note: We recommend that the cap be rinsed thoroughly and hung to air-dry, with the cap lower than the blue
connector to avoid corrosion. At least once monthly, depending on use, we recommend that the metal
electrodes be scraped with an “orange stick” or cotton swab to remove oxide that builds on the electrode.
The cap straps are washed with a brush and soapy water separately at
least once weekly. If the cap is soiled with blood or other body fluids, we
recommend that it be cleaned with Metri-Zyme® or an equivalent
enzymatic detergent and then again washed promptly and thoroughly
with liquid dishwashing detergent, rinsed well, blotted, and air-dried.
Contaminated liquids are disposed of according to the facility standards.
As some sterilizing techniques can injure the fabric of the cap, facilities
must be more selective in the patients than for standard EEG. Electrode
caps or similar commerical products are suitable for routine out-patient
use, provided patients do not have scalp lesions, dementia, or potentially
transmissible viral diseases.
Electrode caps are acceptable for in-patient use, provided they are not
used for prolonged recordings and that the guidelines for patients with
scalp lesions and infectious diseases are enforced.

Chapter 3 Policies and Procedures
Overview
The Laboratory Director has the primary responsibility for the
development and maintenance of the laboratory manual.
Developing Policies and Procedures

Policies and procedures in the EEG laboratory manual include, but are
not limited to, the following:
• Neuroelectrodiagnostic Technologists of Ontario standards or practice
documents
• mission statement
• an information pamphlet for the patient
• an example of the EEG requisition and report form
• policy for bookings: amount of time allotted per patient and the
documentation procedures which include:
- patient history
- head measurement technique: 10-20 system, application technique
• policies for electrodes: types, cleaning techniques, and disposal policy
• policies for special techniques, indications and contraindications for
activating procedures, and sedation
• recording procedure, including calibration
• infection control policy includes such statements as:
- EEG technologists must be immunized against hepatitis B viruses
- technologists must wear gloves when applying and removing electrodes
or any other procedures on the head or body such as adjusting or
moving electrodes or in altering their impedance. The use of two sets of
gloves (double gloving) is recommended when there is increased risk,
e.g., performing an EEG on patients with hepatitis B, HIV infection, any
dementing illness or any active systemic infection
- avoiding needle electrodes or the use of blunt-tip needles for skin
abrasion
- procedures to be followed in the event of contamination with body
fluids from a patient with possible transmissible infectious illness
• technologists reporting EEG results in emergency situations.
These policies and procedures are reviewed annually, revised as
necessary, and dated to indicate last time of review or revision.

Chapter 4 EEG Requisition Records and
Reports
Overview
Requisition records and reports are maintained by the facility.
EEG Requisition
The EEG requisition contains the following clinical details:
• reasons for requesting the test
• medications the patient is taking
• clinical history
• any special precautions (e.g., infection with human immunodeficiency,
hepatitis viruses, allergies)
• any requests for special procedures or special electrode positions.
The requisition is completed and signed by the referring physician prior
to the test being performed.
Legal Aspects of EEG Records and Reports

Records meet the requirements for medical record keeping as stated in the
Public Hospitals Act (Regulation # 518/88-19[3]20[2], updated as
Regulation #965) or Regulated Health Professions Act (Regulation #114/
94) and the Independent Health Facilities Act (Regulation #57/92) for the
Province of Ontario.
These regulations require the following information:
• patient data documentation
- name
- home address
- date of birth
- health number and laboratory/hospital identification number
• name of the referring physician.

Records Retention and Storage
Facilities retain records for the length of time as required by the relevant
legal regulations.
A permanent record is kept of the names of all patients receiving
electroencephalographic services, their identifying numbers, and the
dates of services provided.
Informed Consent
All patients, or their substitute decision-makers, should make an informed
decision before having an EEG performed. For routine EEGs, written
consent is not necessary. The patient/substitute decision maker should
receive adequate information including:
• the purpose of the EEG examination (being as specific as necessary)
• the nature of the test
• the procedures used
• the potential risks and benefits.
Competent patients should be informed that they have the right to consent
to or refuse the test in whole or in part at any time during the procedure.
When activating procedures (e.g., reducing medications, depriving
patients of sleep, or using sedative drugs) place the patient at risk of
having seizures, excessive sedation or other complications, we
recommend that the patients or their care-givers be at least verbally
informed of these risks.
We strongly recommend that a fact sheet that gives the above-mentioned
general information be provided to the patient for elective EEGs.
Note: In special situations, e.g., invasive procedures (i.e., inserting sphenoidal electrodes), written consent is
strongly recommended.
EEG Reports
Contents
The EEG reports contain the following:
• date of receipt of requisition

• factual information:
- patient name
- date of birth
- other identifying information (e.g., hospital number)
- EEG number
- clinical reasons for the test as per referring physician
- relevant medications
- state of patient (awake, asleep, coma, drug induced state)
- any variation from routine electrode positions or recording techniques
that depart from the usual procedures of the laboratory
•reasons should be given for departing from routine protocols
- location of EEG if not in laboratory
- special electrodes or techniques (e.g., sleep deprivation, sedative or
other drugs used for the recording, drugs given during the recording)
- duration of recording if prolonged or if for electrocerebral silence.
• description of EEG activity:
- background rhythms and reactivity
- normal and abnormal rhythms
- normal and abnormal nonrhythmic phenomena
- seizures
- sleep (including staging)
- response to activating procedures e.g., hyperventilation and photic
stimulation, alerting stimuli. Artifacts are noted if they interfere with
reliable interpretation.
• clinical interpretation of EEG data and clinical information:
- interpretation of the EEG normality or abnormality relevant to the
clinical problem
- correlation of the present with past recordings
- diagnosis if apparent, or differential diagnoses.
Feedback to Referring Physician

Appropriate feedback to the referring physician is provided. Except in
emergency situations, the EEG technologist may convey only the
electroencephalographer's official interpretation of the tracing to the
referring physician's office.
Note: In emergency situations, where the electroencephalographer is not immediately available and with the
previous agreement of the electroencephalographer, an electroencephalography technologist may inform
the referring physician of the EEG findings. The technologist must record the technologists’ preliminary
report given to the physician for later review. In these situations, however, the electroencephalographer
is ultimately responsible for reviewing these interpretations in a timely fashion and reporting any

variations to the referring physician.
Timelines
Routine EEGs are reported in a timely fashion. Non-urgent EEGs are
usually interpreted within five working days. Typed, signed reports are
usually sent to the referring physician within 10 days of the EEG.
Note: If the results of the EEG suggest a medical emergency or a problem that needs urgent attention, the
results are promptly conveyed by telephone or by some other means to the referring physician. When the
referring physician requires the written report urgently, the typed report may be sent as “dictated but not
signed”, providing a signed report will follow within 10 days.

Chapter 5 Quality Improvement
Overview
Every laboratory has an ongoing quality improvement/management
program in place which is designed to objectively and systematically
monitor and evaluate the quality and appropriateness of services, to
improve services, and to resolve identified concerns. The program
includes means for staff to review the results of quality improvement
activities, to plan corrective actions, and to monitor the effectiveness of
actions taken, if required.
Goals of a Quality Improvement/Management Program

The goals of a quality improvement/management program are to:
• inform the referring physicians as to the appropriate use of
electroencephalography
• ensure that testing is safe and reliable
• provide prompt and properly interpreted reports to the referring physician
• improve the quality of services provided by the facility staff through
educational programs by attending conferences and meetings or other forms
of continuing education, and reading current relevant literature.
A successful quality improvement/management program depends on
regularly maintaining and reviewing the laboratory records required of
each laboratory.
Quality assessments of all EEG laboratories in Ontario are undertaken by
a team of assessors under the supervision of The College of Physicians
and Surgeons of Ontario. The team may consist of one
electroencephalographer and at least one registered EEG technologist.
The electroencephalographer associated with the laboratory is informed
in writing of the results of the visit. Site reviews will follow a
standardized protocol and checklists appropriate for the type of
laboratory.

Quality Management Activities
Quality management activities include, but are not limited to, the
following:
• establishing a mechanism for periodically reviewing results of tests
performed by the laboratory to establish that the tests are properly
performed and that the test results are reliable
• regularly reviewing calibration and validation data on testing equipment,
noting any deviations from accepted norms and recording corrective action
taken where necessary
• reporting, to a member of the physician staff, all patient related events
occurring during testing, the actions taken, the outcomes achieved
• establishing a mechanism for reviewing the pattern of testing that the
laboratory is requested to perform
- This is to determine whether the tests ordered are appropriate to the
presenting clinical problem and whether the most effective use of the
EEG laboratory facilities is being made in assessing these various
clinical problems. Information and insights obtained from these reviews
are used to educate the EEG laboratory staff and referring physicians as
to the most effective and efficient use of the laboratory.
• reviewing periodically the reports issued by the laboratory to ensure that test
results are issued in a timely fashion and that physician interpretation is
performed accurately
• surveying patients periodically to determine their satisfaction with the
services provided by the laboratory and to seek their suggestions for
improvements. Questions that might be asked in a survey include waiting
time for the test, and the technical and professional treatment by laboratory
staff
• surveying referring physicians periodically to determine their satisfaction
with the service provided by the laboratory, their opinion as to whether the
laboratory results have favourably influenced patient health outcomes, and
to seek their suggestions for improvement
• documenting and trending clinical quality improvement activities.

Chapter 6 Long Term EEG Recordings in
Intensive Care Units
Overview
Long term EEG monitoring in intensive care units represent a new area of
EEG application and there are special concerns and considerations which
are addressed in this chapter which are not addressed elsewhere in this
document.
These guidelines are derived from the International Federation of Clinical
Neurophysiology (IFCN) recommended standards for
electrophysiological monitoring in comatose and other unresponsive
states. Long-term EEG monitoring involves recording either continuously
or intermittently over at least six hours.
Infection Control
Infection control guidelines for facilities performing electrophysiologic
studies are outlined in Appendix I, Infection Control Guidelines for
Facilities Performing Electrophysiological Studies, March 1996.
Long-Term EEG Recordings in Intensive Care Units

Electrodes are applied with the collodion technique. Disk electrodes are
preferred. The rationale for using needle electrodes is carefully
documented by the attending physician, e.g., in patients with scalp lesions
that preclude the use of disk electrodes.
Note: In the neonatal intensive care unit, the problem of volatile vapours from diethyl ether in the collodion
technique can be addressed by either opening one end of the isolette until the collodion has dried or
applying the electrodes while the baby is on a warming tray that is open to the air. Once the diethyl ether
has dried, the baby can be recorded in a closed isolette/incubator.
If needle electrodes are used, only disposable sterile subdermal platinum-

iridium electrodes should be utilized. They should be discarded after
single use. Needle electrodes should be avoided in patients with systemic
infections.

The International 10-20 system of electrode placement, or recognized
modifications of this with additional electrodes, is recommended. The use
of fewer than 21 electrodes in neonates and children under eight weeks
from term is acceptable. Inter-electrode impedences is between 1,000 and
10,000 ohms and approximately equal (within 1,000 ohms of each other).
Digital EEG
The use of digital electroencephalography is recommended for long term
monitoring.
The characteristics meet the minimal standards of the CSCN. Storage on
optical disks or CD-ROMs is acceptable. This meets the standards
established for other EEG storage. This is discussed in Chapter 4, EEG
Equipment and Recording Techniques.
Electrical Safety
Electrical equipment is checked before each recording. Current leakage
is checked at least twice yearly. Two-wire ungrounded devices, that are
not essential to patient survival, are unplugged, if agreed upon by the
attending staff. If needed, these instruments must be properly grounded
and plugged into an isolation transformer. The electroencephalograph is
plugged into a three-wired grounded outlet located in the same circuit
branch that is used to power the other instruments connected to the
patient.
Note: Extension cords must not be used.
The reference or common line from the patient is electrically isolated

from the power line ground or includes an appropriate type of current-
limiting device. No additional ground electrode is used. When indwelling
catheters or pacemaker electrodes are already connected to the patient,
special precautions are used to ensure that all these connections are
properly isolated or current-limited. Switching the machine on and
calibrating the electroencephalograph before the patient is connected and
disconnecting the patient before switching off the instrument are
recommended procedures.
Note: We recommend that electrical interference be promptly investigated, as this may indicate that there is a
current leakage.

Staff
The electrode application and initiation of the recording are performed by
an experienced technologist who has the CBRET qualification.
Recording
The recording uses standardized bipolar and referential montages, with
the former arranged in straight-line longitudinal and transverse arrays.
Longer distance derivations are appropriate in recordings for suspected
brain death and in babies less than eight weeks post-term. Low frequency
(high-pass) filters are approximately 0.5 Hz.
High frequency filters are set at 70Hz; however, the use of 60 Hz digital
notch filters is acceptable. Temporary sampling is performed frequently
at the bedside but only relevant segments of the EEG are permanently
archived.
Recording Comatose Patients

In recording comatose patients, it is important to test for and record their
reaction to stimulation. Usually passive eye opening, reaction to sound
(speaking loudly in the patient's ear) and applying somatic stimuli to the
supraorbital nerve and nail beds are done. Before applying painful
stimuli, it should be assured that this is medically acceptable, e.g., it may
need to be avoided in cases of markedly raised intracranial pressure or
extreme cardiovascular-pulmonary instability.
Drug-induced muscular relaxation may be necessary in some cases where
muscle artifact contaminates the recording. This is negotiated with the
medical team who would perform any such drug administration.
Documentation
The technologist or personnel present during the recording save portions
of the recording that contain significant clinical phenomena such as:
• seizures
• response testing
• the administration of centrally-acting drugs
• significant changes in blood pressure or blood gases during the examination.
A list of medications is noted at the start of the recording.

Reporting
The electroencephalographer reports promptly to the ICU team the results
of the EEG examination and the clinical significance of the results. This
is recorded in the chart the first day and daily while the patient is
monitored. A formal transcription is generated at the end of the recording
procedure. The report summarizes the main findings on the recording and
their clinical significance. Such notes are made the same day on a daily
basis, as long as the recording continues.

Chapter 7 Long-Term EEG Monitoring for
Epilepsy
Overview
In this chapter, long-term EEG monitoring involves recording the patient
either continuously or intermittently over at least six hours. These
guidelines are largely derived from Guidelines: Long-Term Monitoring
for Epilepsy, published by the American Electroencephalographic
Society February, 1991 and from CAET-CSCN Minimal Technical
Standards for EEG/EMG 1993.
Infection Control
Infection control guidelines for facilities performing eletrophysiologic
Electrodes
Three types of electrodes are used:
• beveled disk
• sphenoidal
• intracranial.
Beveled Disk
A beveled disk electrode with a hole in the top is preferred. We
recommend that the collodion technique be used.
Note: Needle electrodes and electrocaps should not be used.
For location, we recommend the 10-20 International System of Electrode

Placement with supplementary positions. Atypical electrode positions
(e.g., T1 , T2, and Nz2 (nose tip) and other special electrodes may be used,
depending on the clinical indications. Recording characteristics are
checked daily.

Sphenoidal
Sphenoidal electrodes are inserted by the electroencephalographer or
qualified physician. These are used to record epileptiform activity from
the anterior or mesial parts of the temporal lobes. Fine, flexible, braided
stainless steel wire, insulated except at the tip, is best. These electrodes
can be used for days to weeks. Care is taken to minimize stress on the
recording wires. The external wires are checked periodically to ensure
proper fixation to the skin.
Note: We do not recommend long-term use of nasopharyngeal, supraoptic, and auditory canal electrodes.
Intracranial
Intracranial electrodes are used mainly in specialized epilepsy centers.
Please see Chapter 7, Long-Term Monitoring for Epilepsy Patients.
EEG Amplifiers
The following are recommended performance specifications:
• low frequency response of less than or equal to 0.5 Hz
• high frequency response of 70 Hz
• noise level less than 1µV rms
• input impedance of less than 1MÛ
• common mode rejection of at least 60 dB
• dynamic range of at least 40 dB.
Pre-Amplifier Location
The closer the pre-amplifier to the signal source (i.e., the shorter the
electrode leads), the less opportunity is for artifact.
EEG Recording and Storage

The following EEG recording and storage media are acceptable:
• paper write-out
• analog magnetic tape: including video component

• digital disk (with or without video component, selective, or continuous)
• CD-ROM or optical disc.
Recording Techniques
Recording techniques are as follows:
• a minimum of 16 recording channels, and up to 64 or 128 channels (if
desired) to obtain accurate localization. Two or more electro-
encephalography machines may be necessary for write-out, or the channels
can be multiplexed and recorded on tape or stored on computer disk.
• montages are selected using the electroencephalographer's discretion.
• filter and sensitivity settings: settings are adjusted to prevent blocking.
Usually the high linear frequency filter can be set at 70Hz and the low linear
frequency filter setting at 1 Hz.
• a 60 Hz notch filter is acceptable.
• monitoring the electrocardiogram, electro-oculogram, electromyogram,
respiration or peripheral events may be indicated in certain clinical
situations.
Minimum Standards for Specific Indications
Presurgical Evaluation
For EEG transmission, standard cable (hard wire), or telemetry with at
least 16 channels of EEG data.
Note: Ambulatory EEG is not acceptable for final evaluation, but may be useful in a triage function.
For EEG recording/storage, a continuous paper write-out with time code

is adequate. Continuous computer assisted selective tape: analog
instrumentation, video cassette or disk (digital) recording with a
synchronized time code and subsequent selective playback on paper or
other high quality display is preferable.
For EEG review/analysis, a detailed visual analysis of all seizures and
representative interictal EEG abnormalities from a paper write-out or
other high quality display is adequate. Repeat analyses of seizures
recorded on tape or disk with variable playback guidelines are preferable.
Additional computer analyses may be beneficial.

Reporting
Formal typewritten reports at frequent intervals are recommended. Report
documentation includes the:
• intent
• scope
• electrical/technical features of the recording
• patient characteristics/behavior
• correlation of electrical and clinical features of the recording.
A conclusion is given at least at the end of the long-term recording, but
conclusions regarding individual time periods can also be inserted.
Daily handwritten reports are entered in the patient's chart to briefly
summarize the pertinent findings in rapidly evolving situations to
circumvent delays in receiving typewritten reports. Longer intervals may
be acceptable for longer recordings if little useful information is found.
Typewritten reports are placed on the patient's chart. Reports are mailed
to the referring physician(s).
The final report consists of:
• patient identification
• description of the clinical problem
• documentation of relevant electrical and clinical information obtained
• an interpretation of the findings.

Chapter 8 Ambulatory Monitoring
Overview
Ambulatory EEG monitoring provides a continuous recording of
electrical brain activity for 12-24 hours. The following guidelines are in
keeping with the Minimal Standards Document of 1991-1993, published
by the Canadian Association of Electroneurophysiology Technologists
(CAET).
Infection Control
Equipment
Recording Equipment
At least eight channels are recommended for standard cassette tape
recording. Digital recording may allow for monitoring of more channels.
Electrodes
Electrodes are applied with collodion.
Note: Needle electrodes are not used under any circumstances.
A reduced array of electrodes maybe used, but the placement must be in

accordance with the International 10-20 System of Electrode Placement.
Electrode impedances are equal and between 1000 and 5,000 ohms.
The technologist ensures that signals are recorded on the tape by checking
all the amplifier, tape advancement, and batteries of the recording system.
The technologist identifies and eliminates any initial artifacts before the
patient leaves the laboratory.

Patient Preparation
In addition to the routine clinical history, the technologist documents on
the requisition the patient's current, relevant clinical status.
The technologist clearly explains the procedure and reviews any
restrictions for the patient during the recording procedure (bathing,
chewing gum, brushing teeth, etc.) Caregivers and/or nursing staff are
also to be advised of the time required for the application and removal of
electrodes.
Recording Procedure
We recommend that the patient and/or caregiver be given a daily log to
document a description of the clinical events as well as to note the time of
medication, meals, bedtime, etc.
The montage used for the recording is established by the
electroencephalographer.
To accurately display low frequency activity, we recommend a low
frequency filter setting of 0.3 to 0.6 Hz (time constant of 0.27 to 0.53
seconds) when the tapes are reviewed.
Technologist Qualifications and Duties

The ambulatory EEG is set up and recorded by a registered EEG
technologist who has received special ambulatory EEG training to
develop the expertise necessary for recording and reviewing ambulatory
EEG.
The technologist reviews the tape and prepares samples of all events as
well as samples of all abnormalities seen for review by the
electroencephalographer.
Reporting
A formal typewritten report is sent in a timely fashion to the referring
physician. The report documents the electrical features of the recording,
identifies any correlation between the events in the patient diary and
problems that interfere with the interpretation. A clinical interpretation
concludes the report.

Chapter 9 EEG Recordings in Neonates and
Infants up to 8 Weeks Post-Term
Overview
The unique circumstances and findings in neonatal EEG require the use
of special techniques and additional requirements.
The use of special requirements (technical and other) are listed below and
are used in conjunction with the Minimal Standards EEG/EMG 1991-
1993 published by the Canadian Congress of Neurological Sciences and
Canadian Association of Electroneurophysiology Technologists.
Infection Control
Equipment
Electroencephalograms consist of at least 16 channels of simultaneous
recording, including or in addition to four or more channels devoted to
extracerebral variables such as electro-oculogram, electrocardiogram,
electromyogram and respiration.
Electrodes
Electrodes are applied with either paste or collodion. Paste is preferred
since fumes from acetone and collodion may be offensive and hazardous
when dealing with neonates in isolettes/incubators.
Note: Needle electrodes are not to be used under any circumstances.
A reduced array of electrodes is used with placement according to the 10-

20 system. When using a reduced array Fp1 (or F1), Fp2 (or F2), C3, C4,
T3, T4, O1, O2, M1, M2 (ear or mastoid electrodes), Fz, Cz, Pz and a
ground electrode.

The 12.5-25 system (IFCN version of the 10-20 System applied to small
head size) can also be used. This system consists of 12 electrode positions
of equal distribution over the scalp.
Electrode impedances are equal and between 1,000 and 10,000 ohms. The
higher impedances may be allowed in order to avoid excessive bleeding
or handling of the skin.
Patient Preparation
In addition to routine clinical history, the technologist documents on the
requisition, the gestational and conceptional age of the patient, relevant
birth history including Apgar scores, medication, body temperature, and
current clinical status.
The technologist communicates with the nursing staff and/or caregivers
and advises them of the length of time required for the procedure in order
to facilitate scheduling of care.
Infants should be comfortable and well fed prior to the electrode
application and recording.
Recording and Review Procedures

The infant’s gestational age at birth, chronological age as well as the
conceptional age (gestational age plus chronological age) stated in weeks/
days is documented on the front of the EEG or with the patient
information on digital EEG, along with the patient's name, identification
number, medication, drug levels, and cephalic asymmetries.
Frequent accurate annotations of patient and environmental activities are
essential when interpreting neonatal recordings. During the recording,
movements such as eye, head, limb movement, lip smacking, smiling,
and all state changes, etc., are frequently and clearly marked.
The use of a single standardized montage throughout the recording is
preferred.
To allow accurate display of low frequency activity, a low-frequency
filter setting of 0.3-0.6 Hz (time constant of 0.27-0.53 seconds) is used.
A paper speed of 15 mm/sec is used for at least part of the recording.
Note: A variety of paper speeds, including 15 mm/sec, are recommended to facilitate interpretation.

Length of Recording
As a minimum, the neonatal EEG is recorded during sleep until both
sleep states (active sleep and quiet sleep) are obtained. This usually
requires a recording time of at least 45 minutes.
When the neonatal EEG is grossly abnormal, 30 minutes recording time
is usually sufficient.
Response Testing
Stimulation is carried out in stuporous or comatose infants over 28 weeks
conceptional age, when there is evidence of an invariant EEG pattern or
lack of state change.
Stimulation is performed near the end of the recording. Response testing
includes, somatic stimulation (rubbing face, squeezing nailbed), auditory
stimulation (clapping or calling in baby’s ear) and passive eye opening
and closing during the recording are recommended.
Extra-Cerebral Monitoring
Eye movements (EOG), respiration and heart rate (EKG) are recorded as
a minimum.
Submental electromyogram (EMG) is recorded whenever possible.
Upper and lower airway monitoring is used in infants with suspected
apnea.
Activation
Photic Stimulation
The use of photic stimulation in neonates is not clinically necessary or
recommended.
Sleep
It is recommended to include spontaneous, natural sleep in the recording.
It is rarely necessary or recommended to use sedation to obtain a sleep
recording in a neonate.

Technologist Qualifications
The EEG is recorded by, or done in the presence of, a registered
technologist who has received special neonatal training required to
develop the expertise necessary for performing neonatal EEG.
Reporting
A formal typewritten report should be sent in a timely manner to the
referring physician. The electroencephalographer should comment on the
features of active and quiet sleep, wakefulness and reactivity in the body
of the report. Following this, a clinical interpretation should be given,
with conclusions and recommendations.

and Facility Standards:
Volume 2
Clinical Practice Guidelines

Chapter 10 Clinical Indications for
Overview
This volume contains general recommendations for ordering and
interpreting an electroencephalogram (EEG) and related tests. These
guidelines are not meant to override clinical judgement in EEG for an
individual patient. Rather, they represent a consensus statement
concerning the utility of EEG in common conditions.
Before ordering an EEG, the physician should have a general
understanding about the information provided by a recording. An EEG
provides information about the physiological state of the brain. The
signals recorded vary with age, state of consciousness, and the
medications taken by the patient being tested. It may provide localizing
information when the patient has partial epilepsy. It provides quite
different, and often complementary, information compared to computed
tomography or magnetic resonance images of the brain.
Applications of EEG
New applications of electroencephalography continue to be refined such
as the application of quantitative methods of analysis, long term EEG
monitoring in the intensive care unit, and recordings for pre-surgical
evaluation of epilepsy. The indications for EEG discussed in this chapter
represent the present common applications of the test and will change as
new scientific information about EEG is published.
A normal EEG recording should not be interpreted as “ruling out”
conditions such as epilepsy. For instance, in patients with epilepsy, it is
not unusual to find a normal EEG between seizures and sometimes no
EEG changes can be detected on the scalp surface during a seizure.4
Abnormalities may be found in asymptomatic individuals or in
association with common conditions like migraine headaches. The
clinician is best suited to determine the significance of EEG findings as
they relate to the results of history, physical examination, and other
laboratory studies.
In considering a referral for an EEG, the Task Force recommends that:
• the referral should ask a question about brain physiology that EEG can
reasonably answer such as whether there is paroxysmal activity suggestive
of epilepsy or diffuse slowing which is compatible with a dementia

• relevant clinical information should be available at the time of the test to
allow a clinical interpretation of the EEG, whether the recording is normal
or abnormal
• an attempt should be made to reproduce the circumstances of the symptoms,
for example, if a seizure occurs only during sleep, then a recording
incorporating sleep is desirable
Note: To ensure that the EEG interpretations are as reliable and reproducible as possible, the recording must be
performed by a highly skilled and qualified technologist. This individual must be able to modify the test
conditions to maximize the information obtained during the recording and to reduce artifacts in the EEG
that originate outside the brain.
General Guidelines for EEG

This volume includes general guidelines for ordering EEG recordings.
These guidelines are not a compendium of indications for EEG and there
is considerable overlap in the chapters.
Note: There is a paucity of Class I evidence from randomized controlled clinical trials in EEG. Most of the
following recommendations result from a consensus opinion of the Task Force 2.

Chapter 11 Administering Sedation to Adults
and Children
Overview
The administration of sedative drugs is seldom necessary for EEG
recordings. Other methods of obtaining co-operation of the patient or of
obtaining a sleep recording should be considered or attempted before
sedative drugs are used.
Administering Sedation to Adults and Children

Before administering a sedative drug the risk/benefit ratio is considered
and:
• informed consent is obtained by the referring physician
• the patient is screened for contraindications before administering a sedative
drug.
The sedation is administered and the subsequent recording is performed
only under supervision of a physician or delegated nurse who is readily
available.
Before a patient is discharged from a laboratory or facility, the physician
or nurse assesses whether the patient is sufficiently awake and is
adequately protecting his or her airway.
Sedatives administered to patients are documented.

Chapter 12 Adult and Adolescent Neurological
Disorders
Overview
This chapter addresses general indications for EEGs in adults and
adolescents, and is divided into two major sections:
• reasonable probability
• low probability of useful clinical information.
Reasonable Probability of Useful Clinical Information
First Seizure
Approximately half the patients referred for an EEG after a first tonic-
clonic seizure have a normal recording in the waking state. Recordings
with sleep can often detect relevant abnormalities missed if only an
awake recording is done. Some types of epileptiform patterns are best
studied during sleep. Patients with partial seizures especially those
originating in the temporal or frontal lobes may not show abnormalities in
the surface recorded EEG. Special electrodes may be necessary to
evaluate these areas.
Epilepsy
Initial Diagnosis and Classification

An important goal in EEG recordings for epilepsy is to assist the clinician
in classifying the seizures or the epileptic syndrome. This can have
important implications for the selection of appropriate therapy. Once the
diagnosis is made, there is little need for repeated or follow-up recordings
unless the pattern of seizures changes adversely or a new type of seizure
develops.
Non-convulsive or Convulsive Status Epilepsy

An EEG may be useful when the patient was not previously diagnosed
with epilepsy or continues to be in status despite appropriate initial drug
therapy. Some patients will have partial status epilepticus manifest
mainly by changes in mental state. An EEG will be useful in diagnosing

these patients. When it is necessary to paralyze and ventilate a patient in
status, EEG monitoring will be important in guiding anticonvulsant
therapy as the usual motor signs of a seizure cannot be observed.
Intractable Symptoms to Assess Possible Non-Epileptic Events

Up to one third of the patients referred for intensive EEG monitoring will
have non-epileptic seizures or a combination of epilepsy and non-
epileptic seizures. Since experienced clinicians may have difficulty
making this distinction, EEG studies both standard and long term
monitoring during symptoms may be useful to make an accurate
diagnosis. It should be remembered that a normal scalp-recorded EEG
during some types of seizures (i.e., complex partial and simple partial)
does not exclude epilepsy.
Follow-up
For many types of epilepsy, there is low correlation between the
occurrence of seizures and epileptiform discharges in the EEG. However,
in some types such as absence seizures with 3 Hz spike and wave EEG
pattern, treatment response can be confirmed with the EEG.
For patients with poorly controlled tonic-clonic seizures, a recording
during follow-up may disclose focal changes not previously seen. These
observations may influence drug selection and suggest the need for
neuroimaging.
Note: For patients who are seizure-free, an EEG is not a useful routine test.
Stopping Anticonvulsant Therapy

An EEG is often performed when there is consideration of stopping
anticonvulsant drugs. Moderate or severe epileptiform abnormalities
usually predict a recurrence of seizures. An EEG that is normal or which
does not show paroxysmal activity does not reliably predict whether a
patient can stop or reduce dosage of anticonvulsant medication.
Seizure Surgery
EEG recordings done in epilepsy surgery centres are an important
component in the patient evaluation. These recordings usually include
long-term EEG monitoring sometimes with surgically implanted
electrodes. Repeated out-patient recordings may be necessary to
establish that a consistent epileptogenic focus is present.

Myoclonus
Myoclonus may originate in cortical or subcortical brain regions. An
EEG can help in the differential diagnosis of myoclonus and therefore
assist understanding the cause and appropriate treatment of the disorder.
Stupor and Coma

EEG can be used to quantify the impairments produced by metabolic
encephalopathy, for example in hepatic encephalography. An EEG can
aid in diagnosing diffuse cortical disorders and assist in locating focal
functional abnormalities when these are not evident clinically. Some
findings can suggest drug toxicity or overdose.
An EEG can assess the contribution of epileptiform activity to the altered
state of consciousness. There is interest in long-term EEG monitoring for
comatose patients in the intensive care unit setting to detect seizures.
Some data suggests that an EEG has a role in determining the prognosis
after cardiac arrest with hypoxic-ischemic encephalopathy.
Brain Death
An EEG can be used to assess brain death. However, current protocols
for determining brain death do not include EEG criteria. 5 The EEG
evaluation of brain death, such as an isoelectric EEG, is very unreliable in
patients who are less than three months old. If a confirmation test for
brain death is required, a test directly assessing cerebral blood flow is
superior to EEG.
Head Injury
In an acute severe head injury, an EEG gives little useful information. In
some patients, status epilepticus may occur without tonic-clonic
movements resulting in a depression in level of consciousness. An EEG
would be necessary to detect this event. This may be more applicable to
patients with a co-existing spinal cord injury. Patients in an intensive
care unit, who are paralyzed and ventilated, may be studied by EEG to
evaluate seizure activity that would not otherwise be clinically evident.
Neurodegenerative Disorders-Dementia
The EEG changes in dementia approximately parallel the severity and
rate of decline in mental functioning. An EEG is more useful than
conventional neuroimaging to quantify these changes. An abnormally
slow EEG may help in differentiating a degenerative disorder from
pseudodementia caused by depression. The presence of focal

abnormalities may suggest a vascular dementia but can also be seen with
Alzheimer’s disease. The hallucinatory state that commonly
accompanies dementia is rarely associated with specific EEG changes.
Creutzfeldt-Jakob Disease
A fairly specific pattern of periodic sharp waves can be seen in up to 70
percent of patients with this rapidly progressive form of dementia.
Repeated recordings are often necessary to study the evolution of EEG
changes and exclude other disorders.
Herpes Simplex Virus Encephalitis

Repetitive sharp waves from the temporal regions can assist with the
diagnosis of herpes simplex encephalitis when other studies are
inconclusive or not available. These changes are not specific for this
diagnosis.
Atypical Transient Ischemic Attack to Evaluate Partial Seizures

An EEG is not usually performed when evaluating stroke and transient
ischemic attacks unless there are additional symptoms in the patient’s
history or an examination which suggests a seizure disorder. Localizing a
stroke is best performed by neuro-imaging techniques.
Third-Party Referrals
There are many situations in which a person with or without neurological
symptoms may be directed to have an EEG study to comply with
regulations. The physician must be satisfied that there is a valid reason to
perform this test. As in the usual clinical situation, referrals for these
studies should contain complete and relevant health information to allow
the electroencephalographer to make an interpretation of the results.
Low Probability of Useful Clinical Information
Follow-up in Asymptomatic Patients

In this clinical situation, the standard thirty-minute EEG does not have
good value for predicting seizure recurrence.

Family Studies Except in a Research Environment
Many families are made aware of the genetic aspects of epilepsy. This
may lead to EEG examinations of asymptomatic siblings and other family
members. The finding of EEG abnormalities in these persons will
sometimes cause undue psychological distress.
Syncope, Presyncope and Dizziness

There are many referrals to EEG laboratories for these conditions to rule
out epilepsy or to decrease the probability of missing a seizure disorder.
Most of these recordings are normal, a finding that does not rule out a
seizure disorder.
Some recordings will show paroxysmal findings or epileptiform
abnormalities that may lead to an inappropriate diagnosis of epilepsy or
cause unnecessary patient anxiety about such a possibility. Brief tonic
spasms or clonic movements are seen with syncope. The clinical findings
will best determine whether these movements are suggestive of a seizure
and therefore represent an indication for EEG.
Vertigo is rarely attributed to epilepsy and there are usually other
symptoms to suggest this diagnosis. An EEG is not usually indicated to
evaluate vertigo. Sometimes children with an absence epilepsy will
complain of dizziness but usually a careful history will disclose the
correct diagnosis in this situation.
Assessing Cerebrovascular Disease Unless Complicated by Seizures

There is a poor correlation between EEG changes and disability due to
stroke. There are better methods for determining stroke location and size.
Only when neuro-imaging is not available is EEG an alternative in the
study of cerebrovascular disease.
Classifying Headaches
There are no specific features seen in an EEG that would assist in
classifying common types of headaches such as migraine, tension, or
analgesic-dependent headaches. Classifying of the common types of
headache remains a clinical decision6.
Although there can be EEG changes in the vicinity of a brain tumour, an
EEG will be normal in many patients with tumour and should not be
relied upon to exclude this diagnosis. Neuro-imaging is the test of choice
when a tumour or other space-occupying lesion is being considered.

Note: Some patients have an EEG to help reassure them that their chronic headaches are a benign disorder.
This type of referral is best kept to a minimum.
Tremor, Spasms, and Tic Disorders

Unless there are features suggestive of a seizure disorder, the EEG has no
role in the evaluation of tremors, spasms, or tic disorders.
Brain Injury after Mild Head Trauma or “Whiplash” Injury

An EEG is commonly ordered to assess patients with a brain injury
following a mild head trauma or whiplash injury. Minor abnormalities
are occasionally seen but require careful and conservative interpretation
as medication effects and EEG changes of drowsiness often complicate
the clinical interpretation of the EEG. After a head injury there remains
considerable variation in the EEG findings and this may persist months
after the injury.
The EEG may suggest that a contra-coup type of injury has occurred, a
finding that may have both diagnostic and legal implications. Mild
changes in the EEG that persists for months to years after injury are
difficult to relate to trauma, as it is uncommon to have a pre-trauma EEG
with which to compare.
After a concussive or more severe head injury, some organized or
professional sports may require a normal EEG before the patient re-enters
competitive activities.
Chronic Fatigue Syndrome and Daytime Sleepiness

There are no specific abnormalities described in patients with chronic
fatigue syndrome or daytime sleepiness. If a sleep disorder is suspected
then a referral to a sleep laboratory is preferable. Most EEG laboratories
are not equipped to perform multiple sleep latency tests appropriate for
possible narcolepsy. A request to look for REM-onset sleep during a
standard EEG is rarely useful. These patients are better served by a
referral to a sleep laboratory.

Chapter 13 Paediatric Neurological Disorders
Overview
The indications for EEG in neonates, infants, and children are similar to
those for adults with the additional recommendations discussed in this
chapter.
Neonatal Seizures
Seizures in the newborn period may be subtle; signs may include
bicycling, lip smacking, or apnea spells. An EEG can be useful in
diagnosing and classifying these events. In myoclonic, tonic-clonic, and
partial motor seizure, an EEG can describe the extent of epileptiform
activity in the brain, thereby assisting with treatment planning. In
neonatal apnea, the EEG only rarely shows epileptiform activity that is
responsible for apnea. It should be recognized that the EEG may be
normal during typical neonatal seizures. An EEG during administration
of pyridoxine for suspected pyridoxine-responsive seizures is also very
useful.
Acute Neonatal Encephalopathy

An EEG for suspected seizure activity is reasonable. Attempts to predict
neurological outcome with EEG are more difficult and usually require
several recordings. Such recordings should be interpreted with caution.
Neonatal Infections
Infections in the neonate may be complicated by seizures. Also in herpes
simplex virus encephalitis there be may EEG patterns that suggest this
diagnosis.
Complicated Febrile Seizures

The EEG is usually normal in typical febrile seizures. However in
prolonged or repetitive febrile seizures, an EEG may be useful in
evaluating focal brain dysfunction and in the determining continuing
electrographic seizure activity.

Follow-up
An EEG is useful to follow-up on seizures in very young children with
conditions such as infantile spasms, absence seizures, and those with
refractory epilepsy. In these patients, the extent of the epileptiform
abnormality correlates with the clinical seizures frequency. The results of
repeated recordings in children with other types of epilepsy are quite
variable and could be misleading in guiding drug therapy. 7
Episodic behaviour and movement disorders that mimic seizures can be
best evaluated by attempting to record when the patient has symptoms.
Such recordings are often difficult to interpret due to movement artifacts.
Diagnosis of Subacute Sclerosing Panencephalitis (SSPE)

In this rare disorder, the EEG shows a specific periodic pattern that is
useful in diagnosing subacute sclerosing panencephalitis (SSPE).
Classifying Headaches
The same considerations noted about headache in adults apply to
children. An EEG cannot exclude a brain tumour.
Typical Febrile Seizures

The EEG is usually free of epileptiform abnormality in these children,
unless the seizure is prolonged, focal, or occurs in the presence of other
indications of previous cerebral damage. For an uncomplicated febrile
seizure with prompt recovery, an EEG recording either just after the
seizure or several weeks later has a low yield of useful information. In
children who have a history of repeated seizures, or when the linkage
with fever is not definite, an EEG may be help to determine if
epileptiform activity is present.
Learning Disability Unless Complicated by Seizures

Learning disability is not usually associated with a seizure disorder.
Since the range of normal for EEG in children is wide, most often useful
information about language and other skills development is not obtained
for an EEG.

Autistic Behaviour
Patients with stable clinical findings, without seizures, are unlikely to
benefit from an EEG. However for patients who show speech regression
or change in behaviour, an EEG may be useful to find focal epileptiform
discharges. To detect these changes, an EEG may be necessary during
sleep.
Attention-Deficit Hyperactivity Disorder

Patients with an attention deficiency related to seizures should be evident
from the clinical examination. Otherwise, patients in this category
generally do not have EEG changes that would affect diagnosis or
management.
Behavioural Disorders
An attack of anger, rage, or violent behaviour in a child sometimes raises
the question of focal epilepsy. Such problems in the absence of other
indications of epilepsy are not indications for an EEG.
Breath-holding Attacks
These symptoms are usually diagnosed by patient history and
examination. The EEG is normal between attacks. Atypical symptoms
that raise the question of seizures or marked parental anxiety can be
indications for an EEG.
Substance Abuse
There are no diagnostic changes in this patient group apart from changes
associated with overdose of drugs such as benzodiazepines or tricyclic
antidepressants.
Assessing Degenerative or Developmental Disorders Complicated by Seizures

An EEG is not usually of diagnostic value in this patient population
unless there are seizures.
Brain Death in Patients under Three Months of Age

An EEG is not a reliable laboratory indicator of brain death in patients
who are less than 3 months of age.

Overview
The appropriate use of EEG in psychiatric disorders is more difficult to
define than for most neurological disorders. The definition of psychiatric
diseases continues to be refined. Despite much research, the biological
basis of many conditions remains elusive.
EEG Research
EEG was first discovered in a psychiatric hospital and psychiatrists
remain a common source of EEG referrals. There are numerous studies
concerning EEG findings in various mental disorders, yet few definite
conclusions can be drawn about the specificity and sensitivity of EEG
studies or the impact of EEG in psychiatric diagnosis and treatment.
The limitation of most research in this field is the retrospective nature of
the data collected. Furthermore, the degree of clinical rigor in evaluating
general medical and neurological problems is not addressed in many of
these studies. Consequently, a recommendation concerning the use of
EEG in psychiatry cannot be made to cover all settings.
Role of EEG In Psychiatry

There is no consensus regarding the role of EEG in psychiatry. Since the
standard EEG is normal in most of the serious psychiatric disorders such
as schizophrenia, depression, anxiety states, and personality disorders, a
request for an EEG in these situations should usually include
consideration of an alternative diagnosis or complicating illness to justify
the test. More research in this area of clinical neurophysiology, including
better techniques of data analysis, is needed before comprehensive
practice guidelines can be developed.
It should be kept in mind that many of the medications commonly used to
treat psychiatric disorders often in themselves cause changes in the EEG
that may be, but should not be interpreted as abnormal.

EEG Referral Survey
To study the current reasons for EEG referral, a questionnaire was sent to
160 Ontario psychiatrists. There were ninety responses to the survey.
Among the many possible reasons for referral listed in the questionnaire,
only the following disorders often or always lead to a conventional EEG
referral:
• memory disorders
• hallucinatory states.
Note: There was also interest in the use of overnight sleep studies when evaluating depression.
There was disagreement concerning the utility of EEG in pseudoseizures,

childhood anxiety, eating disorders, mild mood disorders, somatoform
disorders, and alcoholism.
In psychoactive substance abuse, drug toxicity, depression,
schizophrenia, dissociative states, developmental disorder, disruptive
behaviour, personality disorder, deviant behaviour, and delusional
disorder this group would order an EEG infrequently or not at all.
Possible Organic Etiology

In this situation, a neurological disorder is suspected but cannot be
clinically diagnosed. An EEG can detect both focal and generalized
changes that can assist in the diagnosis and measurement of severity of
these conditions. Examples in this category would include a patient with
dementia or confusional state. Serial EEG recordings may assist in the
diagnosis of neurodegenerative disorders.
Hallucinatory States and Delirium

The main reason for ordering an EEG in this clinical situation is to
evaluate possible seizure activity.

Assessing Medication Toxicity
In some toxic states due to medication, an EEG may be a sensitive
indicator of an adverse effect. An example of this is lithium toxicity. For
other medications commonly used in psychiatric conditions, there are no
recognizable EEG effects unless severe toxicity is present.
Possible Partial Seizures

Partial seizures originating in the temporal or frontal lobes may present as
episodic behavioural disorders. An EEG may be help detect the presence
of these disorders, however, it must be stressed that a normal EEG does
not exclude epilepsy.
Certain Screening Procedures

Most psychiatrists would agree with the following quote from Boutros: It
seems reasonable to suggest that if psychiatric patients customarily
receive complete neurological examinations from qualified clinicians,
screening EEG are not necessary. If on the other hand, such
neurological examinations are not customarily performed then screening
EEGs, particularly for ill patients, may play an important role in
detecting organicity8.
Hughes reviewed the role of EEG in psychiatry, suggesting that about
two-thirds of the referrals for EEG can be anticipated to yield useful
information.9, 10 In a 1998 Canadian study of 150 psychiatric inpatients
consecutively referred for EEG, 11.3% of the recordings were abnormal
but rarely did the EEG help identify an organic etiology that was not
already diagnosed.11
Schizophrenia, Depression, Obsessive-Compulsive Disorder, Personality

Disorder
There are no consistent EEG changes that would allow specific diagnosis
of these conditions or sub-categories of them.

Overview
Ambulatory EEG records eight or more channels of EEG and ECG
continuously for up to 24 hours, using a small data recorder and miniature
EEG amplifiers. The patient may take the equipment home but must
report to the laboratory for an electrode and battery change every 24
hours.
The recordings are reviewed by an EEG technologist and
electroencephalographer to correlate EEG changes with symptoms
recorded by the patient or other observer in a diary. Most systems have
an alarm button that can be pressed on the recorder to give a precise
correlation on the tape with an event.
As in a standard EEG, competent technical ability is required to place the
electrodes firmly on the scalp and to teach the patient the procedures to be
followed.
The advantage of this technique is that a prolonged recording may allow
the physician to correlate EEG waveforms and symptoms to make a more
accurate diagnosis of intermittent neurological symptoms. The study
should be preceded by awake and sleep standard EEG recordings to
determine where any abnormalities may be located in order to plan the
recording montage using only seven or eight EEG channels.
Limitations
The disadvantages and limitations of the technique are considerable and
include the following:
• the patient is away from the laboratory so that the condition of the electrode-
scalp electrical connection cannot be assessed or artifacts corrected.
Electrodes and recording leads can become disconnected or give rise to
unusual artifactual waveforms that can be confused with abnormalities.
While training and experience can overcome some of these difficulties,
these problems remain with each recording.
• artifacts related to chewing, swallowing, eye movements or other head and
neck movements are not visible to the recording technologist and therefore
can be difficult to differentiate from brainwaves
• there is a high cost to acquire and service the equipment.

Both technologist and physician must be properly trained in the use of
this equipment and be prepared to spend several hours looking at the EEG
on a rapid replay station.
Note: The diagnostic yield of these recordings is low and as in the standard EEG, these recordings cannot be
used to exclude epileptic seizures.
We recommend that these recordings be restricted to:

• patients with difficult problems with epilepsy or other paroxysmal
symptoms that might be seizures
• the clinician has not been able to manage the patient successfully with
standard EEG data.
Note: Intensive EEG and video monitoring may be considered as a more reliable alternative test. The patient
must have frequent symptoms to ensure that there is a reasonable chance of evaluating them in one or
two days of recording.
We recognize that this is still a developing technology with possible

applications in sleep disorders and in obtaining prolonged recordings in
the intensive care unit setting.

Overview
Quantitative EEG refers to 20 or more channels of EEG subjected to
computerized spectral analysis and the results compared to a database of
normal EEG recordings matched for age and other characteristics. Often
multi-channel evoked potentials are also performed as part of the test.
Other forms of analysis may also be done such as correlation or
coherence between channels.
Advantages
The advantage of this test is information about the EEG and evoked
potentials which allows precision of data description that cannot be
performed with standard visual analysis.
Limitations
Unfortunately, artifacts cannot be entirely removed from this type of
recording before starting the analysis and the results must be reviewed
with a standard paper/ink or digital EEG to avoid misinterpretation of the
data. Superb technical work is necessary as well as familiarity with both
EEG and evoked potentials.
There is insufficient data about normal multichannel long-latency
evoked, potential changes in them with medications, and other patient
variables. There are no valid clinical studies showing the sensitivity and
specificity of these recordings in diagnostic situations. 12
Spectral analysis may improve the sensitivity of the standard EEG in
cerebrovascular disease.13 There are no studies of the sensitivity and
specificity of these techniques in psychiatric disorders or head trauma.
At the present time, there are no accepted indications for this test,
although much research is being done in this area, especially concerning
major psychiatric conditions.

Chapter 17 Intensive EEG/Video Monitoring for
Epilepsy
Overview
Intensive EEG or video monitoring provides prolonged EEG data. It is
usually performed for many days to provide a correlation between
symptoms and brain electrical signals. Under the appropriate supervised
clinical setting, and on the information needed, the test may be done as an
out-patient or as an in-patient. Depending on the objectives of the
study, invasive electrodes may be used, for example, in pre-surgical
monitoring for epilepsy.
Indications for Intensive EEG/Video Monitoring for

Epilepsy
This test has a well-established application for the following indications:
• diagnosis of epilepsy and classification when other methodologies have
failed to characterize the problem
• distinguish epileptic and non-epileptic events, resulting in a change in
diagnosis and treatment for the patient
• pre-surgical evaluation in epilepsy to localize the region of epileptogenesis.
Note: These techniques are expensive and should only be performed in highly selected patients in which there
is some likelihood of a change in treatment plan after the test.
The electroencephalographer must realize that the absence of a scalp-

recorded EEG change does not rule out a seizure disorder in many types
of events and that the diagnosis of pseudoseizures is often difficult
despite long-term EEG recordings.
Note: There is usually little value in a videotape recording during a standard EEG unless the patient is having
active, frequent symptoms or the events in question can be provoked. A prolonged outpatient EEG with
video monitoring may have some application in paediatric epilepsy.14

Endnotes
Endnotes
1 A search of MEDLINE was conducted for the years 1966-1997 using
a keyword search with the terms:
•electroencephalography
•EEG and standards or indications
•clinical practice guidelines or CPG
•psychiatry
•paediatrics
•specific disorders (seizures, epilepsy, headache, syncope).
MEDLINE review of all abstracts containing EEG for 1995, 1996 for
relevant content
Standard textbooks on Electroencephalography were reviewed.
2 A consensus was reached by a majority vote. No formal consensus
reaching methods were used.
3 Ratified by recommendations at the 1996 CAET meeting on minimal
standards for EEG.
4 Desai, B.T., Porter, R.J., Penry, J.K., Psychogenic Seizures. “A
study of 42 Attacks in Six Patients with Intensive Monitoring”. Arch
Neurol (1982) vol. 39 pg. 202-209.
5 Canadian Congress of Neurological Sciences (CCNS). “Guideline
for the diagnosis of brain death”. Canadian Journal of Neurological
Sciences 1987; 14;653-54.
6 Gronseth, G.S., Greenberg, M.K. “The utility of the
electroencephalogram in the evaluation of patients presenting with
headache: a review of the literature”. Neurology 1995; 47:1263-7.
7 Camfield, P., Gordon, K., Camfield, C., Tibbles, J., Dooley, J.,
Smith, B. “EEG results are rarely the same if repeated within six
months in children with epilepsy”. Canadian Journal of
Neurological Sciences 1995; 22:297-300.
8 Boutros, N.N. “A review of indications for routine EEG in clinical
psychiatry”. Hospital and Community Psychiatry 1992; 43:716-719.
9 Hughes, J.R. “The EEG in psychiatry: An outline with summarized
points and references”. Clinical Electroencephalography 1995;
26:92-101.

10 Hughes, J.R. “A review of the usefulness of the standard EEG in
psychiatry”. Clinical Electroencephalography 1996; 27:35-39.
11 Lam, R.W., Hurwitz, T.A., Wada, J.A. “The clinical use of EEG in a
general psychiatric setting”. Hospital and Community Psychiatry
1988; 35:533-6.
12 American Academy of Neurology. “Assessment: intensive EEG/
video monitoring for epilepsy”. Neurology 1989; 30:1101-1102.
13 Pfurtscheller, G., Jonkman, E.J., and Lopes da Silva, F.H. (eds).
“Brain Ischemia: Quantitative EEG and Imaging Techniques”.
Progress in Brain Research, Volume 62, Elsevier, Amsterdam,
318pp, 1984.
14 Foley, C.M., Legido, A., Miles, D.K., Grover, W.D. “Diagnostic
value of paediatric outpatient video-EEG”. Paediatric Neurology.
1995; 12:120-124.

References
General References
McLachlan, R.S., Young, G.B. “Minimal Standards for Digital/
Quantitative Electroencephalography in Canada”. Canadian Journal of
Neurological Sciences (in Press).
Fisch, B.B. Spehlman’s EEG Primer. Elsevier 1991 (book)
Binne, C.D., Prior P.M. “Electroencephalography” [review]. Journal
Neurological, Neurosurgical, and Psychiatry 1994; 57:1308-19 [124
refs].
American Association of Electromyography and Electrodiagnosis.
Guidelines in Electrodiagnostic Medicine. February 1984.
Bureau of Communicable Disease Epidemiology Health Protection
Branch and Health Services Directorate Health Services and Promotion
Branch. Infection Control Guidelines. Second Printing February 1990.
Minimal Technical Standards, EEG/EMG. 1991-93.
The College of Physicians and Surgeons of Ontario. Infection Control in
the Physician’s Office. May 1995.
Health and Welfare Canada. “Bloodborne pathogens in health care
setting: risk for transmission”. Canada Communicable Disease Report
1992; 18:177-184.
Journal of Clinical Neurophysiology, volume II, Number 1; 1994; Raven
Press
Nuwer, M.R., Comi, G., Emerson, R. et al. “IFCN standards for the
clinical recording of digital EEG”. Electroencephalography and Clinical
Neurophysiology 1998; 106: 259-261.
Royal College of Dental Surgeons of Ontario. Guidelines Respecting
Infection Control in the Dental Office. June 1995.
Rutala, W.A., “APIC guidelines for selection and use of disinfectants”.
American Journal of Infection Control 1990; 18: 99-117.
Young, G.B. “Minimal standards for electroencephalographic
laboratories”. Canadian Medical Association Journal 1991; 144(7): 865-
67.

Chapter 12 Neurological Disorders
Camfield, P., Gordon, K., Camfield, C., Tibbles, J., Dooley, J., Smith, B.
“EEG results are rarely the same if repeated within six months in children
epilepsy”. Canadian Journal of Neurological Sciences 1995; 22:297-
300.
Canadian Congress of Neurological Sciences (CCNS). “Guideline for the
diagnosis of brain death”. Canadian Journal of Neurological Sciences
1987; 14:653-54.
Gronseth, G.S., Greenberg, M.K. “The utility of the
electroencephalogram in the evaluation of patients presenting with
headache: a review of the literature”. Neurology 1995; 47:1263-7.
Parker, B.L., Frewen, T.C., Levin, S.D., Ramsay, D.A., Young, G.B.,
Reid, R.H., Singh, N.C., Gillett, J.M. “Declaring paediatric brain death:
current practice in a Canadian paediatric critical care unit”. Canadian
Medical Association Journal 1995; 153:909-16.

Boutros, N.N. “A review of indications for routine EEG in clinical
psychiatry”. Hospital and Community Psychiatry 1992; 43:716-719.
Hughes, J.R. “The EEG in psychiatry: An outline with summarized
points and references”. Clinical Electroencephalography 1995; 26:92-
101.
Hughes, J.R. “A review of the usefulness of the standard EEG in
psychiatry”. Clinical Electroencephalography 1996; 27:35-39.
Lam, R.W., Hurwitz, T.A., Wada, J.A. “The clinical use of EEG in a
general psychiatric setting”. Hospital and Community Psychiatry 1988;
35:533-6.

Ebersole, J.S. (editor) Ambulatory EEG Monitoring. 1989, Raven Press,
New York, New York.
Cull, R.E. “An assessment of 24-hour ambulatory EEG/ECG monitoring
in a neurology clinic”. Journal of Neurology, Neurosurgery and
Psychiatry. 1985; 48(2): 107-10

Nuwer, M. “Assessment of Digital EEG, Quantitative EEG, and EEG
Brain Mapping: Report of the American Academy of Neurology and the
American Clinical Neurophysiological Society”. Neurology 1997;
49:277-92.

Pfurtscheller, G., Jonkman, E.J., and Lopes da Silva, F.H. (eds). “Brain
Ischemia: Quantitative EEG and Imaging Techniques”. Progress in
Brain Research, Volume 62, Elsevier, Amsterdam, 318pp, 1984.
Chapter 17 Intensive EEG/Video Monitoring for Epilepsy

American Academy of Neurology. “Assessment: intensive EEG/video
monitoring for epilpesy”. Neurology 1989; 30:1101-1102.
Foley, C.M., Legido, A., Miles, D.K., Grover, W.D. “Diagnostic value of
paediatric outpatient video-EEG”. Paediatric Neurology. 1995; 12:120-
124.
Lagerlund, T.D., Cascino G.D., Cicora, K.M., Sharborough, F.W.
“Long-term electroencephalographic monitoring for diagnosis and
management of seizures”. [Review] Mayo Clinic Proceedings 1996;
71:1000-1006.

Appendix I College of Physicians and Surgeons of
Ontario
Infection Control Guidelines for Facilities Performing

Electrophysiologic Studies - March 1996
These guidelines supplement the Infection Control in the Physician’s
Office document published by The College of Physicians and Surgeons of
Ontario. This document was distributed to all Ontario Physicians in May
1995 and updated January 1999 and provides detailed information
regarding the recommendations for infection control. In addition, this
document provides a summary of pertinent information from publications
by societies, provincial, and national organizations.
Background
Infection control is a discipline integral to the practice of medicine. At all
levels of operation, the tenets of infection control minimize the risk of
infection. In a physician's office, just as in a hospital or at a community
public health level, pathogenic microbes can be spread unnecessarily,
and guidelines must be in place to prevent this from occurring. An added
risk exists in those facilities which use needle electrodes. Needle
electrodes pose a threat of bloodborne disease transmission to the patient
because of contaminated equipment, and to the health care workers who
might be exposed to blood due to sharp injuries.
Precautions
Universal Precautions acknowledge that blood and certain body fluids are
infected and can transmit bloodborne pathogens. It should be regarded as
the minimum standard of practice for preventing transmission of
bloodborne pathogens in all health care settings.
Body Substance Precautions acknowledge that all body substances may
be infectious, so precautions should be taken for contact with any body
substance.
Common to both programs, however, is that all patients can harbour
bloodborne infections, whether symptomatic or not; therefore, a
consistent approach or standard precautions for the handling of blood and
body substances from all patients is recommended. The use of gloves and
other barrier precautions form the basis of these practices.

Infection Control Strategy
To protect both patients and health care workers from cross infection, an
infection control strategy is planned, implemented, monitored, and
updated to ensure it is functioning in accordance with the current state of
knowledge.
An infection control strategy for the use of needle electrodes for
physiologic studies includes the following components:
• staff training
• infection control practices
• occupational exposure policy
• monitoring program.
Staff training
Staff should clearly be competent in the area of expertise in which they
are practising. As well, staff should understand their role in the infection
control strategy, the infection control practices to be followed during the
course of their work, and the protocol to be followed in the event of an
occupational exposure incident.
Infection control practices

The most important and frequent mode of spread of infections is by direct
or indirect contact transmission. Universal Precautions/Body Substance
Precautions are the appropriate standard of precautions. All patients can
harbour infectious organisms, whether symptomatic or not. In the use of
needle electrodes, bloodborne infections are a particular risk. Therefore,
a consistent approach for the handling of blood and body substances from
all patients is recommended.
The following are essential in preventing the spread of disease from
patient to patient, patient to health care worker and health care worker to
patient:
• appropriate handwashing
• appropriate equipment type, use, and disinfection/sterilization
• appropriate use of gloves as barriers
• proper handling of sharps
• environmental cleaning
• skin preparation.

Appropriate Handwashing
Handwashing is the single most important measure to prevent infection.

Hands must be washed:
• before and after contact with every patient, body substances or specimens,
and contaminated or soiled items (i.e., waste, linen, countertops, used
instruments, etc.)
• between “clean” and “dirty” procedures on the same patient
• after removing gloves
• before and after performing invasive procedures.
Appropriate Equipment Type, Use and Disinfection/Sterilization
Needle electrodes have been used primarily for electroencephalography

and electromyography. Disk electrodes have replaced needle electrodes
for the following reasons:
• the risk of potential occupational needlestick injuries is unusually high for
staff handling the 21 contaminated needles post-procedure
• disk electrodes reduce the risk to the patient inherent in ensuring appropriate
cleaning and sterilization of reusable needles
• disk electrodes have recording characteristics that are superior to needle
electrodes.
Note: There is, therefore, no longer any place for needle electrodes for electroencephalography.
If disk electrodes are used and the patient's skin is intact, they should be
treated as non-critical medical instruments (see Appendix II, Classifying
Medical Instruments) and undergo cleaning and intermediate-level
disinfection (see Appendix III, Decontamination Procedures).
If the patient's skin is not intact, they must be treated as semi-critical
instruments (see Appendix II, Classifying Medical Instruments) and
undergo cleaning and sterilization. If sterilization may damage the
instrument then high-level disinfection (see Appendix III,
Decontamination Procedures) must be used as a minimum standard.
If needle electrodes must be used, as in electromyography, single use
disposable electrodes are recommended. The cost of disposable needles
is usually less than the staff and equipment costs and technical
difficulties involved in needle electrode reuse. If needle electrodes must
be reused because of cost considerations (i.e., concentric needles),
cleaning and sterilization using an appropriate method is mandatory after
each use. However in a case of suspected or proven Creutzfeldt-Jakob
disease, only single use disposable electrodes must be used.

The platform which reusable needles are inserted and the electrode lead
can be a source of contamination and disease transmission. These items
could potentially contribute to secondary transmission by contaminating
the hands of health care workers or by contact with medical equipment
that will subsequently come into contact with the patient. Consequently,
these platforms should be treated as semi-critical items and require
cleaning and sterilization. If sterilization may damage the instrument,
then high-level disinfection must be used as a minimum standard.
Any disinfection and sterilization process will fail in the presence of
organic material, therefore, adequate cleaning is critical in this process.
Appropriate use of gloves as barriers
Gloves are used to:

• provide a protective barrier to blood or body fluids and preventing gross
contamination of health care workers' hands
• reduce the likelihood of transfer of micro-organisms present on the hands of
personnel to patients during invasive or other patient care procedures which
involve touching patients' mucous membranes or non intact skin. Gloves
too, can become contaminated with micro-organisms from the environment
and pose a risk of transfer of organisms to patients, so should be put on only
before beginning the procedure, not in preparation of the task
• reduce the likelihood that hands of personnel contaminated with micro-
organisms from a patient or a fomite can transmit these organisms to another
patient.
Guidelines for the appropriate use of gloves are as follows:
• wear gloves only when performing the procedure. Do not wear gloves
during the preparation of tasks
• change gloves between patients
• change gloves between tasks and procedures on the same patient after
contact with material that may contain a high concentration of micro-
organisms
• remove gloves promptly after use, before touching noncontaminated items
and environmental surfaces
• wash hands after removing gloves.
Note: If the health care worker's hands has dermatitis or non-intact skin, gloves must be worn to protect the
patient as well as the provider.

Proper handling of sharps
Contaminated sharp items, such as needle electrodes, are considered

potentially infective and need to be handled with extreme care. Needles
should not be recapped. If recapping is necessary, a one-handed
technique should be used. Sharps are discarded in a designated puncture-
proof container.
Environmental cleaning
Surfaces in the office are regularly cleaned and disinfected. Special

measures are needed for the cleaning and disinfection of blood or body
substance spills.
Skin preparation
Surface skin oils, perspiration and dirt are removed from a patient prior to
nerve conduction studies by cleansing with soap and water or alcohol
swabbing and drying. Skin abrasion should be performed only if
necessary because of technical difficulties. Abrasion creates non-intact
skin and electrodes touching it require cleaning and sterilization. If
sterilization may damage the instrument then high-level disinfection must
be used as a minimum standard.
Before needle examination or the use of subdermal clip electrodes, the
site is scrubbed with an antimicrobial solution such as tincture of iodine
1%-2%, 70% isopropyl alcohol or chlorhexidine. It must be applied with
friction in a circular motion for a minimum of 30 seconds starting at the
intended site and working outward. The solution is allowed to air dry
before electrode insertion.
Occupational exposure policy

Prompt and organized action is required when staff are inadvertently
exposed to blood or body fluids through percutaneous (needlestick) or
mucous membrane (splashes) incidents. Each office has in place a
protocol for the appropriate management of such incidents.
Monitoring program
Each facility has a system in place to monitor the infection control
strategy and practices used in the office. This includes monitoring of
staff compliance with the infection control practices as well as time/
temperature, chemical and/or biological monitoring of the sterilization
process.

Appendix II Classifying Medical Instruments
Classifying Medical Instruments

Classification of medical instruments is as follows:
• Critical: instrument enters sterile body site or vascular system. This requires
cleaning by sterilization.
• Semi-critical: instrument comes in contact with intact mucous membranes
or non-intact skin. This requires cleaning followed by sterilization. If
sterilization may damage the instrument then high-level disinfection must be
used as a minimum standard.
• Non-critical: instrument comes in contact with intact skin.

Appendix III Decontamination Procedures
Decontamination Procedures
Decontamination procedures are as follows:
• Cleaning: mechanically removing all organic material using soap and water
or by ultrasonic machines. Organic material interferes with the sterilization
or disinfection process.
• Sterilization: kills all forms of microbial life; including spores. This can be
accomplished by the use of a steam autoclave.
• High level disinfection: kills all forms of microbials but may not be able to
kill large numbers of bacterial spores. This can be accomplished by boiling
or by chemicals such as, glutaraldehyde, 6% hydrogen peroxide or sodium
hypochlorite.
• Intermediate level disinfection: does not kill large numbers of bacterial
spores. Some examples of intermediate level disinfectants are:
- 70 to 90% ethanol and isopropanol
- phenols and phenolics
- sodium hypochlorite.

Appendix IV References
American Association of Electromyography and Electrodiagnosis.
Guidelines in Electrodiagnostic Medicine. February 1984.
Bureau of Communicable Disease Epidemiology Health Protection
Branch and Health Services Directorate Health Services and Promotion
Branch. Infection Control Guidelines. Second Printing February 1990.
Minimal Technical Standards, EEG/EMG. 1991-93.
College of Physicians and Surgeons of Ontario. Infection Control in the
Physician's Office. May 1995.
Health and Welfare Canada. Bloodborne pathogens in the health care
setting: risk for transmission. Canada Communicable Disease Report
1992; 18:177-184.
Royal College of Dental Surgeons of Ontario. Guidelines Respecting
Infection Control in the Dental Office, June 1995.
Rutala WA. APIC guidelines for selection and use of disinfectants. Am J
Infect Control 1990; 18: 99 -117.
Young GB. Minimal standards for electroencephalographic laboratories.
Can Med Ass J 1991; 144(7):865-67.

Index
A adult neurological disorders, head

Acquired Immune Deficiency injury 43
Syndrome (AIDS) 10 adult neurological disorders, herpes
adolescent neurological disorders (see simplex virus 44
adult neurological adult neurological disorders,
disorders) 41 myoclonus 43
adult neurological disorders, adult neurological disorders,
asymptomatic patients 44 neurodegenerative
adult neurological disorders, brain disorders 43, 52
death 23, 43 adult neurological disorders, non-
adult neurological disorders, convulsive epilepsy 41
classification 41 adult neurological disorders, seizure
adult neurological disorders, coma 43 surgery 42
adult neurological disorders, adult neurological disorders, stopping
convulsive status epilepsy 41 therapy 42
adult neurological disorders, adult neurological disorders, stupor 43
Creutzfeldt-Jakob disease 44 advisor 6, 13
adult neurological disorders, AIDS (see Acquired Immune
dementia 43 Deficiency Syndrome) 10
adult neurological disorders, ambulatory EEG 27, 55
diagnosis 41 ambulatory EEG, advantages 55
ambulatory EEG, definition 55
Index
ambulatory EEG, limitations 55 B

ambulatory EEG, recording 56 behavioural disorders 49
ambulatory EEG, restrictions 56 beveled disk 25
ambulatory EEG, staff bloodborne disease transmission 67
qualifications 56 blunt tip needles 9
ambulatory monitoring 29 body substance precautions 67, 68
ambulatory monitoring, electrodes 29 Boutros 53
ambulatory monitoring, infection brain activity 29
control 29 brain activity, death 43, 49
ambulatory monitoring, patient brain activity, infants 23, 49
preparation 30 brain activity, injury 46
ambulatory monitoring, recording brain activity, physiology 37
equipment 29 brain activity, tumour 45
ambulatory monitoring, recording breath-holding attacks 49
procedure 30 burns 7, 9
ambulatory monitoring, staff
qualifications 30 C
American Academy of Neurology Canadian Association of
(AAN) 5 Electroneurodiagnostic
American Academy of Neurology Technologists (CAET) 6
(headache, digital EEG) v Canadian Association of
American Clinical Neurophysiology Electroneurophysiology
Society 4 Technologists 31
American Clinical Neurophysiology Canadian Association of
Society (ACNS) v, 5 Electroneurophysiology
American EEG Society v Technologists (CAET) 29
American Electroencephalographic Canadian Board of Registration of
Society (AES) 25 Electroneurophysiological
American Electroencephalographic Technologists (CBRET) 5
Society Guidelines in Canadian Congress of Neurological
Electroencephalography, Sciences (CCNS) 5, 31
Evoked Potentials, and Canadian EEG Technologists
Polysomnography 7 (CAET) v
American Epilepsy Society (AES) 5 Canadian Society of Clinical
analgesic-dependent headaches 45 Neurophysiologists
anticonvulsant therapy 42 (CSCN) iii, v, 3
anxiety states 51 Canadian Standards Association
apnea 33, 47 (CSA) 9
Association of Ontario Neurologists v CBRET (see Canadian Board of
asymptomatic patients 44 Registration of
attention-deficit hyperactivity Electroneurophysiological
disorder 49 Technologists) 5
autistic behaviour 49 CD-ROM 8, 22, 27
cerebrovascular disease 45, 57
chronic fatigue syndrome 46

Index
Class I evidence 38 E
classifying medical instruments 69, 73 EEG Guideline Development Task
cleaning 10, 68, 69, 70, 71, 73, 75 Force i, ii, iv
cleaning electrode caps 10 EEG recordings 8, 10, 21, 31, 38, 39
clinical practice guidelines i, ii EEG recordings, comatose patients 23
clinical practice guidelines, purpose ii EEG recordings, digital EEG 22
Clinical Quality Improvement EEG recordings, documentation 23
Committee, development EEG recordings, electrical safety 22
guidelines iii EEG recordings, infection control 21
College of Physicians and Surgeons of EEG recordings, intensive care
Ontario, mission statement units 21
(inside front cover) 2 EEG recordings, neonatal 21
College of Physicians and Surgeons, EEG recordings, recording 23
quality assessments 19 EEG recordings, reporting
College of Physicians and Surgeons, requirements 24
role i EEG recordings, staff qualifications 23
coma 17, 43 EEG recordings, techniques 27
comatose infants 33 EEG recordings, transcripts 24
comatose patients 23, 43 EEG, amplifiers 26, 55
compact disk read-only-memory 8 EEG, applications 37
computed tomography 37 EEG, clinical indications iv, 37
contaminated liquids 11 EEG, definition iii
continuing medical education 5 EEG, guidelines 37, 38
Creutzfeldt-Jakob disease 10, 44, 69 EEG, laboratories iii
critical instruments 69 EEG, new equipment 7
CSA (see Canadian Standards EEG, referral survey 52
Association) 9 EEG, reporting 15, 16
EEG, standards iv
D EEG, storage 26
daytime sleepiness 46 electrical safety 9, 22
decontamination procedures 69, 75 electrode caps 10
degenerative disorders 43, 52 electrode caps, cleaning 10
delirium 52 electrode caps, patients with
dementia 11, 37, 43, 52 communicable diseases 10
depression 43, 51, 52, 53 electrode caps, prolonged use 11
developmental disorders 49 electrode placement 7, 10, 22
digital EEG v, 8, 9, 22, 32, 57 electrodes iii, 7, 9, 10, 11, 13, 16, 17, 21,
disinfection 68, 69, 70, 71, 73, 75 22, 29, 30, 31, 41, 42, 55, 59, 67,
disk electrodes 21, 69 68, 69, 71
displaying recordings 8 electrodes, single-use 9
dizziness 45 electroencephalogram ii, iii
documentation 13, 15, 23, 28 electroencephalogram, definition iii
double gloving 13 electroencephalographers i, ii, v, 3, 4, 5
electroencephalography ii, iii
environmental cleaning 68, 71

Index
epilepsy 37, 41 herpes simplex virus encephalitis 44,

epilepsy recordings, beveled disk 25 47
epilepsy recordings, EEG HIV infection 13
amplifiers 26 hospitals, general and psychiatric iii
epilepsy recordings, EEG recording 26
epilepsy recordings, electrodes, types I
used 25 Independent Health Facilities Act 15
epilepsy recordings, infection infants 31, 32, 33, 47
control 25 infection control 21, 25, 29, 31, 67
epilepsy recordings, pre-amplifier infection control, definition 67
location 26 infection control, disinfection 68, 69
epilepsy recordings, presurgical infection control, environmental
evaluation 27 cleaning 68, 71
epilepsy recordings, standards 27 infection control, equipment 68, 69
epilepsy recordings, storage 26 infection control, gloves 68, 70
epilepsy recordings, techniques 27 infection control, handling sharps 68,
epilepsy, adolescent 41 71
epilepsy, adult 41 infection control, handwashing 68, 69
epilepsy, classification 41 infection control, monitoring 71
epilepsy, convulsive status 41 infection control, occupational
epilepsy, diagnosis 41 exposure 71
epilepsy, genetic links 45 infection control, policy 13, 71
epilepsy, non-convulsive 41 infection control, practices 68
epilepsy, paediatric 48 infection control, precautions 67
epileptiform 41, 42, 45 infection control, skin preparation 68,
epileptiform activity 26, 43, 47, 48 71
equipment ii, iii, 4, 7, 9, 22, 29, 31, 69 infection control, staff training 68
equipment, manufacturers 9 infection control, sterilization 68, 69
extra-cerebral monitoring 33 infection control, strategy 68
informed consent 16, 39
F intensive EEG, definition 59
facility standards i intensive EEG, indications 59
facility standards, purpose ii intensive EEG, paediatric 59
facility, staffing 3 intensive EEG, video monitoring 56,
febrile seizures 47, 48 59
frequency filters 23 International Federation of Clinical
Neurophysiology (IFCN) v,
H 21
hallucinatory states 52 intracranial electrodes 26
handwashing 68, 69
L
head injury 43, 46
Laboratory Director 4
head trauma 46, 57
Laboratory Director, qualifications 4
headaches 37, 45, 46, 48
hepatitis B 13 Laboratory Director, responsibilities 4
learning disability 48

Index
legal records 15 neonates, EEG recordings, photic

liquid dishwashing detergent 10, 11 stimulation 33
locum tenens 4 neonates, EEG recordings,
qualifications 34
M neonates, EEG recordings,
magnetic resonance images 37 recording 32
medication toxicity 53 neonates, EEG recordings,
MEDLINE v reporting 34
Members’ Dialogue i, iv neonates, EEG recordings, response
metabolic encephalopathy 43 testing 33
Metri-Cide 10 neonates, EEG recordings, review
Metri-Zyme 11 procedures 32
migraine headaches 37, 45 neonates, EEG recordings, sleep 33
Minimal Standards Document 29 neurodegenerative disorders 43, 52
Minimal Standards EEG/EMG 31 Neuroelectrodiagnostic Technologists
Minimal Technical Standards EEG/ of Ontario (NETO) 6, 13
EMG 7 Neuroelectrophysiological
Mission Statement (inside front Technologists of Ontario iv
cover) 2 neuro-imaging 44, 45
myoclonic seizure 47 neurological disorders 41, 47, 51
myoclonus 43 non-critical medical instruments 69
N O
needle electrodes iii, 9, 13, 21, 25, 29, obsessive-compulsive disorder 53
31, 67, 68, 69 occupational exposure policy 68, 71
neonatal apnea 47 Ontario Medical Association iv, v
neonatal encephalopathy 47 Ontario Psychiatric Association iv, v
neonatal infections 47 optical disk 8
neonatal recordings 7, 32 organic etiology 52, 53
neonatal seizures 47
neonates 31 P
neonates, EEG recordings, paediatric neurological disorders 47
activation 33 paediatric neurological disorders, acute
neonates, EEG recordings, neonatal encephalopathy 47
electrodes 31 paediatric neurological disorders,
neonates, EEG recordings, attention-deficit hyperactivity
equipment 31 disorder 49
neonates, EEG recordings, extra- paediatric neurological disorders,
cerebral monitoring 33 autistic behaviour 49
neonates, EEG recordings, infection paediatric neurological disorders,
control 31 behavioural disorders 49
neonates, EEG recordings, length of paediatric neurological disorders, brain
recording 33 death 49
neonates, EEG recordings, patient paediatric neurological disorders,
preparation 32 breath-holding attacks 49

Index
paediatric neurological disorders, psychiatric disorders, obsessive-

degenerative disorders 49 compulsive disorder 53
paediatric neurological disorders, psychiatric disorders, organic
developmental disorders 49 etiology 52
paediatric neurological disorders, psychiatric disorders, partial
febrile seizures 47, 48 seizures 53
paediatric neurological disorders, psychiatric disorders, personality
headaches 48 disorder 53
paediatric neurological disorders, psychiatric disorders, referrals for
learning disability 48 EEG 52
paediatric neurological disorders, psychiatric disorders, role of EEG 51
neonatal infections 47 psychiatric disorders, schizophrenia 53
paediatric neurological disorders, psychiatric disorders, screening 53
neonatal seizures 47 psychiatric hospitals (see hospitals) iii,
paediatric neurological disorders, 51
subacute sclerosing psychiatrists 51, 52, 53
panencephalitis 48 Public Hospitals Act 15
paediatric neurological disorders,
substance abuse 49 Q
paroxysmal activity 37, 42 quality, assessments 19
partial seizures 41, 44, 53 quality, improvement i
patient assessment iv quality, improvement activities 19
patient discharge 39 quality, improvement program 19
patient preparation, adults 30 quality, improvement, goals 19
patient preparation, neonates and quality, management activities 20
infants 32 quality, management program 19
personality disorders 51, 52, 53 quantitative EEG 8, 57
photic stimulation 17, 33 quantitative EEG, advantages 57
playback systems 8 quantitative EEG, definition 57
policies and procedures 13 quantitative EEG, limitations 57
pre-amplifier location 26
precautions 67 R
premeasured elastic caps 10 record retention 16
presurgical evaluation 27 record storage 16
Provider Services Branch iii recording, digital 8
pseudoseizures 52, 59 recording, displaying 8
psychiatric disorders 51 recording, documentation 23
psychiatric disorders, delirium 52 recording, electrical safety 9
psychiatric disorders, depression 53 recording, electrode caps 10
psychiatric disorders, EEG research 51 recording, electrode placement 10
psychiatric disorders, hallucinatory recording, equipment 29
states 52 recording, length 7
psychiatric disorders, medication recording, needle electrodes 9
toxicity 53 recording, procedure 30
recording, retention 16

Index
recording, sampling rate 8 staff, continuing medical education 5,

recording, screen resolution 8 6
recording, techniques 7 staff, duties 29, 30
recording, telephone transmission 7 staff, qualifications 3, 5, 30
recording, topographic mapping 9 staff, qualifications after Jan. 1, 2001 3
records, contents 15 staff, training 6
referring physicians 5, 19, 20 sterilization 68, 69, 70, 71, 73, 75
Regulated Health Professions Act 15 stroke 44, 45
reporting 3, 4, 13, 17, 20, 24, 28, 30, 34 stupor 43
reports, contents 16 substance abuse 49, 52
requisition 15 surgery 42
requisition, legal records 15 survey iii, 52
requisition, records retention 16 syncope 45
requisition, storage 16
requisiton, informed consent 16 T
requisiton, timelines 18 Task Force, acknowledgements vi
response testing 33 Task Force, College’s role i
review procedures 32 Task Force, compensation i
risks, patient 16 Task Force, development process i
Royal College of Physicians and Task Force, external review process v
Surgeons of Canada 3, 4 Task Force, goals 5
Task Force, guidelines i
S Task Force, members iv
scalp lesions 7, 10, 11, 21 Task Force, members (see edition page
schizophrenia 51, 52, 53 opposite side of front book
screen resolution 8 title page) 2
screening procedures 53 Task Force, methodology v
sedation 13, 16, 33, 39 Task Force, objectives ii
sedation, adults 39 Task Force, principals ii
sedation, children 39 Task Force, principles i
seizure surgery 42 Task Force, subgroups iv
semi-critical instruments 69, 73 Task Force, survey iii
serum hepatitis 10 telephone transmission 7
sharps 68, 71 tension headaches 45
single-use needle electrodes 9 tic disorders 46
site reviews 19 tonic-clonic seizure 41, 42, 47
sixteen channel recordings 7 topographic mapping 9
skin preparation 68, 71 training 3, 4, 6, 30, 34, 68
sleep 33 transcripts 24
sleep disorders 56 tremors 46
sleep studies 52
spasms 45, 46, 48 U
spectral analysis 57 Universal Precautions 67, 68
sphenoidal electrodes 16, 26

Index
V
vertigo 45
video monitoring 56, 59
volatile vapours 21
W
waveform recording 8
whiplash 46
written consent 16

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Guidelines for Clinical Practice

& Facility Standards

Facilitated by the College of Physicians and Surgeons of Ontario

GOALS OF THE COLLEGE ACCOUNTABILITY AND THE COLLEGE

Facilitated by the College of Physicians and Surgeons of Ontario

Published and distributed by the College of Physicians and Surgeons of

Daniel J. Klass M D, FRCP (C)

Toll free (800) 268-7096

Volume 1 Facility Standards

Chapter 2 EEG Equipment and Recording Techniques

Guidelines for Clinical Practice and Facility Standards for Electroencephalography i

Chapter 4 EEG Requisition Records and Reports

Chapter 5 Quality Improvement

Chapter 6 Long Term EEG Recordings in Intensive Care

Chapter 7 Long-Term EEG Monitoring for Epilepsy

ii The College of Physicians and Surgeons of Ontario

Chapter 9 EEG Recordings in Neonates and Infants up to

Volume 2 Clinical Practice Guidelines

Chapter 11 Administering Sedation to Adults and Children

Chapter 13 Paediatric Neurological Disorders

iv The College of Physicians and Surgeons of Ontario

Chapter 14 Psychiatric Disorders

Chapter 15 Ambulatory EEG

Chapter 16 Quantitative EEG

Chapter 17 Intensive EEG/Video Monitoring for Epilepsy

Guidelines for Clinical Practice and Facility Standards for Electroencephalography v

Appendix II Classifying Medical Instruments

Appendix III Decontamination Procedures

vi The College of Physicians and Surgeons of Ontario

Role of the College of Physicians and Surgeons

The Task Force adhered to the following principles:

Purpose of Clinical Practice Guidelines

viii The College of Physicians and Surgeons of Ontario

In developing these clinical practice guidelines, our objective was to

Definition of Electroencephalography (EEG)

Guideline Development Process for

Guidelines for Clinical Practice and Facility Standards for Electroencephalography ix

x The College of Physicians and Surgeons of Ontario

External Review Process

Guidelines for Clinical Practice and Facility Standards for Electroencephalography xi

Dissemination and Implementation

Updating this Document

xii The College of Physicians and Surgeons of Ontario

Physicians Currently Practicing Electroencephalography

Physicians Entering Electroencephalography After January 1, 2000

Guidelines for Clinical Practice and Facility Standards for Electroencephalography 3

4 The College of Physicians and Surgeons of Ontario

Continuing Medical Education

Qualifications of Electroencephalography Technologists

Guidelines for Clinical Practice and Facility Standards for Electroencephalography 5

Technologists beginning to perform electroencephalographic services

Note: Entry into training occurs according to CBRET specifications.

Continuing Education for Technologists

Note: It is recommended that EEG technologists become members of the Neuroelectrodiagnostic

6 The College of Physicians and Surgeons of Ontario

EEG Equipment and Recording Techniques

Guidelines for Clinical Practice and Facility Standards for Electroencephalography 7

8 The College of Physicians and Surgeons of Ontario

Guidelines for Clinical Practice and Facility Standards for Electroencephalography 9

If the cap is used on a patient with a communicable disease, the cap is

Cleaning Electrode Caps or Similar Commercial

10 The College of Physicians and Surgeons of Ontario

Guidelines for Clinical Practice and Facility Standards for Electroencephalography 11

Developing Policies and Procedures