1. Current CDC guidelines recommend all staff wear surgical masks at all times while in clinical care areas or unable to maintain safe social distancing. Masks are typically being used for the entire shift unless they become soiled.
2. Current CDC guidelines also recommend all people (patients, family members, etc) wear face covering when not able to social distance.
3. Institutional policies should guide visitation, however, a maximum of 1 family member/caregiver should accompany patients for inpatient or outpatient procedures.
4. Most institutions are screening patients as well as staff for symptoms of infection each day using questionnaires and/or temperature screening.
5. CDC recommends N95 respirator, face shield or goggles, nonsterile gloves and gown for all COVID+/PUI (patients under investigation). If N95 respirator is not available, a surgical face mask is considered an appropriate alternative.  Data has shown that COVID 19 can survive up to 3 hours following aerosolizing procedures. https://www.nejm.org/doi/full/10.1056/NEJMc2004973
6. Inquire about COVID/ PUI status prior the procedure
   1. For PUI - Ask clinical team if the procedure can be postponed until test results are available.
7. CDC recommends conservation of PPE given short supply. Therefore, PPE may be reused in accordance with institutional protocols.
8. Activation procedures, especially hyperventilation, should not be performed on a COVID positive patients or PUI.
9. In patients with low concern for COVID, consider performing hyperventilation ONLY on patients where it is likely to have high diagnostic yield, for example, a patient with suspicion of absence or other primary generalized epilepsies.
10. Due to the concern that use of an air hose for application of collodion may constitute an aerosolizing procedure, in COVID+/PUI patients alternative approaches should be considered, such as using paste, taping down the electrodes and/or using head wrapping.
11. If technologists are not comfortable entering a patient room, encourage them to contact the EEG attending or NDT lab director for consultation
12. See the ASET Newsletter for additional useful information -- “Practical Considerations when Performing Neurodiagnostic Studies on Patients with COVID-19 and Other Highly Contagious Conditions” (https://www.tandfonline.com/doi/full/10.1080/21646821.2020.1756132)

NOTE: Policies and procedures are rapidly evolving and vary considerably between institutions and units. So, keep current with national, state and institutional updates.

Technologist Staffing

1. Many hospitals are experiencing staffing difficulties due to illness, lack of child care and self-quarantine directives. In addition, many NDT staff experience considerable anxiety about frequent and prolonged exposures to potentially infectious patients, and the impact that their illness could have on themselves and their family. Furthermore, many institutions were operating with minimal NDT staffing even prior to COVID 19 due to a national technologist shortage. Therefore, efforts should be made to limit technician exposure to potentially infectious patients and to provide resources for counseling.
2. Consider reduction of inpatient tech hours of coverage.
   1. Even if you currently have full staff, this could change very rapidly.
   2. To reduce burn out and ensure well-being of techs, consider eliminating overnight call backs and shorter daytime hours of operation.
3. For continuous EEGs/ prolonged studies: Limit number of different techs going into each patient room, particularly for COVID+/PUI.
4. Consider rapid application EEG with disposable, single use caps/ templates particularly if tech staffing is limited.

1. Use antiseptic wipe to clean all surfaces of the NDT equipment that has entered any COVID+/PUI patient room.
2. Consider clear plastic bags to cover EEG equipment in COVID+/PUI rooms
3. Consider keeping the machine outside the patient’s room (via long wiring). This minimizes equipment contamination and the amount of time the EEG tech needs to stay in the room.
4. See University of Maryland equipment cleaning protocol.
5. Disposable electrodes should be utilized whenever possible.
6. If disposable electrodes are not available, then consider soaking electrodes in a disinfecting solution for minimum of 1 minute. Although not specific for EEG electrodes, CDC recommends 70% isopropyl alcohol or dilute bleach solution for disinfection of solid surfaces.

Inpatient Testing

1. Inpatient EEG
   1. ACNS Consensus Statement on Continuous EEG (https://www.acns.org/UserFiles/file/Consensus_Statement_on_Continuous_EEG_in.1.pdf) provides recommendations regarding indications for continuous EEG n critically ill patients.
   2. Neurology or Neurophysiology attending should establish medical necessity and appropriate timing of all NDT studies on COVID +/PUI, in conjunction with the involved neurology team.
   3. If NDT staffing is limited then consider Neurology or Neurophysiology approval of ALL NDT procedures, regardless of COVID status
   4. Give careful consideration to whether EEGs ordered routine (~20 minute) should be converted to continuous EEG prior to the start of the procedure to reduce the chance of re-hooks and time in the room
   5. Activation procedures, especially hyperventilation, should not be performed on COVID positive patients or PUI.
   6. In patients with low concern for COVID, consider performing hyperventilation ONLY on patients where it is likely to have high diagnostic yield, for example, a patient with suspicion of absence or other primary generalized epilepsies.
   7. Due to the concern that use of an air hose for application of collodion may constitute an aerosolizing procedure, in COVID+/PUI patients alternative approaches should be considered, such as using paste, taping down the electrodes and/or using head wrapping.
   8. Please see the ASET Newsletter for additional useful information: --Practical Considerations When Performing Neurodiagnostic Studies on Patients with COVID-19 and Other Highly Virulent Diseases (https://www.tandfonline.com/doi/full/10.1080/21646821.2020.1756132).
2. Elective EEG monitoring/EMU
   1. In keeping with national directives to limit elective admissions to optimize bed availability for potential COVID-19 patients, beginning in March, 2020, many institutions cancelled elective EMU admissions. While many institutions have now resumed elective admissions and procedures, some are still forced to limit admissions. Consider alternatives to elective EEG monitoring (particularly for diagnostic evaluations)
      1. Acquire home video of events
      2. Assess index of suspicion and consider empiric treatment or Ambulatory EEG (see below)    
      3. Benefit may outweigh the risk of “semi elective” admission. For example- a patient with very frequent events and/or recent ED visits and the options above have been exhausted
   2. For patients presenting to the ED with frequent events, consider admission for non-elective video EEG monitoring to get rapid diagnosis and avoid subsequent ED visits (if resources allow), or consider home (ambulatory) video/EEG if readily and rapidly available.
   3. Considerations for re-opening elective EMU procedures
      1. CMS Statement: https://www.cms.gov/files/document/covid-flexibility-reopen-essential-non-covid-services.pdf
      2. Joint statement from AAN, ACNS, AES, ASET and NAEC
      3. Some specific items to consider:
         1. Safety of patients and staff
            1. Ensure adequate staffing levels – NDT staff may have been reassigned to other duties
            2. Consider institutional policies on visitors/family members
               1. Are family members essential for safety and diagnostic accuracy?
               2. Availability of masks for patients (if allowed to leave room) and visitors (when outside of patient room)
            3. Masking of patient during EEG hookup and electrode maintenance
         2. Availability of COVID testing, including POC testing
            1. Consider COVID testing for patients prior to admission, particularly in institutions and geographic regions with high COVID volumes
         3. Consider physical location of the EMU and proximity to COVID patient care areas
         4. Assess availability of ICU beds – for status epilepticus, post-operative care
         5. Ensure availability of rescue medications (IV benzodiazepines)
         6. Review logistics related to specific surgical procedures (e.g., SEEG, implants, etc.)
         7. Be prepared to postpone admissions if conditions change

Outpatient Testing

1. Ambulatory EEG (with video if available)
   1. As above, balance risk vs. benefit; Ambulatory EEG data may inform treatment to avoid ED visits
   2. Cleaning – as above, clean all surfaces with antiseptic wipes
   3. If possible, have the same tech perform hook up and take down
   4. If not already being done, consider having hookup/take down done at the outpatient lab and not the hospital to limit exposure and hospital traffic
   5. If using a third party for home video EEG, make sure they are following CDC guidelines related to COVID-19.
2. Outpatient “Routine” EEG
   1. Determine risk vs. benefit and relative urgency of outpatient NDT procedures
      1. Could information gained from a routine OP EEG potentially avoid ED visits or other morbidity?
      2. Will EEG results immediately alter the treatment plan?
3. Activation procedures, especially hyperventilation, should not be performed on a COVID positive patient or PUI. In patients with low concern for COVID, rather than routinely performing hyperventilation and photic stimulation on all patients, patients should be selected for high diagnostic yield. For example, a patient with concern/suspicion for absence epilepsy or other primary generalized epilepsies is most likely to benefit from hyperventilation.

Sleep Studies

1. Very good information available on AASM website: https://aasm.org/clinical-resources/covid-19-faq/
2. One specific area of concern is exposure of health-care workers by aerosolized particles during positive-airway ventilation. Many institutions are rescheduling or foregoing CPAP titration studies, instead relying on autotitration.
3. Home sleep testing remains an option. As above, balance risk vs. benefit and importance of cleaning all equipment between uses

EMG/NCS Studies

1. AANEM website for guidance on COVID19, including considerations for resumption of non-urgent electrodiagnostic studies: https://www.aanem.org/Practice/COVID-19-Guidance  

1. In areas with significant ongoing COVID-19 activity, it is prudent to work remotely whenever possible. This is especially true for educational and clinical conferences and interpretation of neurophysiologic studies. If resources and rules permit, a significant proportion of clinic visits may still be conducted in virtual environments.
2. Follow institutional and ACGME recommendations regarding scheduling of residents and fellows (www.acgme.org/covid-19).