Skin Safety During EEG Procedures

ASET Position Statement

 

Skin Safety During EEG Procedures – A Guideline to Improving Outcome

 

The ASET Standards & Practice, Skin Safety Task Force was charged with developing best practices to protect the skin integrity of patients undergoing EEG procedures. 

 

An extensive literature search was conducted (see attached bibliography), as well as a review of the American Clinical Neurophysiological Society (ACNS) and the International Federation of Clinical Neurophysiology (IFCN) guidelines, to determine recommendations for skin safety. A survey, posted on the ASET website, soliciting input on this subject with emphasis on patient population (adult/child), technique and products (including electrodes), and length of recording time was conducted.

 

The committee concludes that products and electrodes have less impact on skin safety than the technique in which they are used. One should review the manufacturers’ “recommended use” of the products used for skin preparation and electrode application. 

 

A better understanding of how skin responds related to hydration, air temperature, changing medical condition and external pressure will help guide technique and improve skin safety. Additional skin safety considerations should be employed for neonatal, pediatric, and geriatric populations due to the nature of their thin, delicate skin. 

 

The following suggested techniques are for consideration:

 

1. Skin Preparation:

2. Electrodes:

3. Electrode Application:

4. Applied Electrode Impedance:

5. Skin Safety Checks:

The Skin Safety Task Force collected data, which strongly discourages the following techniques: 

The Skin Safety Task Force recommends the following: 

REFERENCES 

 

  1. Berlin F, Carlile JA, de Burgo MI, Rochon A, Wagner EE, Sellers MC, Worrell AR, Andal EL, Woods LR. Technical Tips: Electrode application and preventing skin techniques. Am J Electroneurodiagnostic Technol. 2011 Sep;51(3):206–19.
  2. Best Practices for Prevention of Medical Device-Related Pressure Ulcers in Pediatric Populations. National Pressure Ulcer Advisory Panel (NPUAP). 2013. Accessed July 13, 2014.
  3. Braden Scale for Preventing Sore Risk. Prevention Plus. 1988. Accessed July 13, 2015 https://en.wikipedia.org/wiki/Braden_Scale_for_Predicting_Pressure_Ulcer_Risk.
  4. Crawford, J. F.L.E.S.H. scale. University of Florida Health Neurodiagnostics Laboratory 2013. 
  5. Curley MA, Razmus IS, Roberts KE, Wypij D. Predicting pressure ulcer risk in pediatric patients: the Braden Q Scale. Nurs Res. 2003 Jan-Feb;52(1):22–33.
  6. De Weerd AW, Despland PA, Plouin P. Neonatal EEG: The International Federation Clinical Neurophysiology. Electroencephalogr Clin Neurophysiol Suppl. 1999; 52:149–57.
  7. Ebner A, Sciarretta G, Epstein CM, Nuwer M. EEG Instrumentation: The International Federation Clinical Neurophysiology. Electroencephalogr Clin Neurophysiol Suppl. 1999; 52:7–10.
  8. Falco C, Sebastiano F, Cacciola L, Orabona F, Ponticelli R, Stirpe P, Di Gennaro G. Scalp electrode placement by EC2 adhesive paste in long term video EEG monitoring.J Clin Neurophysiol. 2005 Aug;116(8):1771–3.
  9. Ferree TC, Luu P, Russell GS, Tucker DM. Scalp electrode interface, impedance, infection risk, and EEG data quality. J Clin Neurophysiol. 2001 Mar;112(3):536–44.
  10. Garcia-Fernandez FP, Pancorbo-Hidalgo PL, Agreda JJ. Predictive capacity of risk assessment scales and clinical judgment for pressure ulcers: a meta-analysis. J Wound Ostomy Continence Nurs. 2014 Jan-Feb;41(1):24–34. 
  11. Guideline One: Minimum Technical Requirements for Performing Clinical Electroencephalography. American Clinical Neurophysiology Society. Neurodiagn J. 2016 Dec:56(4).
  12. Guideline Twelve: Guidelines for Long-Term Monitoring for Epilepsy. American Clinical Neurophysiology Society. Am J Electroneurodiagnostic Technol. 2008 Dec:48(4):265–86.
  13. Gutierrez-Colina A, Topjian A, Dlugos D, Abend N. Electroencephalogram monitoring in critically ill children: indications and strategies. Pediatr Neurol. 2012 Mar;46(3):158–61.
  14. Ives JR. New Chronic EEG Electrode for Critical /Intensive Care Unit Monitoring. J Clin Neurophysiol. 2005 Apr;22(2):119–23.
  15. Jarrar R, Buchhalter J, Williams K, McKay M, Luketich C. Technical Tips: Electrode Safety in Pediatric Prolonged EEG Recordings. Am J Electroneurodiagnostic Technol. 2011 Jun;51(2):114–7.
  16. Joellan M, Morton W. Preventing skin breakdown in EEG patients: best practices techniques. J Pediatr Nurs. 2014 Sep-Oct;29(5):478–80.
  17. Jordan KG. Continuous EEG monitoring in the Neuroscience Intensive Care Unit and Emergency Department. J Clin Neurophysiol. 1999 Jan;16(1):14–39.
  18. Kiss EA, Heiler M. Pediatric skin integrity practice guideline for institutional use: a quality improvement project. J Pediatr Nurs. 2014 Jul-Aug;29(4):362–7.
  19. Kwon JH, Olsen MA, Dubberke ER. The morbidity, mortality, and costs associated with Clostridium difficile infection. Infect Dis Clin North Am. 2015 Mar;29(1):123–4.
  20. Lau RR, Powell MK, Terry C, Jahnke D. Neurotelemetry electrode application techniques compared. Am J Electroneurodiagnostic Technol. 2011 Sep;51(3):165–82.
  21. Lyder CH, Ayello EA. Pressure Ulcers: A Patient Safety Issue. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 12. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2650/.
  22. Magnan MA, Maklebust J. The nursing process and pressure ulcer prevention: making the connection. Adv Skin Wound Care. 2009 Feb;22(2):83–92.
  23. McNichol L, Lund C, Rosen T, Gray M. Medical adhesives and patient safety: state of the science. Consensus statements for the assessment, prevention, and treatment of adhesive-related skin injuries. J Wound Ostomy Continence Nurs. 2013 Jul-Aug;40(4): 365–80.
  24. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (2014). Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Cambridge Media: Perth, Australia.
  25. Noonan C, Quigley S, Curley MA. Using the Braden Q scale to predict pressure ulcer risk in pediatric patients. J Pediatr Nurs. 2011 Dec;26(6):566–75.
  26. Nuwer MR, Comi G, Emerson R, Fuglsang-Frederiksen A, Guerit JM, Hinrichs H, Ikeda A, Luccas FJ, Rappelsberger P. IFCN standards for digital recording of clinical EEG: The International Federation Clinical Neurophysiology. Electroencephalogr Clin Neurophysiol Suppl. 1999; 52:11–4.
  27. Oster CD. Proper skin prep helps ensure ECG trace quality. 3M Health Care. 2005. Accessed October 15, 2014.
  28. Palfreyman, SJ. Stone, PW. A systematic review of economic evaluations assessing interventions aimed at preventing or treating pressure ulcers. Int J Nurs Stud. 2015 Mar;52(3):769–88.
  29. Preventing and caring for pressure ulcers for nursing assistants and family caregivers. StopPain.org. Accessed October 15, 2014.
  30. Sanchez SM, Carpenter J, Chapman KE, Dlugos DJ, Gallentine WB, Giza CC, Goldstein JL, Hahn CD, Kessler SK, Loddenkemper T, Riviello JJ Jr., Abend NS, Pediatric Critical Care EEG Group. Pediatric ICU EEG monitoring: current resources and practice in the United States and Canada. J Clin Neurophysiol. 2013 Apr;30(2):156–60.
  31. Sanders JE, Goldstein BS, Leotta DF. Skin response to mechanical stress: adaptation rather than breakdown- a review of the literature. J Rehabil Res Dev. 1995 Oct;32(3):214–26.
  32. Shellhaas RA, Chang T, Tsuchida T, Scher MS, Riviello JJ, Abend NS, Nguyen S, Wusthoff CJ, Clancy RR. The American Clinical Neurophysiology Society’s Guideline on Continuous Electroencephalography Monitoring in Neonates. J Clin Neurophysiol. Dec;28(6) 611–7.
  33. Stansby G, Avital L, Jones K, Marsden G, Guideline Development Group. Prevention and management of pressure ulcers in primary and secondary care: summary of NICE guidance. BMJ. 2014 Apr;23:348:g2592.
  34. Stjerna S, Alatalo P, Maki J, Vanhatalo S. Evaluation of an easy, standardized and clinically practical method (SurePrep) for the preparation of electrode-skin contact in neurophysiological recordings. Physiol Meas. 2010 Jul;31(7):889–901.
  35. Tescher AN, Branda ME, Byrne TJ, Naessens JM. All at-risk patients are not created equal: analysis of Braden pressure ulcer risk scores to identify specific risks. J Wound Ostomy Continence Nurs. 2012 May-Jun;39(3):282–91.
  36. Thomas DR. Does Pressure Cause Pressure Ulcers? An Inquiry into the etiology of pressure ulcers. J Am Med Dir Assoc. 2010 Jul;11(6):397–405.
  37. Young GB, Ives JR, Chapman MG, Mirsattari SM. A comparison of subdermal wire electrodes with collodian applied disk electrodes in long-term EEG recordings in ICU. J Clin Neurophysiol. 2006 Jun;117(6):1376–9.
  38. Young GB, Campbell VC. EEG monitoring in the Intensive Care Unit: Pitfalls and Caveats. J Clin Neurophysiol. 1999 Jan;16(1):40–5.

-- Approved by the ASET Board of Trustees, November 16, 2016 

Skin Safety During EEG Procedures Video