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:
- Start with a clean skin surface.
- Use a cotton swab, preferably with a flexible stick, to apply the skin preparing product. Do not use the tip of the swab but the side of the cotton tip end to prepare the skin surface.
- When using preparing solution with a cotton-tipped applicator, apply the solution using light, quick strokes in one direction only. Avoid rubbing the solution on the skin back and forth in two directions, which can cause friction of the skin and an uncomfortable, burning sensation for the patient.
- Very thin, delicate skin may tolerate the preparation more safely by using clean gauze wrapped around the fore finger with the skin preparing agent and gently massaging the marked area.
- Wipe skin preparing solution off after preparation of the area. This will eliminate irritating material between the electrodes and the skin.
- Consideration of disposable electrodes should be evaluated for use on the critically ill patients.
- If using reusable electrodes be sure that policies for cleaning are adhered to and infectious disease policies address the use of reusable electrodes on patients in isolation.
- Scott NK. Infection prevention: 2013 review and update for neurodiagnostic technologists. Neurodiagn J. 2013 Dec;53(4):271–88.
- A flat rimmed electrode exerts less pressure on the skin.
- Thinner, less heavy electrode wire/cable choices will reduce pressure on the electrode and skin underneath.
- Caution should be taken with electrode metal choice when setting up neonates who are under heat lamps as there have been reports of some metals heating up under heat lamp exposure. It has been noted that the temperature of gold-plated electrodes seems to remain constant in comparison to other metals. Further investigation is encouraged.
3. Electrode Application:
- Fill the head of the electrode with a conductive medium. An ample amount of the conductive medium should be used.
- Float the conductive filled electrode on the prepared area. Pressing the electrode metal firmly on the skin should be avoided.
- Cushion the electrode hub and tail with soft cotton or gauze on all exposed skin surfaces (FP1/2, F7/8, A1/2 and any additional low/extra temporal skin surface electrodes).
- Cover the electrode to secure. The medium for covering and securing the electrode should be assessed. Research has not demonstrated whether Collodion or other medical adhesives reduce or increase skin breakdown. The facility should determine which works better for their patient population.
- If using collodion-applied electrodes with a thin conductive agent, caution should be taken when filling the electrode cup. A blunt needle tip can easily over-abrade the skin causing injury to the skin surface.
- If wrapping the head, stretchable, breathable, gauze should be considered. You should be able to place two fingers easily under the head wrap. When securing the wrap, do not tape the wrap over the electrode cup, electrode shaft, and tail. An open tubular retainer net dressing allows access to electrodes, visibility of the skin and air flow to aid in skin health. Tubular net dressing works best when a quarter size hole is cut on one side about 2 inches from the end. The net dressing should then be placed over the head prior to electrode application and pulled upwards to cover the head after the electrodes are applied.
- Patients who are unable or have minimal movement of their head and neck (ICU, neonates, and physically challenged patients) should have a cushion placed under the head/neck to relieve the pressure of the electrodes. Silicone/gel packs are helpful in relieving pressure. Nursing/wound care at your facility should be available for recommendation and facilitation of such an apparatus.
4. Applied Electrode Impedance:
- In accordance with the recently revised ACNS guidelines, it is the recommendation that impedances be balanced and maintained up to 10 kilo ohm for extended EEG recordings to help maintain skin integrity.
5. Skin Safety Checks:
- Laboratories should establish a tracking system to ensure skin safety. Consideration regarding impedance (initial and subsequent) values, frequency of electrode site examination, clear delineation of roles and responsibilities of each team member for daily skin integrity check(s) (nursing, wound care specialists, ND technologist) should be established.
- Any evidence of skin change indicates the electrode site should be cleaned and the electrode moved away from the original site. Adjust homologous areas when necessary to maintain symmetry during recording and document per facility policy.
The Skin Safety Task Force collected data, which strongly discourages the following techniques:
- Non-breathable tape
- Tight head wraps
- Prolonged recordings, over 48 hours, with no skin integrity checks
- Blunt-tipped needles to reduce applied electrode impedance
The Skin Safety Task Force recommends the following:
- Offload the head with EEG leads in place – consider use of a pressure redistribution device.
- Develop a Protocol to include documentation for frequency of skin checks with electrodes, i.e., every 12 or 24 hours, minimal number of electrodes to be checked and designate head region.
- A Statement regarding collaborating with bedside nursing and wound care nurses should be included.
- For critical care LTM patients, consider MRI/CT conditional/compatible electrodes. This will avoid removing and reapplying frequency due to need for imaging purposes. Approval of your Radiology department should be obtained before investing in MRI/CT compatible electrodes.
- 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.
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- 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.
- Crawford, J. F.L.E.S.H. scale. University of Florida Health Neurodiagnostics Laboratory 2013.
- 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.
- De Weerd AW, Despland PA, Plouin P. Neonatal EEG: The International Federation Clinical Neurophysiology. Electroencephalogr Clin Neurophysiol Suppl. 1999; 52:149–57.
- Ebner A, Sciarretta G, Epstein CM, Nuwer M. EEG Instrumentation: The International Federation Clinical Neurophysiology. Electroencephalogr Clin Neurophysiol Suppl. 1999; 52:7–10.
- 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.
- 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.
- 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.
- Guideline One: Minimum Technical Requirements for Performing Clinical Electroencephalography. American Clinical Neurophysiology Society. Neurodiagn J. 2016 Dec:56(4).
- Guideline Twelve: Guidelines for Long-Term Monitoring for Epilepsy. American Clinical Neurophysiology Society. Am J Electroneurodiagnostic Technol. 2008 Dec:48(4):265–86.
- 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.
- Ives JR. New Chronic EEG Electrode for Critical /Intensive Care Unit Monitoring. J Clin Neurophysiol. 2005 Apr;22(2):119–23.
- 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.
- Joellan M, Morton W. Preventing skin breakdown in EEG patients: best practices techniques. J Pediatr Nurs. 2014 Sep-Oct;29(5):478–80.
- Jordan KG. Continuous EEG monitoring in the Neuroscience Intensive Care Unit and Emergency Department. J Clin Neurophysiol. 1999 Jan;16(1):14–39.
- 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.
- 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.
- Lau RR, Powell MK, Terry C, Jahnke D. Neurotelemetry electrode application techniques compared. Am J Electroneurodiagnostic Technol. 2011 Sep;51(3):165–82.
- 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/.
- Magnan MA, Maklebust J. The nursing process and pressure ulcer prevention: making the connection. Adv Skin Wound Care. 2009 Feb;22(2):83–92.
- 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.
- 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.
- 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.
- 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.
- Oster CD. Proper skin prep helps ensure ECG trace quality. 3M Health Care. 2005. Accessed October 15, 2014.
- 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.
- Preventing and caring for pressure ulcers for nursing assistants and family caregivers. StopPain.org. Accessed October 15, 2014.
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- 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.
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-- Approved by the ASET Board of Trustees, November 16, 2016