Neurodiagnostic specialists require clinical knowledge and responsibility beyond what basic technologists can be expected to provide (Table 1). It is important to emphasize that the role of neurodiagnostic specialists is not to replace the ICU EEG-trained physician neurophysiologist but rather to support and work under their direct supervision for the purpose of expanding capacity and improving efficiency. As opposed to neurodiagnostic technologists, neurodiagnostic specialists may not be located at the same physical location as the patients undergoing EEG monitoring but in a centralized location either elsewhere in the facility or remotely, particularly in programs where multiple hospitals are being monitored by one integrated staff. In addition to monitoring patients in “real time” to identify and respond to critical changes, they also might prepare descriptive EEG reports, which, the neurophysiology physician will review for final interpretation and clinical correlation. Typical staff-to-patient ratios vary but with an average maximum of six patients assigned to each specialist in order to ensure quality of care.

The neurodiagnostic specialist must possess high levels of knowledge in specific areas. While senior level EEG technologists have been serving in similar roles for many years, only recently has there been progress toward formalization of this role across the field of EEG monitoring. Knowledge expectations are not simply EEG pattern recognition but a comprehensive understanding of the impact of any significant EEG change on the patient’s overall clinical care. For example, a neurodiagnostic specialist would not only be expected to recognize electrographic seizures but also identify changes in background activity and how those changes are impacted by medications and the overall clinical status of the patient. An additional skill that is vital to the neurodiagnostic specialist is the ability to communicate critical EEG changes to the appropriate team in a timely and efficient manner.

Neurodiagnostic specialists should have at least 3 years of EEG experience including exposure to ICU EEG monitoring. EEG registry is required and Certification in Long Term Monitoring (CLTM; from ABRET) is recommended. Specific training programs have been employed by some centers in order to provide appropriate education to technologists wishing to pursue a career as a neurodiagnostic specialist. Specific content areas in the training should include neuroimaging, neuropharmacology, and a basic clinical understanding of the common disease entities encountered in critical care units. Competency in the use of ACNS Standard Critical Care EEG terminology is also crucial [8]. Structurally, these programs include a combination of formal didactics, clinical teaching, and practical experience.

Non-EEG procedural staff include those who typically have their primary function in some other clinical role, such as nursing care, but who have received limited, targeted training to function as ancillary staff. Some care models include use of nursing staff to initiate EEG recordings “after hours” [9]. This is usually accomplished with the aid of electrode templates or EEG caps to guide electrode placement or limited recording montages such as a hairline recording. The increased use of qEEG measures has made bedside monitoring for identification of significant EEG changes including seizures feasible for non-EEG-trained staff. Neurocritical care nursing staff are ideally suited to train in pattern recognition of qEEG trends. Studies have demonstrated that with minimal training, critical care personnel (including attendings, fellows, and critical care nurses) are able to detect seizures using qEEG. In one study there was little difference in the sensitivity of seizure detection between neurophysiology fellows, critical care nurses, and physician attendings [10].

Lab assistants, or non-EEG-trained clinical staff, can help free up more highly trained EEG staff to focus on areas where their skills and knowledge are maximized. Lab assistants can help with gathering and stocking supplies, cleaning of equipment, and removal of electrodes. A safety measure taken in some institutions is to have a non-EEG staff monitor patient video in real time. It is important to be aware that staff performing this type of cEEG “monitoring” are watching video only and therefore can only detect obvious clinical seizures and events. While such non-EEG-trained patient monitors can have great utility in settings such as the epilepsy monitoring unit, it must be clear that there are certain limitations of employing non-EEG monitoring staff in the ICU setting given the majority of electrographic seizures in this patient population are without clinical correlate, and there are a variety of involuntary, non-seizure-related movements that could be mistaken for ictal events. As long as these considerations and limitations are well understood and communicated, non-EEG video monitoring staff can be very beneficial.

Administrative support will vary depending on the size of the program. Tasks can include billing, productivity tracking, patient appointments and communication, as well as staff scheduling, although not all of these tasks are necessarily accomplished by the same person. While the same administrative staff usually supports the entire EEG and epilepsy monitoring programs, it is important to factor in the additional workload represented by initiation or growth of ICU EEG monitoring.

The neurophysiology technical director serves a key function in bridging the gap between the priorities of the clinical team and objectives of hospital administration, which are not always congruent. The medical director provides a leadership role within the ICU EEG team and ensures that facility policies and procedures are in compliance with current medical standards. While managing day-to-day operations and logistics is essential, the neurophysiology director’s most important role is ensuring long-term goals are being met including program growth and development. This includes staying up to date with the latest information within the field and incorporating new technologies.