EEG in the Intensive Care Setting —
Training activity: 7

Details

Interpret, annotate and produce a full factual report for patients with: Encephalopathic EEG pattern Periodic/rhythmic patterns and electrographic seisures Non-convulsive status epilepticus (NCSE)

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to accurately interpreting, annotating, and producing a full factual report for EEG recordings showing encephalopathic patterns, periodic/rhythmic patterns, or electrographic seizures/NCSE.
• Consider how the learning outcomes apply, specifically in relation to identifying features of abnormal EEGs within the intensive care setting, generating a factual report, and demonstrating effective communication through clear reporting.
• Discuss with your training officer to gain clarity of what is expected of you in relation to assessing the clinical urgency of these specific patterns and writing a comprehensive and clinically useful report that guides patient management.

What is your prior experience of this activity?

• Think about what you already know about interpreting abnormal EEG patterns and writing factual reports, particularly for critical findings.
• Consider possible challenges you might face during the activity, such as distinguishing between different periodic/rhythmic pattern types, assessing the clinical urgency of findings, or articulating complex electrographic seizure features clearly and concisely in a report, and think about how you might handle them.
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example:
  • When a specific pattern suggests non-convulsive status epilepticus (NCSE) and requires immediate escalation and senior pathological verification prior to reporting
  • If correlating the EEG pattern with the patient’s clinical history/medication leads to ambiguity in interpretation e.g., drug effect vs. genuine encephalopathy
• Acknowledge how you feel about undertaking the responsibility of interpreting and reporting on potentially critical EEG findings in an intensive care context.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as recognising and differentiating key abnormal EEG patterns e.g., generalised slowing from specific periodic patterns relevant to critically ill patients.
• Identify the specific insights you hope to gain into the clinical significance of different patterns in prognostication, effective annotation techniques, or strategies for writing reports that clearly and concisely guide clinical management.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of interpreting complex data, diagnosing conditions based on physiological recordings, or writing reports that require clinical judgment.

Identify important information you need to consider before embarking on the activity, such as reviewing standardized terminology for critical care EEG patterns (e.g., NCSE criteria), understanding the patient’s specific clinical history and medications, and reviewing examples of well-structured factual reports for these conditions.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst interpreting the EEG and annotating patterns?
• Are you encountering situations such as:
  • You encounter an EEG pattern (e.g., periodic/rhythmic or potentially NCSE) that is significantly more complex, ambiguous, or unusual than expected based on the clinical history?
  • The patient’s clinical presentation or medication history seems to contradict or not fully explain the severity or type of EEG abnormality observed?
  • You find artefacts (e.g., from equipment, patient movement) that are particularly challenging to distinguish from true cerebral activity, making interpretation difficult?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to data analysis or annotation density?
• Consider the steps you are taking in the moment, such as:
  • Spending more time reviewing specific montages or epochs
  • Looking for corroborating evidence
  • Pausing the interpretation process to consult relevant reference materials or a senior colleague.
• How are you feeling in that moment? For instance, are you finding it difficult to distinguish seizure from non-seizure activity? Is it affecting your confidence in producing a clear and factual report independently?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, were you able to reach a provisional interpretation and annotate the significant findings? Or are you needing support because the findings are highly ambiguous or suggest non-convulsive status epilepticus (NCSE), requiring senior pathological verification?
• What are you learning as a result of the unexpected development? For example, are you mastering a more effective technique for differentiating specific abnormal EEG patterns common in the ICU? Or gaining insight into recognising challenging artifacts during the reporting process?

On action

What happened?

• Begin by summarising the key steps you took when interpreting the EEG, annotating specific critical patterns, and drafting the full factual report for the critically ill patient.
• Consider specific events, actions, or interactions which felt important, such as how you systematically checked for electrographic seizures or non-convulsive status epilepticus (NCSE), or how you phrased the description of periodic/rhythmic patterns for the clinical team.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately consulting relevant reference materials or specialized criteria when encountering an EEG pattern that was significantly ambiguous (e.g., differentiating seizure from non-seizure activity).
• How did you feel during this experience, e.g., did you feel challenged but focused on consulting resources to ensure accuracy, or concerned about the potential misinterpretation of critical findings like NCSE?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding identifying and reporting abnormal ICU EEGs. What strengths did you demonstrate, e.g., systematic review of montages to distinguish technical artefacts from true cerebral activity?
• What skills and/or knowledge gaps were evident, e.g., difficulty distinguishing between specific types of periodic discharges or uncertainty regarding the influence of specific ICU drugs on the observed pattern?
• Compare this experience against previous engagement with similar activities – Has your practice improved in handling complex artefacts or producing a clear factual report for critical, time-sensitive findings?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding the need for senior input to verify a suspected finding of NCSE before proceeding with escalation and final reporting, and how you reacted to this.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to interpreting complex periodic patterns and ensuring factual reporting accuracy.
• What will you do differently next time you approach interpreting an ICU EEG, for instance, by proactively utilising quantitative EEG (if available) or consulting standardised terminology guidelines (e.g., for electrographic seizures) to reduce ambiguity in real-time?
• Do you need to practise any aspect of the activity further, such as reviewing case examples to strengthen your ability to differentiate between seizure and non-seizure periodic activity or applying standardised terminology for critical care patterns?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences interpreting complex ICU EEG patterns (e.g., distinguishing seizures from periodic discharges) or reporting critical findings, since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how an instance where a subsequent case required urgent decision-making regarding non-convulsive status epilepticus (NCSE) forced you to re-evaluate the rigour of pattern differentiation and the speed of escalation you applied during your first attempt at interpretation.
• Considering what you understand about pattern recognition, standardised terminology, and producing factual reports now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your interpretation methodology, annotation efficiency, or report structure based on further learning and experiences? For example, how you proactively integrated specific, standardised clinical terminology for periodic patterns to reduce ambiguity in reporting, demonstrating you have adapted improvements based on further learning.
• Has discussing challenging interpretations, the use of quantitative EEG, or the clinical urgency of critical patterns with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior clinical scientist about a misclassified periodic pattern that delayed appropriate treatment refined your understanding of the critical nature of accurate pattern differentiation and clear factual reporting.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent interpretation and reporting experiences, contributed to your overall confidence and competence in interpreting complex EEGs and generating factual reports, particularly in preparing for assessments like Case-Based Discussions (CBDs)? For example, how your accumulated ability in identifying and differentiating encephalopathic and periodic patterns now enables you to confidently discuss the diagnostic value and limitations of ICU EEG during a CBD assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to interpretation and reporting of critical findings? How does this evolved understanding help you better recognise when something is beyond your current scope of practice in terms of interpretation or requires escalation? For example, how your evolved approach means you now routinely seek advice from the senior reporting scientist or medical consultant immediately when a finding is ambiguous or suggests highly urgent pathology like NCSE, ensuring appropriate clinical context and safety.
• Looking holistically at your training journey, how has this initial interpretation and reporting experience, revisited with your current perspective, contributed to your development in identifying features, generating factual reports, and communicating effectively? For example, how this foundational experience in interpreting core critical care patterns supports your ability to successfully appraise the evidence base for continuous EEG use later in the module.

Relevant learning outcomes

#	Outcome
# 1	Outcome Identify features of normal and abnormal adult and paediatric EEGs within the intensive care setting.
# 4	Outcome Demonstrate effective and compassionate communication skills with all stakeholders including patients and the multidisciplinary team.
# 5	Outcome Generate a range of factual reports on a range of conditions.