1 - Implementing aEEG in a Level II NICU: Enhancing Neurologic Outcomes in a Community-Based Setting

Publication Number: 1000.1

Xianhan M. Fei, Stanford University School of Medicine, San Bruno, CA, United States; Jennifer Granger, Lucile Packard Children's Hospital Stanford, Redwood City, CA, United States; Nilima Ragavan, Stanford University School of Medicine, Portola Valley, CA, United States

Background: Video electroencephalography (vEEG) has been the gold standard in the NICU to identify seizures and predict neurological outcomes, but setup and interpretation require specialized expertise. Amplitude-integrated electroencephalography (aEEG) has emerged as a bedside tool to screen for abnormal background patterns in Level III and IV NICUs. However, few published studies describe the use of aEEG in community NICUs. Expanding access to aEEG in lower-acuity NICU settings may enable earlier detection of neurologic compromise, improve triage to higher-level centers, and reduce unnecessary transfers.

Objective: The primary aim for this study was to evaluate the implementation and outcomes of aEEG monitoring in our Level II NICU in the US, which sees approximately 1200 deliveries each year. In October 2022, aEEG was introduced after extensive didactic and hands-on training for nursing and physician staff as well as pre- and post-knowledge quizzes. Outcomes assessed included patient characteristics, aEEG patterns, and the influence of aEEG findings on transfer decisions and clinical management.

Design/Methods: We conducted a retrospective chart review of infants admitted to the Level II NICU between January 2023 and September 2025 who underwent bedside aEEG monitoring. Data collected included demographics, cord gases, aEEG indication, background patterns, Sarnat staging, seizure detection, and disposition. Descriptive statistics were used to summarize findings.

Results: During the study period, 12 infants (34-41 weeks) underwent aEEG in our unit. The most common indication was evaluation for possible seizures from suspected hypoxic-ischemic encephalopathy (HIE). Continuous normal voltage was observed in 11 infants; 1 had discontinuous or abnormal tracings. Electrographic seizures were detected in 2 infants, prompting transfer to a tertiary center. In contrast, aEEG confirmed normal activity in several infants with transient abnormal exams, allowing them to remain in the Level II NICU. No electrode-related complications occurred. All infants were discharged home with length of stay ranging 2-15 days. One family declined monitoring.

Conclusion(s): Institution of aEEG in our Level II NICU was impactful, supporting real-time decisions, facilitating timely consultation, and reducing unnecessary transfers. This study highlights the role of aEEG in bridging neurologic care across NICU levels. Future directions include surveying lower-acuity NICUs statewide and nationally to identify opportunities to expand neurocritical applications beyond tertiary centers.

aEEG Demonstrating Electrographic Seizures in a Term Infant With Suspected HIE
38w5d old infant with suspected HIE. aEEG demonstrated evolving high-amplitude rhythmic activity concerning for electrographic seizures, prompting transfer to a tertiary center for neurocritical care evaluation.

Patient Demographics and aEEG Outcomes
Demographics and clinical outcomes of infants receiving aEEG monitoring in a Level II NICU (N=12).

Summary of Clinical Measures
Clinical characteristics of infants monitored with aEEG in a Level II NICU (N=12). Some variables have been rounded to the nearest whole number to reflect clinical practice. *The "Age at Initiation" value for one infant admitted from the ER represented an outlier and was excluded from the analysis.