Design
A team of investigators with expertise in critical care EEG, neurocritical care, adult and pediatric neurology, and health information collaborated to develop the research question and study design. This systematic review will follow the guidelines set out in the Cochrane Handbook for Systematic Review and Meta-Analyses[14]. The protocol has been registered in PROSPERO and is undergoing review by the editorial team. The research methodology presented in the final manuscript will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines[15]. Deviations from the protocol will be recorded in the final report.
Information sources and search strategy
MEDLINE, EMBASE, Web of Science (WoS), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Central Register of Controlled Trials (CENTRAL) will be systematically searched from their inception date to January 2020. A review of the gray literature will be performed to identify unpublished or ongoing studies using Google Scholar, https://clinicaltrials.gov, and http://www.controlled-trials.com. This systematic review will also include a hand search of the past 10 years of published abstracts from relevant conference proceedings. Before submission for publication, the search will be rerun through each database to account for newly reported findings. Authors of included studies will be contacted up to 3 times to clarify any unclear or unavailable information as necessary.
With the collaboration of a health information specialist, the search strategy will be carefully developed to capture all studies of potential interest, using a combination of free text keywords and subject headings terms. A step-by-step breakdown of inclusions and exclusions will be provided in the final manuscript using the standard PRIMSA flow diagram. An example of our search strategy will be provided as a supplementary file with the final manuscript.
Eligibility criteria and study selection
We will apply the following eligibility criteria to identify studies for inclusion in this review: (1) randomized controlled trials, pre-post interventional studies, and observational studies including descriptive and cohort studies (2) examining adult or pediatric patients in whom EEG recording (including intermittent/short EEG, processed EEG (e.g., Bis, entropy, Sedline), video EEG, cEEG, and QEEG) was performed. (3) Implementation of EEG must occur in either the intensive care unit (ICU), emergency department (ED), or post-anesthetic care unit (PACU) setting, (4) with data analysis performed by a non-expert in EEG interpretation (e.g. bedside nurse, intensivist, ED physician, anesthetist, or trainee physician). (5) Studies must include a program of structured training in EEG interpretation. Cluster RCTs will not be included, since the unit of allocation of included studies must be the individual. Studies will be excluded if they (1) do not adequately describe the structure and content of training programs, (2) are applied to subjects with specialized knowledge of EEG (e.g. neurophysiologists, epileptologists), (3) or if they are conducted in a setting other than the ICU, ED, or PACU. Studies involving medical students, residents, and clinical fellows will be eligible for consideration as long as they meet the remainder of the inclusion criteria. Records will be screened and managed by two reviewers independently using Endnote, version 9.0 (Clarivate Analytics).
Two reviewers (ST, WA) will independently screen all material generated by the search algorithm to identify studies for inclusion. Each reviewer will be blinded to the others’ appraisal of the literature. Studies will initially be screened by title, keywords, and abstract to determine article eligibility. Articles passing the initial step will be reviewed by two reviewers in full, with articles selected based on eligibility criteria. As a further step, the reference list of each selected study will be scanned to identify additional studies for inclusion. In cases of ambiguity, authors of studies in question will be contacted for clarification of uncertain information, with their response rates tracked and reported in the final manuscript. No restrictions will be applied to language and foreign papers will be translated to English. Abstracts without a corresponding full-length manuscript will be considered if they present sufficient material on educational design, implementation, and outcomes. In cases of incomplete information, authors of abstracts will be contacted up to 3 times to obtain further details of the study; studies will be excluded in the event of non-response. In the event of discrepancies in the final study list generated by the two reviewers, a third reviewer will be consulted for arbitration. Reasons for exclusion of studies assessed in full will be presented in the final published manuscript.
Data collection
Two independent reviewers (ST, WA) will extract data from each study in the final list into a standardized pre-piloted data collection form. We will collect and report data on: (1) study design, including but not limited to study type, year of publication, inclusion and exclusion criteria, treatment setting (e.g., ICU, ER, or PACU), sources of funding, and conflicts of interest; (2) baseline patient characteristics including age, sex, comorbidities, and primary pathology (neurological (e.g., traumatic brain injury, subarachnoid hemorrhage, epilepsy) vs non-neurological (e.g., sepsis, acute respiratory distress syndrome (ARDS), trauma)); (3) indication for EEG; (4) type of medical or surgical treatment received, including use of mechanical ventilation or tracheostomy; (5) characteristics of the EEG educational program, including mode of instruction (e.g., self-guided, didactic, case-based); (6) duration of the training program, and whether follow-up sessions were organized; (7) methods for assessing trainee performance (e.g. written quiz, bedside interpretation of EEG recordings); (8) outcome of the intervention (e.g. improvement in EEG interpretation capabilities by the trainee); (9) and trainee feedback on the educational intervention (if reported). The initial data extraction form will be piloted on five included studies to ensure robustness, with subsequent modifications for thoroughness performed if necessary. A template of the data extraction form is appended in the supplementary file. Discrepancies in extracted data will be resolved in discussion between the two primary reviewers. Duplicated studies will be included only once in the final analysis, with the most comprehensive article being represented.
Assessment of methodological quality and risk of bias
If our search identifies a randomized controlled trial (RCT) deemed eligible for inclusion, its risk of bias will be evaluated by two independent reviewers with the Cochrane Collaboration’s risk of bias tool[14]. However, we anticipate the majority of studies to be descriptive studies and pre-post interventional studies. For the assessment of these studies, we will use the National Institute of Health (NIH) quality assessment tools[16]. NIH checklists will be adapted for each study design. Each checklist includes items for evaluating potential flaws in study methods or implementation, including sources of bias (e.g., patient selection, performance, attrition, and detection), confounding, study power, the strength of causality in the association between interventions and outcomes, and other factors. Quality reviewers may select "yes," "no," or "cannot determine/not reported/not applicable" in response to each item on the tool. Studies are assigned a quality rating of “good”, “fair”, or “poor” based on the aggregate total of “yes” responses. Summary reports on the quality of each represented study will be presented in tables in the final manuscript. The assessment of both randomized and non-randomized studies will be undertaken independently by two reviewers (ST, WA), with discrepancies resolved after joint article review and discussion.