A Question About ‘Quality’ Neuromonitoring

As 2014 comes to a close, I’m starting to look ahead to 2015 and plan topics that I’d like to cover on this blog. One such topic, which I think will cause quite a stir, has to do with quality. In my opinion, the field of neuromonitoring has been watered-down, pulverized to the point where it is hardly recognizable compared to what it once was. Whereas neuromonitoring was once provided on a one-to-one patient-to-neurophysiologist basis, with top-tier neurophysiologists performing neuromonitoring in the operative suite, today the landscape is much different.

Most companies out there seem to provide a service that they don’t even understand. They don’t even know where to begin with educating their employees about neuromonitoring, and yet they seem content to provide the service, as long as their “techs” can connect to an online neurologist and receive instructions from internet chat rooms. Neurologists, many of whom have little or no actual training in neuromonitoring, hang out in the chat rooms “supervising and interpreting” data for many patients simultaneously, often from hundreds or thousands of miles away. Surgeons are so used to “bad” neuromonitoring these days, that many tend to place little value on the data.

Despite these shortcomings, the demand for neuromonitoring is really quite high; however, perhaps because of these shortcomings, insurance companies are refusing to reimburse for neuromonitoring and hospitals want the service for next to nothing. This actually seems to feed the cycle as lower reimbursements force companies to find the cheapest possible way to provide a neuromonitoring service. In this scenario, we really can’t afford to have the best neurophysiologists take care of patients, and certainly not in a one-to-one model. Everyone would go bankrupt. Interestingly, as prices for neuromonitoring services have recently bottomed-out, hospitals are starting to talk about quality again. They want the highest quality at the lowest price. Who doesn’t, right?

So, as I start to think about my future posts on the blog, I am certain that quality is a topic that must be covered. 

I want your help, though. Think about this question:

What constitutes quality in neuromonitoring? 

From the perspective of a company, hospital, patient, surgeon, neurophysiologist,.. What constitutes quality neuromonitoring? Tell me your thoughts. Leave a comment below.

Me? I think I know the answers, meaning that I know good neurophysiology when I see it. So, I feel that I could answer the question from the perspective of a hospital, surgeon, anesthesiologist, patient and neurophysiologist. I want to hear your thoughts, though. Tell me what you think.

Cheers and happy holidays!

15 thoughts on “A Question About ‘Quality’ Neuromonitoring

  • Reply Kristina Port December 18, 2014 at 07:33

    One could look retrospectively or prospectively regarding the issue of quality. Retrospective studies are the easiest to ascertain given review of outcomes from data. It would be helpful for those wishing to post comments on what are the IOM quality indicators?

    Some components could include adherence to ACNS Guidelines, credentialing criterion, JCO accreditation, better business bureau complaints, Press Ganey Patient Surveys, etc.

    Surgeon education regarding cost benefit or IOM modality appropriateness for case monitoring selection comes to mind.

    I could expound, yet would like to review other comment posts, and hopefully foster dialogue that you include in your query Richard regarding the current status of roles played by technologists, neurophysiologists, neurologists, audiologists, chiropractors, surgeons, and hospital administration. All components are important.

    Off topic, my recommendation would be inclusive of SAFETY. Have equipment manufacturers get rid of cables to peripheral stim, pods, or head boxes, and have subdermal needles that utilize retractable subdermal needle shields to avoid needle sticks. Now that WOULD be helpful.

    • Reply Richard Vogel December 19, 2014 at 19:29

      Hi Kristina, Thanks for taking the time to comment. All good points. You may have given me ideas for other topics to cover in the future, too. Happy holidays, Rich

  • Reply Richard Slepian December 18, 2014 at 11:47

    While knowing how to run the various diagnostics and understanding the output is obviously important and where most training is concentrated, knowledge about other peri-operative activities/functions/personnel/equipment setup, etc. is also key to quality monitoring. A neurotechnologist (NT) must have knowledge of sterile technique, sterile field, surgical procedures, surgical instruments, the role of other OR personnel is also very important for quality monitoring. It is these other peri-operative areas where training is lacking. The following are several areas that ORIMtec concentrated their training on and a couple of sentences as to the importance of each.

    OPERATING ROOM (OR) PROTOCOL – The OR is a hostile environment for those with minimal experience. There are numerous personnel performing various tasks during setup and during surgery. It is important that the NT is aware of each team member’s function and how to work with each individual to help maintain a smooth running, cohesive OR.

    STERILE TECHNIQUE – A common problem in the OR is sterile field contamination. An experienced neurotechnologist’s knowledge of sterile technique will minimize the possibility of sterile field contamination.

    OPERATING TABLE SELECTION AND SETUP – May save valuable time for the surgeon by noticing if the proper OR table has been selected. Each surgeon has his/her own OR table preference. A well-trained NT in tune to the preference of each surgeon can help guide the OR staff when they are in doubt.

    STRATEGIC LOCATION OF THE NEUROTECHNOLOGIST STATION – It is important for the NT to set up their station proximate to both surgeon and the anesthesiologist so that they can observe the surgical instruments being used and anesthetic concentrations. In addition, it is critical to be positioned away from electrical interference.

    ANESTHETIC VARIATIONS – Knowledge of how anesthetic variations affect the quality of recordings is critical.

    SURGICAL PATHOLOGY AND ANATOMY – Knowledge of surgical pathology and anatomy enables the neurotechnologist to properly prepare the patient for monitoring before surgery begins. Once the procedure is under way it is difficult and sometimes impossible to add additional electrodes.

    BASIC UNDERSTANDING OF X-RAY/CT/MRI IMAGES – Basic understanding of X-ray/CT/MRI images helps the NT understand the surgical pathology and anatomy for electrode placement during patient preparation.

    SURGICAL INSTRUMENTS – The NT must know the surgical instruments so that he or she will be aware of what the surgeon is doing by the instrument in use.

    SURGICAL PROCEDURES – Thorough knowledge of the surgical procedure enables the NT to monitor the appropriate neural structure with the appropriate modality at any given time.

    INTERNAL FIXATION DEVICES – Thorough understanding of how an internal fixation device is used indicates to the NT what procedure will be performed, enabling them to properly prepare and monitor a specific structure with the appropriate modality.

    MONITORING MODALITIES – There are numerous modalities specific to each surgical procedure. The NT must be capable of incorporating the appropriate modality at any time.

    CORRELATION OF MODALITIES TO SURGICAL PROCEDURE – Knowing what modality to incorporate at any given time enhances the chance of identifying a neurological deficit before it is detrimental to the patient.

    COMMUNICATE WITH SURGEON AND ANESTHESIOLOGIST – All of the above knowledge is without value unless the NT is capable of communicating with the surgeon and anesthesiologist in an informative and prompt manner.

    These are many of the areas we concentrated our training. Possessing CNIM was a starting point.

    Hope this helps going forward.

    • Reply Richard Vogel December 19, 2014 at 19:27

      Hi Richard, these are all excellent points. Thank you for taking the time to write. I’ll likely include them when I actually write my post(s) on quality. All the best, Rich

  • Reply Robbie Allen December 19, 2014 at 15:47

    I applaud your effort to comment on this topic! I would argue that your historical and current perspective on the level (and ostensibly the quality) of ionm today and in the past is rather severely colored by the geographic region and specific groups you have worked for. Nationally and globally my experience on balance has seen the level of care and quality of providers rise steadily over the last 25 years in a steady and meaningful way.

    On to the issue of quality – perhaps I am over simplifying here, but ultimately quality in ionm comes down to te indicators that are nIt well measures today: overall reduction in adverse outcomes (including reduced length of stay, etc), and no new clinical issues created by ionm.

    • Reply Richard Vogel December 19, 2014 at 19:26

      Hi Robbie, I really appreciate your comment. The longer I’m in the field, the more I travel, and the more I study the history I neuromonitoring, I certainly see that I’ve had a very unique “upbringing” in a very unique geographic territory. So, I am always learning just how colored my perspectives are; however, these experiences are making me a little more open-minded. I still have a lot to learn about what people are doing out there because the field still so fractioned. That’s why I need to hear others’ perspective before I endeavor to write an actual post on the topic of quality. Honestly, if there is one place where I might disagree with you, it is the simplification. While what you said is absolutely correct (and a good point), I would like to take a look at some of the factors that underlie reduction in adverse outcomes. Beyond that, I would like to look at what “quality ionm” means from the perspective of hospitals, physicians, nurses, etc…not just the end, but the means. Here’s an example… the other day I was with a surgeon and that person said to me, “I never really knew what good monitoring was until I met you.” When I asked what made the monitoring good, it wasn’t a change in outcomes, per se, it was the way the work was done, the style of communication, the knowledge of complex issues, being able to read imaging, and being able to do little things like place electrodes in the right muscles (and not leaving blood and tape behind when I pull them out). This conversation actually spawned my idea to address the topic of quality. So, in the grand scheme of things, I agree that quality can be simplified, but I want to take a look at all of the underlying factors. When I start to think about these factors, the topic of quality gets so big, so multi-dimensional, I’m not sure it can be done in one post. Thanks again for taking the time to read and comment. Cheers. Rich

  • Reply David Kennedy December 19, 2014 at 18:03

    Kristina listed a series of changes that hardware developers can implement to improve safety, but what changes could be made at the hardware to also help facilitate quality?

    • Reply Richard Vogel December 19, 2014 at 19:05

      This is a great question, and a topic that I haven’t really fully considered. I’m sure others will have something more to contribute. My personal perspective is that quality has many different dimensions. One small aspect is being able to work efficiently, work “cleanly” and with all of the different equipment that tends to clog an OR, making a small footprint. Personally, I have only worked with two IONM systems – the NIM (most recently the Eclipse) and the Cadwell Cascade systems. I loved the NIM hardware because the pre-amp and stimulator were rather small, and I only had to run 2-3 wires (maximum) from my base unit to the bed. The hardware design was compact and elegant. Cadwell is much different. There is an obnoxiously-large transcranial stimulator box, an ES-IX box and up to 4 “pods” that have to run from my base unit to the bed. All of that equipment hanging from the bed can be quite intrusive. Running 4-6 wires across the OR to the bed can be intrusive. Aside from that, the pre-amps are huge and the housing unit that sits below the base unit is also consequently large. The whole system is bulky, and that increases the “footprint”. I think the smaller and more compact the system, the better, but I wouldn’t want to sacrifice the 32 channel capabilities. That’s all I have for hardware. Software is a horse of a different color – I could go on forever with that topic.

  • Reply Melissa Hanley December 21, 2014 at 13:05

    Hey Rich,
    I look forward to seeing the final post, once all of the above comments are incorporated. I would add that case documentation is another indicator of quality. The “chat log” and interpretive report should represent the modalities performed and the events that occur. They indicate the level of attention and care that are given to the patient as well as the knowledge of the monitoring team. Oftentimes these documents are requested by payers and can be the difference between reimbursement and denials.
    Happy Holidays!

    • Reply Richard Vogel December 23, 2014 at 10:15

      Hi Melissa, you make a really good point, and one that I hadn’t considered. Thanks for sharing. Let me know if you think of anything else. Happy holidays to you, too!!! Rich

  • Reply clare gale December 24, 2014 at 08:33


    It’s Christmas Eve and right now I don’t have time to be on this blog but ss usual, your post drew me in… while we are on the subject of quality… I must say THANK YOU for what I feel is the best IONM blog on the internet today! I look forward to reading, learning and participating in 2015.

    Have a Merry Christmas and may you see “no changes” in the new year! ; )

    Clare Gale

    • Reply Richard Vogel December 27, 2014 at 15:13

      Hi Clare,
      Thanks so much for the kind words, and for your support. I hope that you continue to read and comment. Please tell your friends and colleagues about the blog. I think 2015 will be a good year. Happy holidays!

  • Reply 2015 at NeuroLogicLabs@NeuroLogicLabs January 28, 2015 at 22:13

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  • Reply Mike Williamson December 1, 2015 at 15:21

    Hey Rich,
    This is an interesting questions, and the comments already made contain valid points, particularly the long one detailing the many different facets of the OR environment. But I think “quality” or the lack thereof, goes beyond the individuals involved in IOM.
    When techs first start out, they are basically trying to correctly complete tasks while remembering some of the basic science background. Some of what seems like it should be common knowledge is what more experienced personnel would describe as a blend of experience and intuition. Most of this, in fact has a rational basis and can be taught (such as anatomy, surgical approach, etc), but there are still some things learned best by experience, even if you’ve “seen” it once before.
    Also, the focus on keeping surgeons happy and complying with neurologist oversight can have an effect on how certain things are handled in the OR. I’m not talking about glaring omissions like not reporting lost responses, but trying to integrate neurologist input, following “protocol”, and communicating with widely varying surgical and anesthetic personalities. Do surgeons freak out if a patient has poor baselines? Can you work with anesthesia? Does you r neurologist have a panicky or calmer interpretation of varying signal responses? I could other give examples but I’d guess you know what I’m getting at.
    My point is, there a number of different factors other than technical skill that can affect how things are done, if not outcomes. What would you say to this?

    • Reply Richard Vogel December 3, 2015 at 18:07

      Hi Mike, There’s one point that you make that really stick out to me. You said that “quality, or the lack thereof, goes beyond the individuals involved in IOM.” It’s so true. You are only as good as the hospital, surgeon, anesthesiologist lets you be. If they want to treat you like a metal rep, won’t let you touch the patient, refuse to cooperate, refuse to communicate and force you to sit in the corner and do nothing, then they will get the lowest possible quality of neurophysiology out of that scenario. Some people justly say that, “Bad monitoring is worse than no monitoring.” So, in this scenario, we’re in the negative. On the other hand, if they treat you like a colleague, cooperate with you, let you do your job and take care of the patient, then they will get the highest quality of neurophysiology that you are capable of performing. In this case, the floor is zero and the sky’s the limit. So, this opens the door to the other side of quality. What is the IOM team capable of doing? If they are experienced in that particular surgery and have a deep knowledge of neurophysiology, physics of electricity, anatomy, surgical approach/risk, anesthesia/pharmacology, etc, etc, etc, and if he/she/they communicate well and work will with a team in a dynamic environment, then the quality of IONM is going to be sky high. Start to chip away at any/all of those factors, and we’re moving back toward the floor. You are correct, there are a ton of factors that go into quality. Even if you have a top-notch neurophysiologist in the OR, he/she can easily be hampered by faulty protocols or a remote “oversight” physician/consultant who lack knowledge/experience. You really need a lot of important factors to come together for quality IOM to emerge.

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