Research Proposal: Barriers to Density Spectral Array EEG Monitoring During Anesthesia in South African Hospitals

Background and Motivation

Density Spectral Array (DSA) electroencephalography (EEG) monitoring is a technology used during anesthesia to visualize brain activity in real-time. Modern depth-of-anesthesia monitors (like BIS or SedLine) generate a DSA, which is essentially a spectrogram – a two-dimensional plot of EEG power over time – to facilitate interpretation of the raw EEG . Each anesthetic drug produces a characteristic EEG signature on the DSA, reflecting the drug’s neurophysiological effects . By providing continuous insight into a patient’s brain activity, DSA EEG monitoring aims to gauge the depth of anesthesia, helping anesthesiologists ensure patients are neither too lightly nor too deeply anesthetized.

The importance of EEG-based monitoring in anesthesia has been increasingly recognized internationally. Research shows that intraoperative EEG monitoring can help titrate anesthetic dosing to avoid both underdosing (which risks awareness) and overdosing (which can cause hemodynamic instability or delayed recovery) . Notably, the BIS (Bispectral Index) monitor – a processed EEG device – was shown in the landmark B-Aware trial to significantly reduce the incidence of intraoperative awareness with explicit recall (0.17% with BIS vs 0.91% with standard care) . Although subsequent studies yielded mixed results (e.g. BIS was no better than end-tidal anesthetic gas guidance in some trials) , the overall consensus is that brain monitoring adds an extra layer of safety for preventing awareness under general anesthesia. Beyond awareness, EEG monitors may improve other outcomes; for example, certain EEG patterns during anesthesia are associated with post-operative delirium and cognitive dysfunction . Titrating anesthetic depth with EEG may thus help minimize cognitive complications upon emergence . Owing to these safety benefits, some guidelines now strongly recommend using a depth-of-anesthesia monitor in high-risk situations – the Anesthesia Patient Safety Foundation (APSF) advises that a brain monitor “is required to reduce the likelihood of awareness whenever total intravenous anesthesia is combined with neuromuscular blockade” .

Despite these advantages and recommendations, the adoption of DSA EEG monitoring in routine practice is far from universal. In many settings, anesthesiologists still rely on traditional signs (heart rate, blood pressure, movement) to infer anesthetic depth, which are known to be imperfect indicators . Several barriers have limited the widespread use of DSA monitors, especially in resource-constrained environments. Cost is often cited – the B-Aware trial estimated a cost of around $2,200 to prevent one case of awareness using BIS monitoring , and many hospitals in low- and middle-income countries struggle to afford the monitors and disposable sensors. Time and workflow are also considerations; busy anesthesia providers may perceive the application of EEG electrodes and interpreting an additional monitor as extra steps that slow down care. Training and familiarity present another hurdle – understanding the EEG waveforms and spectral displays requires education, and many clinicians have not been formally trained to interpret intraoperative EEG  . Indeed, experts highlight that educational programs are essential to improve clinicians’ ability to use raw EEG and DSA data effectively . Access to the technology is uneven, with advanced monitors more readily available in well-resourced hospitals but often absent in smaller or public hospitals. In South Africa, which has a two-tier healthcare system, this likely translates into limited availability of DSA EEG monitors in many government hospitals. All these factors provide the motivation for this study: to systematically investigate what specific barriers are preventing the use of DSA EEG monitoring during anesthesia in South African hospitals. Identifying these barriers can help inform targeted interventions (e.g. training programs, equipment funding, protocol changes) to increase the appropriate use of EEG monitoring and improve patient safety.

Literature Review

International Perspective on DSA EEG Use in Anesthesia

Globally, there is growing literature on the benefits of processed EEG monitoring during anesthesia, but also acknowledgement of its inconsistent uptake. Processed EEG devices typically translate complex brain waves into a user-friendly index (0 to 100 scale) and display features like the raw waveform and DSA spectrogram  . These monitors have proven useful for preventing extremes of anesthetic depth: they alert clinicians to signs of possible patient awareness (e.g. high frequency EEG activity) as well as excessive anesthesia (e.g. burst suppression on EEG) . Clinical studies and trials have yielded mixed evidence on outcome improvements, which partly explains cautious adoption. The early positive findings of the B-Aware trial in 2004 (significantly fewer awareness cases with BIS monitoring)  led to enthusiasm for routine use in high-risk patients. However, later trials like B-Unaware and BAG-RECALL did not show a clear benefit of BIS over end-tidal agent concentration guidance in general populations . A 2014 Cochrane review similarly concluded that while EEG monitoring likely reduces awareness compared to no monitor, it was not superior to existing gas concentration-based practices for that endpoint . Consequently, professional guidelines in high-income countries stop short of universally mandating EEG depth monitors, instead suggesting their use for specific scenarios (e.g. total intravenous anesthesia, high awareness-risk cases) . This nuanced evidence base has led some anesthesiologists to question the utility of depth monitors for every patient, while others champion their potential to improve individualized anesthesia care  .

Notwithstanding the debate, there is a clear trend toward greater acceptance of EEG monitoring as a valuable tool. For instance, surveys have shown that a majority of anesthesiologists believe depth monitors are effective in principle . Educational and quality initiatives are underway in various countries to address knowledge gaps – recent programs by anesthesia organizations have focused on teaching practitioners how to interpret intraoperative EEG and DSA displays  . In practice, however, adoption varies widely across regions. Developed countries report higher usage rates: one survey noted that about 22% of anesthesiologists in the UK and over 50% in Australia use depth-of-anesthesia monitors routinely . In contrast, usage in developing contexts is much lower – only 9% in China and 6.5% in Jordan reported regular use in the same study . These disparities highlight how resource availability and local clinical culture influence the uptake of new monitoring technology. A key barrier identified internationally is the financial cost of EEG monitors. Even though the devices are marketed as relatively affordable and widely available in wealthy settings , their cost can be prohibitive for hospitals with limited budgets. A recent cross-sectional study in Jordan found that the most crucial factor limiting depth monitor use was “the inability to bill (for the monitor) or high cost” of the technology . This aligns with reports from other regions that the initial investment and ongoing costs (disposable sensor pads, maintenance) deter many facilities from adopting these monitors. Additionally, the lack of robust endorsement in guidelines and questions about cost-effectiveness have made some administrators reluctant to invest in the technology .

Beyond cost, international studies point to knowledge and attitude gaps as significant barriers. In the Jordanian survey, over 80% of respondents agreed that depth monitors can prevent awareness, yet one-third felt the monitors were not sufficiently accurate or reliable . Many anesthesiologists were unsure about the sensitivity of current monitors and noted that EEG-based indices do not measure analgesia (pain responses) . Such perceptions can reduce clinicians’ trust in the monitors. Furthermore, a lack of formal training leaves providers uncomfortable with interpreting EEG data. As a result, even when monitors are available, they may be underutilized or used suboptimally. Nawafleh et al. (2022) concluded that anesthesiologists’ attitudes and knowledge about depth monitoring were “inadequate,” and called for greater efforts in clinician education and policy to encourage use of EEG monitors  . In summary, the international literature suggests that while DSA EEG monitoring offers clear clinical benefits (improved dosing precision, avoiding awareness and excessive anesthesia)  , its implementation is hindered by cost constraints, limited training, variable trust in the technology, and the absence of mandates or protocols in many hospitals.

South African Context and Rationale

In South Africa, the status of DSA EEG monitoring in anesthesia has not been well documented in published literature, revealing a notable knowledge gap. Anecdotally, usage of depth-of-anesthesia monitors in South African hospitals is thought to be low, especially in the public healthcare sector. The situation likely mirrors that of other middle-income regions such as the Middle East and parts of Asia, where many anesthesiologists have never used a BIS or similar EEG monitor . South Africa’s public hospitals often operate under severe budgetary constraints, struggling to provide even basic monitoring equipment; costly advanced monitors like processed EEG devices are rarely prioritized. Private hospitals and academic centers in South Africa may have greater access to such technology, but no national data exist on how frequently they are used. This urban or private–public divide is hinted at in international findings – for example, the availability of depth monitors was much lower in public hospitals in Jordan, contributing to fewer anesthesiologists using them . It is reasonable to assume similar disparities in South Africa, where resource allocation is uneven across provinces and hospital tiers.

Another factor in the South African context is the lack of local guidelines or requirements for depth monitoring. The South African Society of Anaesthesiologists (SASA) currently does not mandate the use of BIS/EEG monitors during general anesthesia, instead leaving it to clinician discretion. Without a formal policy, the impetus to acquire and use DSA monitors depends on individual practitioners or hospital administrators, which may be low if awareness is considered a rare event or if staff are not trained in EEG interpretation . Training opportunities in South Africa for intraoperative EEG are limited; most anesthesia training programs focus on core monitoring (ECG, blood pressure, capnography) and may only touch on depth monitors in theory. Thus, many practicing anesthesiologists might feel unprepared to utilize a DSA EEG even if one is available, tying into the training barrier identified globally . Moreover, South Africa’s patient population and surgical load (which includes a high proportion of urgent surgeries in ill patients) present unique challenges – anesthesiologists often manage cases where avoiding hemodynamic instability takes precedence, potentially overshadowing depth monitoring unless it clearly aids immediate management.

In summary, no comprehensive study to date has examined DSA EEG monitor usage in South Africa, but multiple converging factors suggest low uptake. High equipment costs, scarce availability in the public sector, lack of practitioner training, and absent policy support are all plausible barriers. This research is therefore necessary to formally assess these barriers in the South African setting. By doing so, it will provide evidence to guide improvements – for instance, if cost is confirmed as a primary barrier, it could justify budgeting for monitors or exploring lower-cost alternatives; if lack of training is prominent, targeted education and workshops could be implemented. This study’s findings will fill an important gap in the literature and support efforts to enhance anesthesia monitoring standards in South Africa in line with international patient safety goals.

Research Aims and Objectives

Aim: To assess the barriers to the use of Density Spectral Array EEG monitoring during anesthesia among anesthesiology practitioners in South African hospitals, in order to identify factors limiting its adoption and inform strategies to improve its utilization.

Objectives:

1. Determine the current utilization rate of DSA EEG monitors among South African anesthesiologists (e.g. how frequently and in what contexts such monitors are used, if at all).

2. Identify and evaluate specific barriers that hinder the use of DSA EEG monitoring, focusing on factors suggested by prior studies – including cost constraints, time or workflow limitations, lack of training/knowledge, and limited access to equipment.

3. Examine differences in barriers and usage between different hospital settings or practitioner demographics – for example, comparing public vs private sector anesthesiologists, levels of experience, or hospital tiers (tertiary academic vs regional hospitals).

4. Develop a profile of anesthesiologists’ attitudes and knowledge regarding DSA monitoring, such as their confidence in interpreting EEG data, perceived usefulness of the technology, and willingness to use it if barriers were addressed.

5. Propose potential interventions or solutions based on the findings – although this will be exploratory, the study will collect suggestions from participants on what could facilitate greater use of DSA monitors (e.g. training programs, subsidy of costs, guideline changes).

By achieving these objectives, the research will paint a clear picture of why DSA EEG monitors are underutilized in South Africa and provide actionable insights to improve adoption.

Methodology

Study Design

The study will be a descriptive cross-sectional survey of anesthesiologists in South Africa. A quantitative approach is appropriate to systematically capture the prevalence of DSA EEG monitor use and the relative importance of various barriers. The design will involve a structured questionnaire (details below) distributed to practicing anesthesia providers within a defined study period. This cross-sectional snapshot will allow analysis of associations between respondent characteristics and reported barriers or usage patterns at a single point in time. The study is primarily exploratory and descriptive, aiming to gather baseline data in an area with little prior research.

Target Population and Sampling

The target population is qualified anesthesiologists and anesthesia trainees working in South African hospitals. This will include specialists (consultants), registrars (residents in training), and medical officers providing anesthesia care. The rationale for focusing on providers is that they are the decision-makers for monitor use during surgery. We aim to capture perspectives across both public and private healthcare sectors, as well as across different regions of the country.

Sampling will be done through a combination of professional networks and organizational outreach. We intend to collaborate with the South African Society of Anaesthesiologists (SASA) to reach a broad membership base. An invitation to participate, containing a link to an online questionnaire, will be emailed to SASA members. Additionally, we will seek permission to distribute the survey link via departmental listservs at major academic hospitals and at anesthesia conferences or meetings during the study period. This approach constitutes a convenience sample, but we will strive for diversity in respondents. Inclusion criteria are anesthesiology practitioners who currently work in South Africa and who have administered anesthesia in the last year. Participation will be voluntary. Based on membership numbers and expected response rates, we anticipate a sample size of approximately 100–200 respondents, which should be adequate to observe common trends (for context, a similar survey in Jordan had 107 respondents ).

Data Collection Procedure

Data will be collected using a self-administered questionnaire, designed specifically for this study (see outline below). The questionnaire will be delivered electronically (e.g. using a tool like Google Forms or REDCap), enabling participants to complete it at their convenience. The survey will be open for a defined period (approximately 6–8 weeks), with periodic reminders sent to improve response rates. For anesthesiologists who may not have reliable email access, paper questionnaires will be made available at selected hospitals with researcher contacts or local study champions facilitating distribution and collection. However, we expect the online mode to be the primary method to maximize reach across the country.

The questionnaire will first present an information sheet and consent section, explaining the study’s purpose and assuring respondents of anonymity. After consenting, participants will answer the set of questions organized into thematic sections (demographics, current practice, barriers, etc.). The design ensures confidentiality – no identifying personal data (like name or workplace) will be collected beyond broad categories (such as type of hospital, years of experience). Completed responses from the online platform will be exported into a spreadsheet for analysis. Data integrity checks will be performed (e.g. for completeness and to remove any obviously invalid entries). All data will be stored securely on a password-protected computer accessible only to the research team.

Basic analysis will involve descriptive statistics (percentages, means) to summarize findings, and comparative tests (chi-square or t-tests as appropriate) to explore differences in barriers or usage by subgroups (e.g. public vs private sector). For example, we will compare the proportion of public-sector anesthesiologists who cite “lack of access to a DSA monitor” as a barrier versus the proportion in private practice. The results will be compiled to address each objective. Given the primarily descriptive nature, the emphasis will be on identifying the rank-order and frequency of reported barriers and any notable associations in the data.

Questionnaire Design (Concept Outline)

The questionnaire will be developed based on literature and expert input, ensuring it covers all relevant domains related to DSA EEG monitor use. Table 1 below outlines the conceptual structure and key topics of the questionnaire:

• Section 1: Demographics and Practice Setting – This section gathers background information on the respondent. Questions will cover:

• Professional role (consultant anesthesiologist, registrar, etc.) and years of experience.

• Primary practice sector (public government hospital, private hospital, or both) and level of hospital (tertiary academic center, regional/district hospital, etc.).

• Province or region of practice (to see if geographic differences exist).

• Section 2: Current Use of DSA/EEG Monitoring – Assessing how frequently and in what circumstances the respondent uses any form of processed EEG monitoring during anesthesia:

• Availability of DSA EEG or BIS monitors in their main hospital (Yes/No/Unsure).

• Frequency of use (Never, Rarely, Sometimes, Almost every case, Every case). For those who never or rarely use it, a follow-up asks why not (with multiple-choice reasons).

• If they do use monitors: in which types of cases (e.g. high-risk surgeries, total intravenous anesthesia cases, neurosurgeries, etc.) and which brand or model (if known, e.g. BIS, SedLine).

• Any recent training or exposure to using DSA EEG (e.g. attended a workshop or lecture on it).

• Section 3: Perceived Barriers – Focusing on the barriers to using DSA EEG monitors, regardless of current use. Respondents will be presented with a list of potential barriers identified from prior research (cost, time, training, access, etc.) and asked to rate each on a Likert scale (e.g. 1 = “Not a barrier at all” up to 5 = “Major barrier in my practice”):

• Cost of equipment – Including the cost to purchase monitors and the ongoing cost of disposable sensor pads (this addresses whether budget constraints or lack of funding is an issue) .

• Time constraints – Whether the additional time to set up EEG electrodes and interpret the monitor deters use (especially in fast-paced environments or short cases).

• Lack of training or knowledge – Whether the respondent feels insufficiently trained to interpret EEG/DSA data, or lacks confidence in using the monitor .

• Limited availability/access – If a monitor is simply not available or readily accessible in their operating room when needed (for example, only one machine in the hospital, or none at all).

• Doubts about efficacy/accuracy – If the individual is skeptical about whether the monitor truly improves patient outcomes or is accurate in reflecting depth (for instance, awareness of cases where the monitor was misleading) .

• Interference with workflow – Any perception that the monitor is cumbersome, causes alarms or distractions, or is difficult to integrate into routine monitoring.

• Other barriers – An open-ended option for respondents to specify any other barriers (e.g. lack of support from surgeons or colleagues, institutional culture, etc.).

• For each barrier that is rated as significant, an optional follow-up allows the respondent to elaborate (qualitative comment) for richer insight.

• Section 4: Attitudes and Facilitators – This part probes the attitudes of anesthesiologists towards DSA EEG monitoring and what might encourage its use:

• Belief in the usefulness of depth monitors: e.g. “Do you believe that using a DSA EEG monitor can improve patient outcomes (such as reducing awareness or optimizing anesthesia dosage)?” with agreement scale .

• Scenarios where they think DSA monitoring is most important (awareness prevention, monitoring sedation depth in TIVA, preventing overdose in elderly, etc.) .

• Willingness to use: “If the barriers you identified were resolved (for example, if a monitor was readily available and you had training), how likely would you be to incorporate DSA EEG monitoring into your routine practice?” (Likert scale from very unlikely to very likely).

• Facilitators: a checklist or ranking of which potential changes would most encourage use – e.g. lower cost or hospital providing the equipment, training workshops or mentorship in EEG interpretation, hospital protocol or guideline requiring/encouraging use, improvements in monitor technology (smaller, faster, more accurate), etc.

• An optional free-text question for any additional comments or suggestions regarding DSA EEG monitoring in their practice or in South Africa generally.

The questionnaire will be piloted with a small group of 5-10 anesthesiologists (not part of the main study) to ensure clarity and relevance of questions. Their feedback will be used to refine question wording and format. The final instrument will then be approved by the research team and ethics committee before distribution.

Ethical Considerations

This study will adhere to all relevant ethical guidelines for research involving human participants. Ethical approval will be obtained from an appropriate Human Research Ethics Committee (for example, a university or national health ethics board) prior to commencing the survey. All prospective participants will receive detailed information about the study in the survey introduction. This includes the study’s purpose, what participation entails, and any potential risks or benefits of participation. We will emphasize that participation is entirely voluntary and that respondents may choose to skip any question or exit the survey at any time without any negative consequences.

In terms of informed consent, consent will be implied by the completion and submission of the questionnaire (after the participant has read the information and instructions). The first page of the online survey will require participants to confirm that they understand the study and agree to proceed. No minors or patients are involved; only medical professionals are surveyed, which simplifies consent procedures (written consent waiver for anonymous questionnaires will be sought from the ethics committee).

Confidentiality and anonymity are paramount. The survey is designed to collect no personally identifying information. Respondents will not be asked for their name, employer, or any unique identifiers. Data will be reported in aggregate (e.g. percentage of respondents endorsing a particular barrier) and any quotes from open-ended responses will be presented without attribution. All survey responses will be stored in a secure manner – for an online survey, data will be in a protected database, and any downloaded data will be kept on encrypted or password-protected devices. Only the research team will have access to the raw data.

We will also consider the sensitivity of the topic. While asking professionals about their practice habits is low-risk, there is a slight chance some might feel that admitting to not using certain monitors could appear as a “negative” reflection on their practice. To mitigate this, the survey is anonymous and framed in a non-judgmental way – emphasizing that the goal is to improve systemic support and understand challenges, not to evaluate individual performance. We will not collect hospital names, so institutions cannot be identified or singled out. Results will be used purely for research and quality improvement purposes, and this will be clearly communicated.

Finally, participants will be provided with researcher contact information should they have questions or wish to withdraw their data. Upon study completion, we plan to disseminate the findings in a way that could benefit the anesthesiology community (for instance, via a report or conference presentation). This will be done while maintaining confidentiality – only overall results and conclusions will be shared. By following these ethical safeguards, we aim to ensure that participants are comfortable providing honest, insightful responses crucial to the study’s success.

Expected Outcomes and Significance

Expected Outcomes: We anticipate that this study will illuminate a set of key barriers that currently impede the use of DSA EEG monitoring in South African anesthesia practice. Based on prior evidence and the context, we expect to find that limited access to equipment and cost are reported as the top barriers by a majority of respondents. It is likely that many anesthesiologists, particularly in the public sector, simply do not have a DSA or BIS monitor readily available in their theaters – an issue tied to resource allocation and budget priorities . We also foresee that lack of training or confidence in using the technology will emerge as a significant barrier, echoing international findings that clinicians feel they need more education to interpret EEG data  . The survey may reveal, for instance, that a large fraction of respondents have never received formal training on intraoperative EEG, correlating with infrequent use. Another expected finding is that time pressures and workflow concerns moderate the willingness to use DSA monitors – for example, respondents might indicate they avoid using the monitor in short cases or emergencies due to setup time. Additionally, we anticipate that differences by sector will be evident: private hospital practitioners might report slightly higher usage and fewer access issues (thanks to better funding), whereas government hospital practitioners might more strongly emphasize infrastructural barriers. We might also find generational or experience-related differences in attitudes (younger anesthesiologists perhaps more open to new technology vs. older ones relying on traditional methods). Overall, the study will likely quantify the percentage of anesthesiologists affected by each barrier and highlight a subset of barriers that are most prevalent.

Significance: The outcomes of this research will have important implications for improving anesthesia care in South Africa. By clearly identifying the main barriers to DSA EEG monitor use, the study provides a foundation for targeted interventions. For instance, if cost and availability are confirmed as dominant issues, the results can be used to advocate for resource allocation – hospital administrators and health authorities could be lobbied to invest in affordable depth-of-anesthesia monitors, perhaps starting with high-risk surgical centers. Demonstrating that anesthesiologists value these monitors (if the survey shows most believe in their benefit) but lack them due to cost could support budget proposals or inclusion of EEG monitors in standard equipment lists. If lack of training is highlighted, the significance is that professional bodies like SASA and academic institutions could develop training workshops, continuing medical education modules, or simulation scenarios to teach interpretation of DSA and EEG during anesthesia. This aligns with global calls for improved clinician education in EEG monitoring  and could increase confidence and uptake of the technology.

Importantly, the study’s findings can inform the creation of guidelines or protocols at both local and national levels. For example, if a large proportion of respondents indicate that depth monitoring should be mandatory in certain cases (as was seen in studies from other countries where many agreed it should be standard during TIVA with muscle relaxants ), SASA might consider incorporating recommendations about DSA EEG monitoring in future practice advisories. Furthermore, documenting the barriers allows stakeholders to measure progress over time – this study will serve as a baseline, and follow-up studies in a few years can evaluate if interventions (new equipment, training programs, etc.) have improved the situation.

From a patient safety perspective, the significance of addressing these barriers is profound. Enhanced use of DSA EEG monitoring could lead to safer anesthesia: fewer cases of awareness with recall (which, while already rare, could be further reduced), more optimized dosing especially for vulnerable populations (e.g. the elderly or those with limited physiological reserve, where avoiding deep anesthesia can reduce postoperative delirium ), and overall a move toward more individualized anesthesia care. In the long term, embracing such monitoring may improve outcomes like recovery times and possibly reduce anesthesia-related complications by avoiding both under- and over-dosage .

Finally, this research will contribute to the scientific literature, being one of the first studies focusing on South Africa’s experience with intraoperative EEG monitoring. It will allow South African anesthesiology to be viewed in the global context – comparisons can be drawn with data from other countries (such as the lower usage rates in developing nations vs higher in developed ones ), and South Africa’s unique challenges can be recognized. The significance extends to other low- and middle-income countries as well: the barriers identified here may be similar elsewhere in Africa, thus our findings could encourage broader investigations and solutions on the continent. In summary, by pinpointing why DSA EEG monitors are underused and demonstrating the desire (or lack thereof) for their use among South African anesthesiologists, this study will guide practical steps to improve anesthesia monitoring standards and ultimately patient care quality in South Africa.

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