LAB-LTM: Epilepsy Monitoring and ICU/Critical Care EEG Monitoring

REACCREDITATION FORM

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Renewing LTM Laboratory Accreditation requires the following:

Compliance with ACNS Guidelines and ABRET Accreditation Standards documented by signature with evidence of compliance in submitted recordings (a signature page is included in the LAB-LTM renewal packet and should be uploaded below, section IV).
Submission of long-term EEG recordings (no ECI or ambulatory recordings), as specified in the accreditation renewal notification that was emailed to your facility's point of contact (see section V for details). EEG recording data and documentation should be de-identified according to institutional policy, and all sensitive materials be encrypted and/or password protected.
Submission of a reaccreditation fee payable to ABRET. Most major credit cards are accepted.
NOTE: If mailing the fee by check, please ensure that “LAB-LTM” and invoice number are included. Mail to ABRET LAB-LTM, 111 E. University Drive, Ste. 105–355, Denton, TX 76209.

Goals:

To keep accredited labs aware of the expectations and standards.
To provide feedback on any changes that may affect accreditation status with suggested actions to maintain compliance.

Submission requirements:

Submission of the required documentation and LTM recordings are due prior to the end of the expiration year (refer to section V below).

I. Program Overview

Date * +

First & Last Name of Main Point of Contact

Current Title

Email Address *

Hospital/Institution

Department Name

Street Address

Address Line 2 (include Mail Code or Mail Stop)

City

State

Zip Code

Phone Number

	Yes	No
Is your EEG Laboratory ABRET LAB-EEG accredited?	Yes	No

	Adult	Pediatric
The National Association of Epilepsy Centers (NAEC) recognizes adult and pediatric programs within the same facility as separate programs. Which program are you reaccrediting using this form?	Adult	Pediatric

	Epilepsy (EM)	Epilepsy with Invasive (EM+/NAEC IV)	Critical Care (CC-EEG)
Which type(s) of LAB-LTM Accreditation are you renewing?	Epilepsy (EM)	Epilepsy with Invasive (EM+/NAEC IV)	Critical Care (CC-EEG)

	Yes, as a level III center	Yes, as a level IV center	No, but we plan to apply	No with no plans to apply
Does your facility currently hold accreditation through the NAEC?	Yes, as a level III center	Yes, as a level IV center	No, but we plan to apply	No with no plans to apply

Epilepsy Monitoring (EM or EM+)

Not applicable

Medical Director

Phone Number

Email Address

Technical Director (or equivalent*)

*The technical director must hold a CLTM or NA-CLTM credential. The technical director oversees
technologist staff and technical aspects of monitoring.

Phone Number

Email Address

Administrator/Title

Phone Number

Email Address

ICU/Critical Care EEG (CC-EEG)

Same as Epilpesy Monitoring

Not applicable

Medical Director

Phone Number

Email Address

Technical Director (or equivalent)

Phone Number

Email Address

Administrator & Title

Phone Number

Email Address

II. Volume

Epilepsy Monitoring
Indicate the type(s) of procedures/patients you monitor:

	Yes	No	N/A
Diagnostic/Pre-surgical (scalp)	Yes	No	N/A
Invasive extraoperative monitoring	Yes	No	N/A
Adult	Yes	No	N/A
Pediatric	Yes	No	N/A
Has your facility performed at least 24 invasive recordings in the last 4 years?	Yes	No	N/A
Do you taper AEDs during admission	Yes	No	N/A

Total number of epilepsy monitoring tests performed (admissions) in the last year (per the adult -or- pediatric program, not a combined total)

Of the total above, how many were Diagnostic/Pre-surgical?

Of the total above, how many were Invasive Extraoperative monitoring?

ICE/Critical Care EEG
Indicate the patient populations monitored by CC-EEG at your facility:

	Yes	No	N/A
Adult	Yes	No	N/A
Pediatric	Yes	No	N/A
Neonates	Yes	No	N/A

Total number of CC-EEGs performed in the last year (per the adult -or- pediatric/neonate program, not a combined total)

III. Personnel

Interpreting Physicians

List all Physicians involved with interpreting EEG data collected for Epilepsy (EM, EM+) and Critical Care EEG (CC-EEG) monitoring using the data fields and checklists below. If the total number of interpreting physicians exceeds 5, please upload a FULL list using the parameters (i.e., degree, participation, board certifications, etc.) as outlined below (Word or Excel format):

1. First & Last Name, Degree(s)

Participation in:

EMU	ICU/CC EEG

Boards

2. First & Last Name, Degree(s)

Participation in:

EMU	ICU/CC EEG

Boards

3. First & Last Name, Degree(s)

Participation in:

EMU	ICU/CC EEG

Boards

4. First & Last Name, Degree(s)

Participation in:

EMU	ICU/CC EEG

Boards

5. First & Last Name, Degree(s)

Participation in:

EMU	ICU/CC EEG

Boards

Long-Term Monitoring Technologists

LTM Technologists: List all the technologists participating in Epilepsy (EM, EM+) and Critical Care EEG (CC-EEG) monitoring using the data fields and checklists below. If the total number of technologists is >5, please upload a FULL list following the parameters (i.e., participation, credentials, etc.) as outlined below (Word or Excel format):

1. First & Last Name, Degree(s)

Participation in:

EM	EM+
CC-EEG

Boards

2. First & Last Name, Degree(s)

Participation in:

EM	EM+
CC-EEG

Boards

3. First & Last Name, Degree(s)

Participation in:

EM	EM+
CC-EEG

Boards

4. First & Last Name, Degree(s)

Participation in:

EM	EM+
CC-EEG

Boards

5. First & Last Name, Degree(s)

Participation in:

EM	EM+
CC-EEG

Boards

ABPN - Neurology	ABPN - Child Neurology	ABPN - Clinical Neurophysiology (CNP)	ABPN - Epilepsy (EM)
ABCN - CNP	ABCN - EM	ABCN - CC-EEG	ABCN - Pediatric EEG
Other Other

ABPN - Neurology	ABPN - Child Neurology	ABPN - Clinical Neurophysiology (CNP)	ABPN - Epilepsy (EM)
ABCN - CNP	ABCN - EM	ABCN - CC-EEG	ABCN - Pediatric EEG
Other Other

ABPN - Neurology	ABPN - Child Neurology	ABPN - Clinical Neurophysiology (CNP)	ABPN - Epilepsy (EM)
ABCN - CNP	ABCN - EM	ABCN - CC-EEG	ABCN - Pediatric EEG
Other Other

ABPN - Neurology	ABPN - Child Neurology	ABPN - Clinical Neurophysiology (CNP)	ABPN - Epilepsy (EM)
ABCN - CNP	ABCN - EM	ABCN - CC-EEG	ABCN - Pediatric EEG
Other Other

ABPN - Neurology	ABPN - Child Neurology	ABPN - Clinical Neurophysiology (CNP)	ABPN - Epilepsy (EM)
ABCN - CNP	ABCN - EM	ABCN - CC-EEG	ABCN - Pediatric EEG
Other Other

R. EEG T./R.E.T.	CLTM	NA-CLTM	CNIM
None

R. EEG T./R.E.T.	CLTM	NA-CLTM	CNIM
None

R. EEG T./R.E.T.	CLTM	NA-CLTM	CNIM
None

R. EEG T./R.E.T.	CLTM	NA-CLTM	CNIM
None