1 / 23

Managing the Flow SBNS Response to the NCEPOD SAH Study

Explore key findings, care pathways, and audit standards for aneurysmal subarachnoid hemorrhage (aSAH) management. Understand the impact of delays and deficiencies on outcomes, rational for early intervention, and the timing of procedures. Learn about initiatives to improve care and outcomes for aSAH patients.

juliam
Download Presentation

Managing the Flow SBNS Response to the NCEPOD SAH Study

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Managing the FlowSBNS Response to the NCEPOD SAH Study Mr R J Nelson, SBNS President 22nd November 2013

  2. Managing the Flow • Key findings for Neurosurgical Units • National SAH Care Pathway • National SAH Audit • National SAH Care Standards • Aneurysm Intervention Working Party

  3. Key Findings for NSC:Intervention • In a contemporary cohort (2012) of 304 aSAH patients receiving definitive aneurysm treatment 85% underwent endovascular treatment • 6 patients (2%) underwent clipping after attempted coiling

  4. Key Findings for NSC:Deficiencies in Care • Delays • Consent • Documentation • MDT organisation • Protocols

  5. Key Findings for NSC:Delays • General practice 32 • Paramedical service 6 • Prior presentation 2ary care 17 • Initial assessment 2ary care 18 • Diagnosis 2ary care 18 • CT 2ary care 11 Total 102 ………………………………………………. • Referral/contact NSC 15 • Acceptance NSC 18 • Transfer NSC 19 • Consultant review NSC 12 • Treatment planning 6 • Performing procedure 10 • ITU access 2 Total 82 (45%) TOTAL 184

  6. Key findings for NSC:Impact of Deficiencies on Outcome • Primary care 25 • Secondary care 33 • Tertiary care 10 Total 68

  7. National SAH Care Pathway • National care standards • Promote best practice • Minimise delayed and misdiagnosis • Minimise management delays • Embed regional networks • Standardise tertiary management protocols and MDT working

  8. National SAH Care Pathway • Evidence-based guidelines • Consensus statements • Best practice – NCEPOD Study

  9. National SAH Care Pathway • General practice • Emergency medicine • Neurosurgery • Neuroradiology • Neurology • Neurointensive care • Rehabilitation • Patient involvement • Public Health

  10. National SAH Audit • Neurosurgical National Audit Programme • Agreed in principle by HQIP • National SAH Audit • Piloted 2010 • National Service Specification (England) • Incorporate National SAH Care Standards • SBNS Audit Committee

  11. National SAH Care Standards • Adult Neurosurgery CRG • Admission to NSC • < 24 hrs of referral • Aneurysm intervention • < 48 hrs of decision to intervene • Current SBNS/RCR guideline Should aneurysm interventions be provided 24/7?

  12. NSC Provide 24/7 aSAH Services • Neurointensive care • General supportive care • Management of delayed ischaemia • CSF diversion • LD, EVD, shunting • Monitoring of ICP • Decompressive surgery • Clot evacuation • Decompressive craniectomy

  13. Should aneurysm interventions be provided 7 days a week? • Improve aSAH outcomes? • Do not worsen current outcomes? • Cost effective in relation to other measures that would improve outcomes of aSAH patients? • Recommendations must be evidence-based

  14. Rational for Early Aneurysm Intervention • Prevent re-bleeding • Optimise medical management of poor grade patients

  15. Timing of Aneurysm Intervention:NCEPOD Study • General practice 32 • Paramedical service 6 • Prior presentation 2ary care 17 • Initial assessment 2ary care 18 • Diagnosis 2ary care 18 • CT 2ary care 11 • Referral/contact NSC 15 • Acceptance NSC 18 • Transfer NSC 19 • Consultant review NSC 12 • Treatment planning 6 • Performing procedure 10 5.4% • ITU access 2 TOTAL 184

  16. Timing of Aneurysm Intervention:ISAT Study Rebleeding Rates • Day 0 2.7% • Day1 0.39% • Day2 0.95% 0.5% • Day3 0.24% • Day10 4.0% (peak rate)

  17. Timing of Aneurysm Intervention:48 hr Standard vs 7 Day Service • Prevention of re-bleeding 0.5 – 1.0% • Does this impact on outcome?

  18. Timing of Intervention and Outcome: ISAT/Utrecht Data • Intervention < 24hrs from ictus • Intervention >24-72 hrs from ictus • No significant difference in outcome • Includes re-bleeding • Conclusion – intervention within 72 hrs (n = 1238)

  19. Could 7 day a week aneurysm interventions have a perverse effect on outcome? • Reduced personal volumes • Volume/outcome relationship • Prolonged learning curve • Trainees and early years consultants • Isolated practice • Interventionist and neurosurgeon • Inexperienced support staff • Complex aneurysms

  20. Current aSAH OutcomesHELPS & Cerecyte Trials • Good grade patients WFNS Grade 1 & 2 at enrolment and treatment • Outcome mRS 0-2 • HELPS & Cerecyte Coiling 407 / 483 87.9 % • ISAT Grade 1 & 2 : Coiling 685 / 837 82.1% Clipping 647 / 870 74.6 %

  21. Aneurysm Intervention TimingWorking Party • SBNS/UKNG/RCR • Stakeholders • Assess current evidence • Refine National Care Standards • Workforce • Training

  22. Managing the Flow • National SAH Care Pathway • National SAH Audit • National SAH Care Standards • Aneurysm Intervention Working Party

  23. SBNS Response to NCEPOD Report To make the UK and Ireland global leaders in aSAH management

More Related