Subarachnoid Haemorrhage

1. Subarachnoid Haemorrhage

2. SAH: Introduction • Incidence • Relatively uncommon (5%) all strokes • Annual incidence in the UK :7/100,000 • Aetiology • Most caused by rupturing aneurysm in cerebral artery • Blood haemorrhages into subarachnoid space

3. SAH: Introduction • Outlook • 10-15% of people with a SAH will die before admitted to hospital, and 50% will die within 30 days of the SAH. • Of those that survive the first month, half require help with ADL • However prospects are improved if transferred to neurosurgical centre quickly for intervention/surgery

4. SAH: Introduction • Treatment: Secure the aneurysm • Surgical clipping • Endovascular coiling • Timing important: within 3-4 days of SAH • Conservative management in poor grade SAH: • Patients unlikely to benefit from intervention • Delay surgery to stabilise/ complications etc.

5. SAH: Introduction • Complications • Re-bleeds • Secondary ischaemia • Vasospasm- common: responsible for 20% of deaths / cases of serious brain damage associated with subarachnoid haemorrhage • HHH therapy • Epilepsy • Hydrocephalus

6. AIM of the study • To explore remediable factors in the process of care of patients admitted with the diagnosis of subarachnoid haemorrhage, looking both at patients that underwent surgery/ interventional procedure and those managed conservatively

7. Objectives The AIM would be addressed by looking into the following areas: • The organisational structures and policies in place to recognise SAH patients and to quickly and effectively transfer them from where they present in the periphery to the neurosurgical centres equipped to treat them • Protocols and policies in place for the management of these patients • Decision to treat/manage conservatively/transfer • Management pre/post treatment • Rehabilitation/End of life care

8. Objectives • Identifying remediable factors in the following areas of care of SAH patients: • Initial assessment / admission process • Diagnosis/ decision making • Decision to manage conservatively/ treat/ transfer • Quality of care of patients managed conservatively • Quality of care of patients undergoing an intervention: pre-, peri- and post- intervention

9. Objectives • Management of any complications • Ceilings of care/ End of life care pathways • Quality of care post discharge (rehabilitation etc. (in surviving patients)

10. Data collection • Identify patients ICD10 code for SAH via spreadsheet (all acute trusts/ all neurosurgical specialist centres) • Adult patients (aged 16 and older) that suffered a subarachnoid haemorrhage between 01/07/2011 - 30/09/2011 • For cases transferred between different hospitals: Match data on NHS number & DOB

11. Data collection • Data collection questionnaires: • Clinician Questionnaire • Responsible consultant in secondary care • Responsible consultant in tertiary care • Organisational questionnaire • All hospitals that admit acute patients as an emergency

12. Case note extracts for Peer Review Photocopied case notes from the patients’ admission for SAH including: • Clinical notes, nursing notes, Observation charts, operation notes, anaesthetic charts, consent forms, pathology/post mortem report discharge summary. • For patients that are transferred between hospitals, case note extracts will be requested from both hospitals

13. Timeline