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Managing the Flow SBNS Response to the NCEPOD SAH Study

Managing the Flow SBNS Response to the NCEPOD SAH Study. Mr R J Nelson, SBNS President 22nd November 2013. Managing the Flow. Key findings for Neurosurgical Units National SAH Care Pathway National SAH Audit National SAH Care Standards Aneurysm Intervention Working Party.

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Managing the Flow SBNS Response to the NCEPOD SAH Study

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  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

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