Improving the quality of medical and surgical care1

Subarachnoid Haemorrhage

Improving the quality of medical and surgical care

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

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Improving the quality of medical and surgical care

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

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Improving the quality of medical and surgical care

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.

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Improving the quality of medical and surgical care

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

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Improving the quality of medical and surgical care6

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

Improving the quality of medical and surgical care

ObjectivesThe 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

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Improving the quality of medical and surgical care

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

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Improving the quality of medical and surgical care

Objectives

• Management of any complications

• Ceilings of care/ End of life care pathways

• Quality of care post discharge (rehabilitation etc. (in surviving patients)

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Improving the quality of medical and surgical care

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

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Improving the quality of medical and surgical care

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

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Improving the quality of medical and surgical care

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

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Improving the quality of medical and surgical care13

Timeline