1. Service Evaluation of Comprehensive Assessment of Geriatric Neurosurgical Patients with Subdural Haematomas
Carly Welch, Sarin Kuruvath, Urmila Tandon & Jonathan Treml
University Hospitals Birmingham NHS Foundation Trust
Introduction
Traumatic Brain Injury is a considerable problem in older adults with falls being the leading cause. Chronic subdural haematomas particularly are more common over 65 years. Alcohol is a factor in over half of elderly male patients. However, most head injury patients are young men and neurotrauma units are designed with these characteristics in mind.
Elderly neurosurgical patients have prolonged lengths of stay for medical and social reasons. The Society of British Neurological Surgeons (SBNS) has issued standards for patients requiring neurosurgical care: “the Neurosurgical Unit will have available … other specialist consultants e.g. .. Geriatric .. according to the individual needs of patients”.
Falls Assessment
Patients presenting with subdural haematomas should be assessed for falls risk. The National Institute for Health and Care Excellence (NICE) has issued guidelines for falls assessment and prevention, which suggests multifactorial assessment for individual risk factors.
Delirium
Post-operative delirium affects up to 47% of general surgical patients and is associated with poor outcomes. Incidence in neurosurgical patients was 21.4% at Day 3 in one study.
AMT10
The Abbreviated Mental Test (AMT10) pre- and post-op is part of the best practice tariff in trauma and is recommended for patients over the age of 75 as part of the Commissioning for Quality and Innovation (CQUIN) payment framework
Restarting anticoagulants
This is a complex decision and will need to consider individual risk factors including falls risk.
Results
Premorbid Functional Status
34.9% had documentation in medical notes (one of these was on geriatric review only). Including data from therapy notes, 55.6% were independently mobile without aids and a further 35.3% were independently mobile with aids. 79.4% had no formal care prior to admission.
Cause of fall or head injury
55.8% had documented history of falls
Cause for fall or head injury was clearly identified in 18.6%
Falls Assessment
Delirium
No patient had a diagnosis of delirium made during admission.
Cognitive Assessment
1 (2%) patient had an AMT10 performed (by a medical trainee). 6 (14%) patients had a MOCA performed by an Occupational Therapist.
Anticoagulants & Antiplatelets
Patients discharged on medications:
2 patients with metallic valves discharged on warfarin or enoxaparin
1 patient mistakenly discharged on dipyridamole
Patients discharged without medications – advice given:
11 had no documented advice
2 restart in 4-6 weeks
1 review in clinic
1 GP to risk stratify
1 “Consider restarting once well”
Medical Input
17 (39.%) were reviewed by a medical specialist
4 (9.3%) were reviewed by a geriatrician
Outcome:
Conclusions
In this study, older patients with subdural haematomas have good premorbid functional status, although overall documentation was limited.
Evaluation of cause for falls was limited and the cause for fall or head injury was not clearly identified in the majority of patients.
The fact that no patients were diagnosed with delirium suggests likely missed diagnosis, as this group of patients is likely to be at high risk.
AMT10 was rarely used.
Of those patients discharged on anticoagulants or antiplatelets, there was limited documentation of long-term plans for continuing these drugs.
The majority of patients were discharged to the referring hospital, local rehabilitation unit or to their own home.
Recommendations
Older patients are more likely to have complex needs and benefit from a multidisciplinary team response
Comprehensive Geriatric Assessment (CGA) is likely to be the gold standard and would have service implications.
Development of an assessment proforma to guide junior doctors when admitting and discharging geriatric patients to neurosurgical wards is currently in development.
This was a relatively small study designed to evaluate current practice, but the results of this study could be used to set standards for future audits and change in practice
Method
Electronic records accessed for all 46 patients aged over 70 discharged between 1/9/14 – 30/11/14 under neurosurgery and coded as having a diagnosis of subdural haematoma; paper records were accessed for 43 patients. Records were checked for falls assessment, functional history, alcohol history, delirium diagnosis, cognitive screening, medications review and overall outcome.
Limitations
Retrospective data
Small sample size
Currently limited standards to audit against
Limited documentation overall
Copyright Colin Purrington (
References
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