1. Improving the quality of medical and surgical care 1 Subarachnoid Haemorrhage

2. 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 2

3. 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 3

4. 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. 4

5. 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 5

6. Improving the quality of medical and surgical care 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. Improving the quality of medical and surgical care 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 7

8. 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 8

9. 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) 9

10. 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 10

11. 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 11

12. 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 12

13. Improving the quality of medical and surgical care 13 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12Mar 12 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13Mar 13 Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13 Form the Expert Group Write the protocol Design the questionnaire Write the strategy of analysis Write the database Advertise the study with participants Advertise for Advisors Test data collection methods Meet with Expert Group Start data collection Run Advisor meetings Data analysis Presentation to Experts and Advisors Presentation to Steering Group Presentation to CORP IAG Write the report First draft to reviewers Second draft to reviewers Report design and print if appropriate Embargo copies sent Publish the report Disseminate findings Timeline