1. Managing the Flow SBNS 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 practice32 Paramedical service6 Prior presentation 2 ary care 17 Initial assessment 2 ary care 18 Diagnosis 2 ary care18 CT 2 ary care 11Total 102 ………………………………………………. Referral/contact NSC15 AcceptanceNSC18 TransferNSC19 Consultant review NSC12 Treatment planning6 Performing procedure10 ITU access2Total 82 (45%) TOTAL 184

6. Key findings for NSC: Impact of Deficiencies on Outcome Primary care25 Secondary care33 Tertiary care 10 Total68

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? 1.Improve aSAH outcomes? 2.Do not worsen current outcomes? 3.Cost effective in relation to other measures that would improve outcomes of aSAH patients? 4.Recommendations must be evidence- based

14. Rational for Early Aneurysm Intervention 1.Prevent re-bleeding 2.Optimise medical management of poor grade patients

15. Timing of Aneurysm Intervention: NCEPOD Study General practice32 Paramedical service6 Prior presentation 2 ary care 17 Initial assessment 2 ary care 18 Diagnosis 2 ary care18 CT 2 ary care 11 Referral/contact NSC15 AcceptanceNSC18 TransferNSC19 Consultant review NSC12 Treatment planning6 Performing procedure105.4% ITU access2 TOTAL 184

16. Timing of Aneurysm Intervention: ISAT Study Rebleeding Rates Day 02.7% Day10.39% Day20.95%0.5% Day30.24% Day104.0% (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 Outcomes HELPS & 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% Clipping647 / 87074.6 %

21. Aneurysm Intervention Timing Working 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