Chronic subdural haematomas: a single-centre experience developing an integrated care pathway.

OBJECTIVE: To improve quality of care for patients presenting with chronic subdural haematoma (CSDH) by introducing a multi-disciplinary integrated care pathway. SUMMARY BACKGROUND: CSDH is a common neurological condition. Incidence rises with age and currently affects around 58/100 000 people over 70 years. Six-month mortality is high (26%), however integrated care pathways have been shown to improve patient outcomes in other surgical subspecialties. MATERIALS AND METHODS: A baseline retrospective audit completed in 2012 identified areas for improvement in patient management. Stakeholder meetings were held with subsequent development and implementation of a patient care pathway. A post-implementation prospective audit was completed between January and October 2015. DATA COLLECTED: patient demographics, medical co-morbidities, use of anti-platelet and anti-coagulant medication, timing of surgery, length of hospital stay, morbidity and mortality data, and reaccumulation rate. RESULTS: Patient groups were similar with a high incidence of multi-morbidity. The key areas targeted for improvement included enhanced pre-operative optimisation and time to surgery. Implementation of the patient care pathway significantly increased the number of patients undergoing surgery within 24 hours of admission (43% vs. 75%, p = 0.0006) but length of hospital stay did not change. Operative morbidity and mortality remained similar and there was no significant difference in CSDH reaccumulation rate. CONCLUSION: Our patient care pathway appears to have improved pre-operative care and significantly increased the proportion of patients undergoing surgery within 24 hours of admission. Difficulties were encountered with changing existing practice. Prospective research is required to demonstrate the full benefits, which may include a reduction in health and social care costs.

Titanium cranioplasty and the prediction of complications.

OBJECTIVES: Titanium cranioplasty (TC), the operative repair of a skull defect with an ergonomically manufactured plate to restore cosmesis, cranial function and reduce complications is a common neurosurgical procedure. It is technically simple but has high complication rates. This study aimed to determine the incidence and predictors of complications following TC. DESIGN: Retrospective review. SUBJECTS: All patients undergoing TC over a 42-month period in our institution. METHODS: Data was collected from the hospital database and case-notes. 3D CT reconstructions accurately measured defect size and location. Statistical analysis included correlation, independent variable analysis and descriptive methods. RESULTS: A total of 95 TCs were analysed in 92 patients (3 cases of bifrontal cranioplasty). The commonest indications for TC were bony defect following removal of infected bone flap (n = 20), acute subdural haematoma (n = 18) and post-malignant infarction (n = 11). The commonest site was frontotemporoparietal (n = 61) and the overall complication rate was 30.4%. The commonest complication was infection and the overall removal rate was 8.4%. The mean cranioplasty area was 73.26 cm(2) (range 12.78-178.26 cm(2)). There was a significant relationship between area and length of post-operative hospital stay (p = 0.008, Pearson Rank). There was no significant relationship between area and complications, removal rates or infections. There was no relationship between age and total complications, post-operative hospital stay and infections. There was a non-significant trend for older patients to have their cranioplasty removed. CONCLUSIONS: TC size is predictive of postoperative length of stay. However, the TC size is not predictive of complications or removal rate. Also, there was no association between interval since primary operation and complications. There was a non-significant trend for greater rates of TC removal in the elderly. There were no predictors of complications identified but they are common and patients should be consented accordingly.