Challenges and opportunities in the care of chronic subdural haematoma: Perspectives from a multi-disciplinary working group on the need for change
British Journal of Neurosurgery
Society of British Neurological Surgeons
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Dixon-Woods, M., Stubbs, D., Davies, B., Camp, S., Grundy, P., Johannides, A., Kolias, A., et al. Challenges and opportunities in the care of chronic subdural haematoma: Perspectives from a multi-disciplinary working group on the need for change. British Journal of Neurosurgery https://doi.org/10.17863/CAM.80051
Introduction: A chronic Subdural Haematoma (cSDH) is a collection of altered blood products between the dura and brain resulting in a slowly evolving neurological deficit. It is increasingly common and, in high income countries, affects an older, multimorbid population. With changing demographics improving the care of this cohort is of increasing importance. Methods: We convened a cross-disciplinary working group (the ‘Improving Care in Elderly Neurosurgery Initiative’) in October 2020. This comprised experts in neurosurgical care, as well as a range of perioperative stakeholders. An Implementation Science framework was used to structure discussions around the challenges of cSDH care within the United Kingdom. The outcomes of these discussions were recorded and summarised, before being circulated to all attendees for comment and refinement. Results: The working group identified four key requirements for improving cSDH care: (1) data, audit, and natural history; (2) evidence-based guidelines and pathways; (3) shared decision-making; and (4) an overarching quality improvement strategy. Frequent transfers between care providers were identified as impacting on both perioperative care, as well as presenting a barrier to effective data collection and teamworking. Improvement initiatives must be cognisant of the complex, system-wide nature of the problem and may require a combination of targeted trials at points of clinical equipoise (such as anaesthetic technique or anticoagulant management), evidence-based guideline development, and a cycle of knowledge acquisition and implementation. Conclusion: The care of cSDH is a growing clinical problem. Lessons may be learned from standardised pathways of care such as those as used in hip fracture and stroke. A defined care pathway for cSDH, encompassing perioperative care and rehabilitation, could plausibly improve patient outcomes but work remains to tailor such a pathway to cSDH care. The development of such a pathway at a national level should be a priority, and the focus of future work.
DJS is supported by a Wellcome Trust Clinician PhD Fellowship (Grant number: 220542/Z/20/Z) BMD is supported an NIHR Clinical Doctoral Research Fellowship. MDW is supported by THIS Institute’s grant from the Health Foundation. The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK. MD-W is an NIHR Senior Investigator (NF-SI-0617-10026). PJAH is supported by the NIHR (Senior Investigator Award, Cambridge BRC) and the Royal College of Surgeons of England. DKM is supported is supported by the NIHR through the Cambridge NIHR Biomedical Research Centre, and by a NIHR Senior Investigator Award The Authors also wish to acknowledge the Cambridge NIHR Biomedical Research Centre (BRC) funding. The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. Acknowledgements: This work has arisen from a Wellcome Trust funded Clinician PhD Fellowship (to DJS) and, being as the work was funded, in whole or in part, by the Wellcome Trust (Grant number: 220542/Z/20/Z) A CC BY or equivalent licence will be applied to any Author Accepted Manuscript (AAM) arising from this submission, in accordance with the grant’s open access conditions. The work was also supported by the Cambridge NIHR Biomedical Research Centre.
Health Foundation (unknown)
Department of Health (via National Institute for Health Research (NIHR)) (NF-SI-0617-10026)
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This record's DOI: https://doi.org/10.17863/CAM.80051
This record's URL: https://www.repository.cam.ac.uk/handle/1810/332604
Attribution 4.0 International
Licence URL: https://creativecommons.org/licenses/by/4.0/