Challenges and patient outcomes in chronic subdural haematoma at the level of a regional care system A multi-centre, mixed-methods study from the East of England.

BACKGROUND: Chronic subdural haematoma (cSDH) is a common neurosurgical pathology affecting older patients with other health conditions. A significant proportion (up-to 90%) of referrals for surgery in neurosciences units (NSU) come from secondary care. However, the organisation of this care and the experience of patients repatriated to non-specialist centres are currently unclear. OBJECTIVES: This study aimed to clarify patient outcome in non-specialist centres following NSU discharge for cSDH surgery and to understand key system challenges. The study was set within a representative neurosurgical care system in the east of England. DESIGN AND METHODS: We performed a retrospective cohort analysis of patients referred for cSDH surgery. Alongside case record review, patient and staff experience were explored using surveys as well as an interactive c-design workshop. Challenges were identified from thematic analysis of survey responses and triangulated by focussed workshop discussions. RESULTS: Data on 381 patients referred for cSDH surgery from six centres was reviewed. One hundred and fifty-six (41%) patients were repatriated following surgery. Sixty-one (39%) of those repatriated suffered an inpatient complication (new infection, troponin rise or renal injury) following NSU discharge, with 58 requiring institutional discharge or new care. Surveys for staff (n = 42) and patients (n = 209) identified that resourcing, communication, and inter-hospital distance posed care challenges. This was corroborated through workshop discussions with stakeholders from two institutions. CONCLUSIONS: A significant amount of perioperative care for cSDH is delivered outside of specialist centres. Future improvement initiatives must recognise the system-wide nature of delivery and the challenges such an arrangement presents.

Delays in investigation and management of acute arterial ischaemic stroke in children.

The aim of this study was to investigate the timing and course of investigation and diagnosis in children with acute arterial ischaemic stroke (AIS) and factors influencing this using a retrospective case-note review. Participants comprised 50 children (26 males, 24 females; median age at presentation 3 y 4 mo, range 2 mo-16 y 10 mo). Although all had brain infarction, symptoms resolved in less than 24 hours in 21 children (transient ischaemic attack [TIA] group). Thirty-seven children saw a doctor within 6 hours of the attack; 32 did not see a paediatric neurologist until after 24 hours. Initial neuroimaging (computed tomography or magnetic resonance imaging) occurred in less than 6 hours in 13/46 children and in more than 24 hours in 18/46 children. Brain magnetic resonance imaging occurred in more than 24 hours in 43/47 children. Time to clinical diagnosis (data available on 42 children) was less than 6 hours in 14 children, 6 to 12 hours in six, 12 to 24 hours in eight, and more than 24 hours in 14 children. In multiple regression analysis, patients with stroke were more likely to have shorter time to diagnosis than those with TIA. Our results show that most children with acute AIS are seen within 6 hours but definitive imaging and specialist assessment take more than 24 hours. Time to diagnosis is significantly longer in children with TIA (p=0.001). Trials of acute treatment being designed for childhood AIS will require rapid transfer to tertiary centers and access to definitive neuroimaging, but these data suggest that this will challenge existing practice.