title: Chronic subdural haematomas: a single-centre experience developing an integrated care pathway.
abstract: OBJECTIVE
  To improve quality of care for patients presenting with chronic subdural haematoma (CSDH) by introducing a multi-disciplinary integrated care pathway.
  
  
  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.
  
  
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: a Department of Neuroanaesthesia , National Hospital for Neurology and Neurosurgery , London , UK.
authors.forename: Smita
authors.initials: S
authors.lastname: Bapat
authors.affiliation: b Victor Horsley Department of Neurosurgery , National Hospital for Neurology and Neurosurgery , London , UK.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Shapey
authors.affiliation: b Victor Horsley Department of Neurosurgery , National Hospital for Neurology and Neurosurgery , London , UK.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Toma
authors.affiliation: b Victor Horsley Department of Neurosurgery , National Hospital for Neurology and Neurosurgery , London , UK.
authors.forename: Louise
authors.initials: L
authors.lastname: Platt
authors.affiliation: a Department of Neuroanaesthesia , National Hospital for Neurology and Neurosurgery , London , UK.
authors.forename: Astri Maria Valpuri
authors.initials: AMV
authors.lastname: Luoma
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D019033:Delivery of Health Care, Integrated; D005260:Female; D020200:Hematoma, Subdural, Chronic / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D006801:Humans; D015994:Incidence; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D010348:Patient Care Team; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed
keywords: Chronic subdural haematoma; elderly; intregrated care pathway; multidisciplinary; optimisation; preoperative