NORTH WALES NEUROSCIENCES REVIEW

 Head Injury, Spinal Surgery, Critical Care

and Radiology Workstream

 SECOND PHASE REPORT

Dr Paul Birch

May 2009

Head Injury, Spinal Surgery, Critical Care and Radiology Workstream

Workstream Aim

Produce agreed plans to develop services in the following areas;

•neurocritical care

•head injury

•non-complex spinal surgery

•neuroimaging

Areas excluded from remit•Stroke•Rehabilitation•Complex and emergency spinal surgery

Phase 1 - Investigate present knowledge. Phase 2 - Long list of models and options  Phase 3 - Develop final preferred model of implementation against the original areas of recommendation.

Head Injury, Spinal Surgery, Critical Care and Radiology Workstream

Methodology.

Head Injury, Spinal Surgery, Critical Care and Radiology Workstream

The Radiology Group identified that they did not need to meet again until the final cycle.

Head Injury, Critical Care and Spinal Surgery groups generated a list of options prior to discussion at the phase 2 meetings.

Outcome of Phase 1 :

Head Injury, Spinal Surgery, Critical Care and Radiology Workstream

Phase 2 meetings followed similar formats considering:

List of models and options based on information/data gathered in phase1

Questions to be considered     Preferred Option/s & Actions prior to next meeting Work plan and Communication

Spinal Surgery

Members

Dr Paul Birch Workstream ChairCrispin Wigfield, Walton Centre Karen Smith, Case Manager, Community HDT, North West Wales NHS Trust

Lyn Roberts, Senior Nurse, A & E, Ysbyty Gwynedd

Stephen Jones, Head of Speech and Language Therapy, North West Wales NHS Trust

Glynne Andrew, Consultant Orthopaedic Surgeon, North West Wales NHS Trust

Georgina Mudge, Physiotherapist, North West Wales NHS Trust Ian Langfield, Health Commission Wales

Ed Farley Hills, Consultant Anaesthetist, North West Wales NHS Trust

Jeff Pye, Head of I M & T, North West Wales NHS Trust

Wendy Farrington Chad, Chief Executive, Robert Jones and Agnes Hunt Hospital

Spinal Surgery – Options

•Do Nothing

•Refer all patients to a single tertiary provider

•Refer to a mix of tertiary providers

•Develop a local service for non-complex spinal surgery with remaining patients referred to tertiary providers

•Commission a local service from tertiary provider(s)

•Develop a service referring patients to the Countess of Chester for non-complex spinal surgery and all other patients being referred to tertiary providers

Spinal Surgery - Questions

Are there sufficient patients for a local service

•All patients with back problems benefit from triage and appropriate referral. Triage services in North Wales are at different stages of development. For the majority of patients there is no surgical input to decision making.

•Increase in referrals over the 2008 – 2009 period in comparison to previous years.

•Predominant increase in Chester and Walton.

•Greatest growth in unspecified spinal puncture.

•More information on increase expected

•Requirements to develop a service

•Surgery for lower back pain alone- evidence of benefit is equivocal.

•Surgery for patients with lower back pain and sciatica appears to shorten the period of disability allowing early return to functionality.

• Services for patients with back pain require leadership- there are different models across North Wales.

• Both main tertiary providers indicated that they can provide and support a range of services in North Wales, but not local surgery.

Spinal Surgery - Questions

0

20

40

60

80

100

120

140

160

Other specifiedprimary

decompressionoperations onlumbar spine

Other specifiedprimary excision

of lumbarintervertebral

disc

Primaryfenestrationexcision of

lumbarintervertebral

disc

Primaryintertransverse

fusion of joint oflumbar spine

NEC

Primarylaminectomyexcision of

lumbarintervertebral

disc

Primary lateralforaminotomy of

lumbar spine

Primarymicrodiscectomy

of lumbarintervertebral

disc

Primary posteriordecompressionof lumbar spinal

cord andintertransverse

fusion of joint oflumbar spine

Primary posteriordecompressionof lumbar spinal

cord NEC

Primary posteriorfusion of joint of

lumbar spineNEC

Primary posteriorlaminectomy

decompressionof lumbar spinal

cord

Unspecifiedprimary

decompressionoperations onlumbar spine

Unspecifiedprimary excision

of lumbarintervertebral

disc

Grand Total

•Would such a service be viable?

•The numbers of patients undergoing spinal surgery in North Wales shows a significant increase over time. In 2007/08 there were 147 patients identified as undergoing non complex spinal surgical procedures for lower back problems. This is probably sufficient to sustain 2 Spinal Surgeons

Spinal Surgery - Questions

•To develop a detailed model identifying the requirements to set up a local service in North Wales for non complex spinal surgery

•Identify resource in current service provision

Spinal Surgery - ACTIONS

Head Injury & Critical Care

Members

Dr Paul Birch, Workstream LeadCrispin Wigfield, Walton Centre for Neurology and NeurosurgeryDavid Cartlidge, Consultant, A & E, North Wales (Central) Karen Smith, Case Manager, Community HDT, North West Wales NHS TrustLyn Roberts, Senior Nurse, A & E, Ysbyty GwyneddStephen Jones, Head of Speech and Language Therapy, North West Wales NHS Trust Pauline Cutting, Consultant A & E, North West Wales NHS TrustGlynne Andrew, Consultant Orthopaedic Surgeon, North West Wales NHS TrustGeorgina Mudge, Physiotherapist, North West Wales NHS Trust Ian Langfield, Health Commission WalesEd Farley Hills, Consultant Anaesthetist, North West Wales NHS TrustJeff Pye, Head of I M & T, North West Wales NHS TrustAeneas O’Kelly, Consultant Orthopaedic Surgeon, North Wales (Central)

Head Injury & Critical Care - Options

Difficult to generate a formal options list as most recommendations are either do

or not do.

Head Injury & Critical Care – Options Neurosurgery

•Plans in place to expand the critical care capacity of the Walton Centre

• Monitor effect•consider need for further capacity at Walton•consider neurocritical care in North Wales.

•Develop clear and unequivocal guidelines across North Wales for the management of:

•The Management of Acute Head Injury- Achieved. •The management of Spontaneous Subarachnoid Haemorrhage- Pathway development in progress. •The management of an acute Neurovascular event- Pathway development in progress. •The management of Acute Spinal Injury and Cauda Equina Compression- Development in progress by the Walton Centre. •The management of metastatic spinal cord compression (NICE)- NICE guidance available. Walton Centre developing pathways in response to these.•The management of brain and other CNS tumours (NICE)- NICE

guidance available. Walton Centre developing pathways in response.

Head Injury & Critical Care – Neurosurgery Guidelines

Head Injury & Critical CareNeurosurgery Recommendations

A videoconference link to the Walton Centre should be established both to facilitate the above and to improve consultation on individual patients.

Head Injury & Critical CareNeurotrauma

•Agree number and location of receiving units and ensure clearly designate person is responsible for the inpatient clinical care of non-neurosurgical head injuries and ensure that clinicians have the appropriate training and that a governance system is in place- Achieved.

 

•Develop local facilities for overnight monitoring of patients that do not require transfer- Achieved but model of care and senior input inconsistent.

Head Injury & Critical CareNeurotrauma Recommendations

The model for immediate care of patients who do not require transfer should be standardised across North Wales as part of the Unscheduled Care Project.  

•Expand the critical care capacity of the Walton Centre 

•The SBNS (Society of British Neurological Surgeons) and TARN guidelines be adopted- Achieved

Head Injury & Critical CareNeurotrauma Recommendations

The robustness of data collection systems to monitor application varies across the 3 main sites and with time. A robust system of data collection to monitor outcome should be developed.  

•Development of improved transport to address delays e.g. use of air ambulance – Work in progress- Air ambulance Service.

 •Develop local 24/7 MRI services and supporting diagnostic tests- Radiology workstream.

 

Head Injury & Critical CareNeurocritical care Recommendations

•Many of the recommendations are being taken forward under as part of improving service for Neurosurgery  •Develop Accident and Emergency Departments in North Wales to ensure necessary resources to assess, image and stabilise patients with acute neurological conditions and as part of multiple trauma or multi system failure, is available- Currently in place. However will be reviewed as part of the Unscheduled Care project.

 •Develop appropriate facilities locally to allow the transfer/repatriation of patients to in a timely manner- North Wales Critical Care Pathway for severely head injured patients in place.

Head Injury & Critical CareCritical care outreach/Rehabilitation Recommendations

Recommendations are being taken forward via the Rehabilitation workstream and the Walton centre

Head Injury & Critical CareLong Term Ventilation Recommendations

Development of a ‘step-down’ facility for the management of patients who require long term ventilatory support with 24/7 medical cover and located on an acute hospital site/sites.

This forms part of a separate project addressing the need for long term ventilation across Wales.

Head Injury & Critical CareQuestions

•Which workstream should be addressing the intermediate care for disinhibited post acute patients with head injury?

• Should we developing a neuropsychiatric service either locally or with outreach from Walton?

•Will the rehabilitation workstream be making specific recommendations around the care of patients in transition from adolescence to adulthood?

•Confirm the evidence base of each objective

•Confirm the benefits associated with the objective

•Verify the choice of options against the objectives and benefits and that there is an evidence base

•Ensure no tenable options have been eliminated

Head Injury, Spinal Surgery, Critical Care and Radiology WorkstreamNext Stage

Then:Shortlist options using benefit criteria

Then:Undertake Benefits Appraisal