Document 350537
Adult Neurosurgery Quality Dashboard Measure Number Theme Measure Description & Provenance Name of KPI Numerator Denominator Frequency Numerator Data Source Denominator Data Notes Source patient Number of subarachnoid haemorrhage Number of emergency subQuarterly patients admitted to a neurosurgical arachnoid patients referred to centre within 24 hours of referral. a neurosurgical centre Local Data item from neurosurgical centre / Neurosurgery Audit TBC Local Data item from neurosurgical centre / Neurosurgery Audit TBC All patients with a confirmed diagnosis Aneurysmal SAH intervention timing rate Number of sub-arachnoid patients Number of aneurysmal subQuarterly of aneurysmal sub-arachnoid (48 hours) treated by either clipping or coiling arachnoid patients treated at a hamorrhage admitted to a neurosurgical within 48 hours of the MDT decision to neurosurgical centre centre should undergo the selected proceed intervention (coiling or clipping) within 48 hours of the MDT decision to proceed Local Data item from neurosurgical centre / Neurosurgery Audit TBC Local Data item from neurosurgical centre / Neurosurgery Audit TBC AN01 Domain 1: Preventing people from dying prematurely Prompt treatment of sub- All stable patients with a confirmed Subarachnoid haemorrhage arachnoid haemorrhage diagnosis of sub-arachnoid hamorrhage transfer rate (24 hours) should be transferred to a neurosurgical centre within a 24 hours AN02 Domain 1: Preventing people from dying prematurely Prompt treatment to prevent rebleed following admission for aneurysmal sub-arachnoid haemorrhage AN03 Domain 3: Helping people Prompt response by to recover from episodes of network to ensuring the ill health or following injury treatment of isolated brain injury Networks deliver rapid access to urgent Isolated trauma craniotomy Networktiming Number of patients with AIS 3 or above Number of patients with AIS 3 Quarterly neurosurgical intervention rate (4 hours) brain injury receiving craniotomy within or above brain injury requiring 4 hours of injury craniotomy Local Data item from neurosurgical centre / Neurosurgery Audit TBC Local Data item from neurosurgical centre / Neurosurgery Audit TBC AN04 Domain 3: Helping people Prompt treatment of to recover from episodes of patients requiring ill health or following injury craniotomy for isolated brain injury Major Trauma Centres deliver rapid access to urgent neurosurgical intervention Isolated trauma craniotomy MTC timing Number of patients with AIS 3 or above Number of patients with AIS 3 Quarterly rate (2 hour) brain injury receiving craniotomy within or above brain injury receiving 2 hour of arrival at a Major Trauma craniotomy Centre Local Data item from neurosurgical centre / Neurosurgery Audit TBC Local Data item from neurosurgical centre / Neurosurgery Audit TBC AN05 Domain 4: Ensuring that people have a positive experience of care Neurosurgical National Audit Programme Neurosurgery units are committed to audit Full participation in the Neurosurgical Number in time period in registry National Audit Programme Number in time admitted to unit Local Data item from neurosurgical centre / Neurosurgery Audit TBC Local Data item from neurosurgical centre / Neurosurgery Audit TBC AN06 Domain 4: Ensuring that people have a positive experience of care Minimising pre-operative Maximising the number of elective length of stay surgery patients treated on the day of admission (excluding day cases) % of elective surgery patients treated on Number of elective surgery patients the day of admission treated on the day of admission (excluding day cases) Number of elective surgery patients treated (excluding day cases) Quarterly Local Data item from neurosurgical centre / Neurosurgery Audit TBC Local Data item from neurosurgical centre / Neurosurgery Audit TBC AN07 Domain 4: Ensuring that people have a positive experience of care Minimising cancellation of Minimising cancellation of operations operations for patients for patients already admitted for already admitted craniotomy % of elective craniotomies cancelled Number of elective craniotomy Number of elective craniotomy Quarterly operation after admission patients who experience a cancelled patients operation after admission Local Data item from neurosurgical centre / Neurosurgery Audit TBC Local Data item from neurosurgical centre / Neurosurgery Audit TBC AN08 Domain 5: Treating and Implant infection caring for people in a safe environment and protecting them from avoidable harm Neurosurgical Implant 6 month SSI rate Local Data item from neurosurgical centre / Neurosurgery Audit TBC Local Data item from neurosurgical centre / Neurosurgery Audit TBC Infection is minimised period Quarterly Number of patients having a Number of patients having a neurosurgical implant that develop neurosurgical implant infection requiring explantation or admissions for intravenous antibiotics within six months of implantation Quarterly the term “operated” will be recognised as meaning craniotomy or coiling ROCR/OR/2230/001MAND
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