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