Care delays ‘harm brain bleed patients’, warns review
Patients suffering a brain haemorrhage could be unnecessarily harmed due to delays in diagnosis and treatment - especially at weekends and out of hours, a report says.
A lack of good care from GPs and hospitals means some patients do not get brain scans on time or treatment that could save their lives.
The report, from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), looked at brain haemorrhages caused by a cerebral aneurysm (aSAH) - which represents the vast majority of brain haemorrhages.
Around 5,000 people in the UK suffer one every year and half of patients are aged under 60.
Survival rates following a brain haemorrhage are already poor. Half of patients die within a month of the haemorrhage while at least half of those who survive the first month will be dependent on others for help with daily tasks such as bathing, dressing and eating.
Only 25% of those who experience a brain haemorrhage go on to live a normal life.
Today’s report examined the cases of individual patients in detail to work out the rate at which treatment or diagnosis may have been delayed.
In 18% of cases (75/427), patients saw their GP with symptoms, which can include a sudden headache and vomiting.
The study found GPs delayed diagnosis or “overlooked” a diagnosis of haemorrhage in almost half of these cases (32/75).
Out of these 32 patients, 23 had their outcome potentially affected by the delays.
In hospitals, patients were not assessed as often by senior clinicians out of normal working hours, with consultants performing 22/94 initial assessments from 8am to 6pm but only 3/31 between 6pm and midnight none between the hours of midnight and 8am.
In one case, a man admitted to A&E was misdiagnosed as having problems caused by alcohol when in fact he was suffering a brain haemorrhage.
He was only seen by a consultant three days after admission.
The report also found that most patients admitted to hospital (68%) did not have a CT scan within one hour to diagnose the condition, despite the fact haemorrhages can kill quickly.
Delays in requesting CT scans were also more common out of hours than during the normal working day.
Furthermore, there were not enough interventional neuroradiologists available 24 hours a day across the hospitals studied.
The report also found that a quarter of hospitals were unable to perform lumbar punctures - another way of diagnosing aSAH - 24 hours a day seven days a week.
A third of hospitals had no protocol to investigate acute onset headaches and treatment delays were more frequent following admission at the weekend.
Some 70% of weekday admissions had an intervention within 24 hours of admission compared to 30% of weekend admissions.
The study said that despite major improvements in the treatment of patients, there were still “serious concerns” over delays in assessment, diagnosis, referral, transfer and treatment.
Report co-author Dr Alex Goodwin, NCEPOD clinical co-ordinator and consultant in anaesthesia and intensive care, said: “This report highlights a lot of good care, but the lack of protocols for managing the care of patients with aSAH found in this study is most striking.
“I am extremely concerned that delay in diagnosis in primary and secondary care, and delays to treatment, particularly over the weekend, are affecting patient care. It is already known that the-time-to treatment is significantly longer in the UK than it is in other developed countries.”
NCEPOD chairman, Bertie Leigh, questioned why there were longer intervals in treatment at weekends and out of hours.
“Is it true that as a result we must endeavour to present our cerebral bleeds during working hours, and not at weekends?,” he said.
Overall, NCEPOD advisers judged that 58% of care provided to patients in the study was good.
The Society for Acute Medicine (SAM) welcomes the report. Dr Alistair Douglas, SAM president, said: “This study reviewed many aspects of the care of patients with aSAH. Acute onset headache is a common presentation to A&E departments and acute medical units and only a small minority (10% or less) will have aSAH or another serious condition as the cause.
“The good news is that the majority of cases were felt to have no room for improvement in care, 96% received adequate investigation in secondary care and there was no delay in CT scan requesting in 90% of cases. There were cases where care could have been better and all involved in acute medicine are encouraged to read the report”.
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