Clinical audit effectively bridges the evidence-practice gap in chronic subdural haematoma management

Abstract

BackgroundPlacement of a subdural drain after drainage of chronic subdural haematoma (CSDH) has been shown to reduce the rate of recurrence in several randomised controlled trials (RCT). The most recently published RCT was from Cambridge, UK, in 2009. Despite class I evidence for the use of subdural drains, it is unclear whether these results have been translated into clinical practice. In this clinical audit we review the use of subdural drains in our institution before and after the publication of the 2009 RCT results.MethodsA longitudinal retrospective study was performed on all adults having burr holes for CSDH between January 2009 and January 2014. Case notes were analysed to determine subdural drain use, re-operation for CSDH recurrence and post-operative complications. The audit loop was closed with data collected from August 2015 to January 2016.ResultsThirty-one per cent of patients had subdural drains placed at operation. Drain placement was associated with lower reoperation rates (8% vs. 17%, p = 0.021) without increasing complication rates. Drain usage doubled after publication of the Santarius et al. (2009) trial but we observed persisting and significant variability in drain utilisation by supervising consultants. The use of drains in the department increased from 35% to 75% of all cases after presentation of these results.ConclusionsThe use of subdural drains in our unit reduced recurrence rates following drainage of CSDH and reproduced the results of a 2009 clinical trial. Although the use of subdural drains doubled in the post-trial epoch, significant variability remains in practice. Clinical audit provided an effective tool necessary to drive the implementation of subdural drain placement in our unit.

Inner membrane opening during the burr-hole evacuation of a chronic subdural hematoma: risk-adding or recurrence-preventing?

“…Tailor et al [5] performed a retrospective study on burr-hole drainage of CSDH and found that the 6month reoperation rate was 8.1% (10/123) in the subdural drain group. Incision of the hematomas' inner membrane was not done, and 21.1% of cases were bilateral.…”

“…This condition has been treated by various surgical procedures such as burr-hole evacuation, twist-drill craniostomy, and craniotomy. However, all these procedures are associated with several complications including recurrence [1][2][3][4][5].…”

“…Burr-hole evacuation and closed-system drainage are the most common technique worldwide in evacuating a CSDH [1][2][3][4][5][6][7][8][9], but still, there is no consensus about many operative steps including the opening of the inner membrane of the subdural hematoma as there is no conclusive evidence of its benefits or risks.…”

Transition of a Clinical Practice to Use of Subdural Drains after Burr Hole Evacuation of Chronic Subdural Hematoma: The Helsinki Experience

“…11,17 However, numerous questionnaire surveys indicate that there is an evidencepractice gap in the usage of drains, as not all neurosurgeons place them regularly. 4,[18][19][20][21][22] Despite reported evidence supporting the benefits of drain placement, drain usage in everyday practice within the neurosurgical department of Helsinki University Hospital was arbitrary until, on April 1, 2017, consistent management of CSDHs with subdural drains was established in our clinic.…”

Chronic subdural haematoma: disseminating and implementing best practice

“…The accompanying paper by Tailor et al from the King's College Hospital in London provides a unit-specific perspective regarding the post-trial dissemination and implementation phase [12]. The authors report that the use of drains increased from 17% to 35% in the post-trial period, but it was only until after a departmental presentation of the trial results in 2015 that drain utilisation increased to 75%.…”