In search of the perfect outcome in neuroanaesthesia and neurocritical care

Management of traumatic brain injury in the non-neurosurgical intensive care unit: a narrative review of current evidence

Each year, approximately 70 million people suffer traumatic brain injury, which has a significant physical, psychosocial and economic impact for patients and their families. It is recommended in the UK that all patients with traumatic brain injury and a Glasgow coma scale ≤ 8 should be transferred to a neurosurgical centre. However, many patients, especially those in whom neurosurgery is not required, are not treated in, nor transferred to, a neurosurgical centre. This review aims to provide clinicians who work in non-neurosurgical centres with a summary of contemporary studies relevant to the critical care management of patients with traumatic brain injury. A targeted literature review was undertaken that included guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials (published in English between 1 January 2017 and 1 July 2022). Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also eligible for inclusion. Analysis of the topics identified during the review was then summarised. These included: fundamental critical care management approaches (including ventilation strategies, fluid management, seizure control and osmotherapy); use of processed electroencephalogram monitoring; non-invasive assessment of intracranial pressure; prognostication; and rehabilitation techniques. Through this process, we have formulated practical recommendations to guide clinical practice in non-specialist centres.

Value-based Care and Quality Improvement in Perioperative Neuroscience

Value-based care and quality improvement are related concepts used to measure and improve clinical care. Value-based care represents the relationship between the incremental gain in outcome for patients and cost efficiency. It is achieved by identifying outcomes that are important to patients, codesigning solutions using multidisciplinary teams, measuring both outcomes and costs to drive further improvements, and developing partnerships across the health system. Quality improvement is focused on process improvement and compliance with best practice, and often uses "Plan-Do-Study-Act" cycles to identify, test, and implement change. Validated, standardized core outcome sets for perioperative neuroscience are currently lacking, but neuroanesthesiologists can consider using traditional clinical indicators, patient-reported outcomes measures, and perioperative core outcome measures. Several examples of bundled care solutions have been successfully implemented in perioperative neuroscience to increase value; for example, enhanced recovery for spine surgery, delirium reduction pathways, and same-day discharge craniotomy. This review proposes potential individual- and system-based solutions to address barriers to value-based care and quality improvement in perioperative neuroscience.