At the Walton Centre we conduct a relatively large number of complex and lengthy elective (booked) spinal operations. Recently, we have had a particular problem with half or more of these sessions finishing late, resulting in staff discontent and greater use of on-call staff.These operations require patient monitoring by neurophysiology clinical scientists. Before the surgeon can start the operation, in-theatre neurophysiological measurements are required to establish a baseline. We reasoned that reducing this set-up time would reduce the risk of surgery starting late, and so the whole session finishing later than expected.In this project we redesigned the neurophysiology parts of in-theatre patient preparation. We conducted five Plan-Do-Study-Act cycles over 3 months, reducing the duration of pre-surgery preparation from a mean of 70 min to around 50 min. We saw improvements in surgical start times and session finish times (both earlier by roughly comparable amounts). The ultimately impact is that we saw on-time session finishes improve from around 50% to 100%. Following this project, we have managed to sustain the changes and the improved performance.The most impactful change was to conduct in-theatre neurophysiology patient preparation simultaneously with anaesthesia, rather than waiting for this to finish; when we performed this with a pair of clinical scientists, we were able to complete neurophysiology patient preparation by the time the anaesthetist was finished, therefore not introducing delays to the start of surgery. A final change was to remove a superfluous preparatory patient-baseline measurement.This is a very challenging and complex environment, with powerful stakeholders and many factors and unpredictable events affecting sessions. Nevertheless, we have shown that we can make improvements within our span of influence that improve the wider process. While using pairs of staff requires greater resource, we found the benefit to be worthwhile.
IntroductionA first unprovoked seizure is a common presentation, reliably identifying those that will have recurrent seizures is a challenge. This study will be the first to explore the combined utility of serum biomarkers, quantitative electroencephalogram (EEG) and quantitative MRI to predict seizure recurrence. This will inform patient stratification for counselling and the inclusion of high-risk patients in clinical trials of disease-modifying agents in early epilepsy.Methods and analysis100 patients with first unprovoked seizure will be recruited from a tertiary neuroscience centre and baseline assessments will include structural MRI, EEG and a blood sample. As part of a nested pilot study, a subset of 40 patients will have advanced MRI sequences performed that are usually reserved for patients with refractory chronic epilepsy. The remaining 60 patients will have standard clinical MRI sequences. Patients will be followed up every 6 months for a 24-month period to assess seizure recurrence. Connectivity and network-based analyses of EEG and MRI data will be carried out and examined in relation to seizure recurrence. Patient outcomes will also be investigated with respect to analysis of high-mobility group box-1 from blood serum samples.Ethics and disseminationThis study was approved by North East—Tyne & Wear South Research Ethics Committee (20/NE/0078) and funded by an Association of British Neurologists and Guarantors of Brain clinical research training fellowship. Findings will be presented at national and international meetings published in peer-reviewed journals.Trial registration numberNIHR Clinical Research Network's (CRN) Central Portfolio Management System (CPMS)—44976.
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