NCCNet

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NCCNet Neuro-Critical Care Network
nccnet.org.uk
The Concept March 2007 - Paddy Yeoman and Keith
Girling invited interested parties around the UK
to a meeting in Nottingham. There was broad
critical care representation including
neurosurgery and ICNARC. The general feeling was
that neuro-critical care had reached a stage
where there appears to be evidence that care
given in specific neuro-critical care units for
severe traumatic head injuries may lead to better
patient outcomes than in general units, and
therefore a network of neuro-critical care units
was a good idea. This might allow further audit
and research to assess the veracity of this, and
if so why this might be. It could then extend its
view to see if it is true for other serious
neurological disease e.g. spontaneous
subarachnoid haemorrhage. The basic aims of the
group were agreed in principle and that it should
be named the Neuro-Critical Care Network
NCCNet Two further meeting were held 2nd Meeting
- Nov 2007 Nottingham 3rd Meeting Feb 2008
Oxford At which Interim structure
agreed Progress on work streams reviewed

• The grant proposal would be developed accounting
  for ongoing competing studies, thus ensuring
  timely completion of projects, but also ensuring
  equity of access to patient populations.
• Wherever possible we would try to make the best
  use of patient populations, by interleaving
  studies that are complementary and synergistic.
  This would allow for simultaneous observational
  studies.

Other ongoing trials We will also keep members
informed about current or emerging multicentre
studies which they may wish to participate in.
To address this in the current context, there are
two interventional studies either currently
running or on the horizon RESCUEicp A
randomised trial of decompressive craniectomy for
refractory intracranial hypertension in TBI
(www.rescueicp.com Funded by MRC, PI Peter
Hutchinson, Cambridge). Study ongoing, target
600 subjects, currently recruited 146
patients. EuroTherm A planned randomised trial
of hypothermia in TBI (funded by ESICM PI Peter
Andrews, Edinburgh). Protocol being finalised
details will appear on the NCCnet website.

• The Aims
• To develop a national network of critical care
  units providing neuro-critical care.
• To share evidence and best practice, which may in
  time and in conjunction with other stakeholders
  include recommendation of standards for
  neuro-critical care.
• To develop national comparative audit of patient
  outcomes from neuro-critical care in co-operation
  with ICNARC.
• To develop a national network to support
  multi-centre audit and research.

• Current Practice Survey
• Dr John Andrzejowski, Sheffield, Dr Chris Kearns,
  Oxford, Dr Ian Tweedie, Liverpool,
• Dr John Adams, Leeds, Prof. Ravi Mahajan,
  Nottingham
• Aim to collect baseline data on current
  facilities and general management of STBI in all
  UK neuro-surgical critical care units.
• A questionnaire was devised which looked at two
  main areas
• - General unit data and facilities.
• - A Scenario with the aim of gaining an
  insight in to each
• units general management of a
• patient with a severe traumatic brain injury.

• Possible Stakeholders
• All critical care units connected to a neuro-unit
  in the UK
• ICNARC/TARN
• ICS/SICS
• NAS/ SBNS/ BAN
• DOH neuro-critical care stakeholders group

Where does NCCNet fit in?
32 adult neuro-units contacted via NAS linkmen
system 17 UK units have responded

• Survey Interim Results
• In general all the units have similar facilities
• The majority have an STBI treatment guideline
• The majority will use aggressive treatments
  (hypothermia, barbiturate coma or decompressive
  craniectomy) but vary as to when and in which the
  order they are instituted

• Interim Structure
• Chairman/Database coordinator - Dr Paddy
  Yeoman
• Nottingham
• Project steering group lead -
  Prof. David Menon
• Cambridge
• Treasurer -
  Dr Chris Kearns
• Oxford
• Secretary (North) -
  Dr Ian Tweedie
• Liverpool
• Secretary (South)/ Webmaster - Dr Roger
  Lightfoot
• Southampton
• Co-opted Technical advisor - Dr
  Ian Piper,
• Brain IT
• ICNARC -
  Dr Kathy Rowan

Data compared with two similar studies
Comparative CPP targets

• Current work Streams
• Database of contacts/basic info for all ICUs
  associated with a neuro-unit
• Invite all units and potential stakeholders to
  get involved
• Develop an operating document and a website
• Survey current practice of STBI critical care
  management from around the country
• Continue development of neuro-dataset and
  support ICNARCs bid to secure funding for the
• RAIN (risk adjusted outcome in neuro-critical
  care) project.

• Jeevaratnam DR, Menon DK. BMJ 1996 312 944 7
• Matta BF, Menon DK. Crit. Care Med. 1998 24
  1743 - 8

Future funding and projectsProf D. Menon,
Cambridge At the Oxford meeting of NCCnet
stakeholders, we addressed the issue of finding
funding to underpin the collaborative network.
In the long run, we would hope that the data
collection for risk adjustment would be
recognised by the Department of Health as a
clinical governance need (as with ICNARC at the
moment). However, we need to show that such data
effectively aid robust risk adjustment. The
research that underpins this demonstration is the
basis of a collaborative study currently being
considered for funding by the Health Technology
Assessment (HTA) Program RAIN.

• Conclusions from Survey
• From the snapshot of responses, it appears that
  the general thrust of STBI management is similar
  across the UK
• Most units seem to be adopting current evidence
  base for their STBI care
• However - we need a much more robust
  communication system with each neuro-critical
  care unit!

RAIN The HTA application, which is entitled Risk
Adjustment in Neurocritical care (RAIN) seeks to
evaluate and refine existing models of risk
adjustment in Traumatic Brain Injury (TBI). The
study is based at ICNARC, and NCCnet is a key
stakeholder. The project seeks to collect
clinical and imaging data on 3,400 patients with
TBI who require ICU admission, either in District
General Hospitals, or in Neurosciences centres.
All recruited patients will have a postal Glasgow
Outcome Score at follow up. The planned start
date for the project is September 2008, with the
first patients recruited in January 2009, and
follow up completed June 2010. Publications are
expected to emerge in early 2011.

• Website www.nccnet.org.uk
• Features
• Up-to-date information on our activities
• Meeting details
• Registration page to register your details in
  order
• to receive emails re future meetings etc.
• Secure access if needed
• A Blog

• The collaboration that is activated by RAIN will
  provide the data collection framework on which
  further studies will be built. The aim is to
  maximise clinical audit and research in
  neurocritical clinical populations, so as to
  ensure that the best available evidence is being
  translated into clinical practice, and where such
  evidence is not available, we try our best to
  acquire it through high quality multicentre
  studies. We envisage applying for additional
  funding for such subsequent studies in an open
  and collaborative manner, which will replicate
  the success enjoyed by the Canadian Critical care
  Network. Individual members of NCCnet would
  propose ideas for research which will be
  discussed openly, refined and then submitted as
  funding proposals, lead by the centre or
  individual that was responsible for their
  development. We hope that the mechanisms by
  which these proposals reach maturity will
  maximise our chances of funding success
• Topics for research will emerge from analyses of
  existing data, or through analyses specifically
  undertaken to
• underpin proposed studies.
• An additional underpinning will be provided,
  wherever appropriate, by a systematic review of
  the available
• evidence in some instances this will be
  undertaken as a preparatory publication by an
  NCCnet member.
• We would use the NCCnet collaboration to drive
  the collection of pilot data or epidemiological
  data which
• strengthened the case for the study.

• NCCNet Contact Database
• All adult units in UK and Northern Ireland now
  have a contact listed in our database

Anyone with a clinical or academic interest in
neuro-critical care is invited and welcome to get
involved!
You can contact NCCNet via the website or
directly with Dr I Tweedie The Walton Centre
for Neurology and Neurosurgery, Liverpool
Ian.tweedie_at_nccnet.org.uk Dr R Lightfoot
Wessex Neurological Centre, Southampton
roger.lightfoot_at_nccnet.org.uk