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Abdullah Al Jadidi,¹ Adil Al-Kharusi,¹ Keshavan H Venkatesh,¹ Sharma Pradeep Kumar,¹ Ruqaiya Al Harthi²

The Beginning

Neuroscience services in Oman were first established in Khoula Hospital in 1974. Khoula hospital was the first surgical hospital in the Sultanate of Oman and has a current capacity of 530 beds, catering to neurosurgery, neurology, orthopedics, plastic surgery, obstetrics and gynecology, neonatology, and general surgery. In the beginning, between 1974-1982, neurosurgical services were integrated with other surgical specialties. In 1982, Khoula Hospital was designated as the tertiary care hospital for neurosurgery, orthopedic trauma, and plastic surgery for the entire Sultanate of Oman. All patients with neurological problems were managed at Royal Hospital.  In the early years, surgical procedures primarily included neurotrauma-related and orthopedic procedures. However, with the expansion of the department and subsequent technological development, more complex elective surgeries like intracranial tumor resection, aneurysm clipping, trans-sphenoidal endoscopic pituitary tumor excision, and resection of cerebellopontine angle tumors and brain stem lesions were also performed. As the number of trauma and neurosurgical procedures increased, there was also a need for a dedicated neurointensive care unit to optimize patient outcomes. 

Awareness and Training Programs

Oman is the second largest country by geographical dimension in the Persian Gulf region and has had a high rate of road traffic accidents due to poorly motorable roads. In the 1960s, Oman had only 10 kilometers of paved road (Al-Ismaily and Probert 1998),¹ a figure which has since increased to more than 25,000 kilometers by 2009.² At first, this rapid expansion of roads coincided with a higher annual fatality rate, which increased from 300 to nearly 400 between 1976 and 1990.¹ However, Khoula Hospital staff collaborated with the Royal Oman Police (ROP) and the media to increase public awareness by doing many road shows. This led to a decline in annual fatality rate to approximately 342 by 1995.  The number of accidents also showed a decline over the decade (2000-2009), with an average annual decrease of about 7.5%.  This was made possible due to improved infrastructure and the ROP imposing stringent driving laws, while also joining forces with healthcare providers and organizing programs to spread road safety information, education and communication (IEC) programs through mass media.² The Ministry of Health has also improved the state of emergency rooms services, with more staff and better technology to treat trauma victims. Still, motor vehicle accidents contributed to 11.3% of all deaths in 2018 according to WHO statistics.³

Many successful CME programs were conducted in various regional hospitals, and as part of the national program, they were provided with Khoula Hospital’s neurointensive care protocols to ensure uniform initial management of neurotrauma patients across the country. These programs highlighted the initial resuscitation and safe transfer of trauma victims to the nearest tertiary care center, and all of these measures have led to improved outcomes in these patients. 

Establishment of a Dedicated Neurointensive Care Unit

In 1996, the Ministry of Health (MOH) established a 22-bed neurocritical care unit with modern ventilators, invasive monitors, and advanced neuromonitoring facilities. In the same year, CT and MRI scanners were added to the diagnostic facility. Intracranial pressure (ICP) monitoring via intraventricular catheters was introduced soon thereafter. This helped optimize the management of patients with severe brain injury and thereby reduce secondary neuronal injury. With the advent of a dedicated neuro ICU, there was a need for structured institutional guidelines and protocols for traumatic brain injury and stroke that were in line with international recommendations for the management of these patients. 

Training and Protocol Development

By the end of 2000, the MOH established new regional hospitals equipped with modern ICUs across the country, with many also touting neurological and neurosurgical serves. As part of their commitment to receive training at the tertiary care center, all newly recruited staff for these regional ICUs were trained in the care of patients with head injury and polytrauma at Khoula Hospital. This all-encompassing training module in trauma care included didactic lectures, case discussions, and bedside practical teaching. Participants were also evaluated at the end of their training. Progress over the next decade from 2000 to 2010 was exponential, and as operating theaters were expanded, ICU beds were increased to cater to the needs of critically ill patients. The department of neurology was then moved from Royal Hospital to Khoula Hospital in 2016 to form a dedicated team of neurologists and establish an advanced neurosciences center in the Sultanate of Oman.

With the specialties of neurosurgery and neurology being well established there was a need for specialists trained in neuroanesthesia and neurocritical care to further improve quality of care. From the initial years of non-neuro-trained anesthesiologists providing care for these patients, the department has progressed to support the neurosciences departments by adding trained specialists in neuroanesthesia and neurocritical care. The current team includes three consultants trained in neurocritical care, one senior specialist, and 12 specialists to provide care around the clock.

The burgeoning group of intensivists has worked with neurosurgeons and neurologists to set up protocols in various areas of neurocritical care. By 2018, protocols were established for the initial management of patients with head injuries, management algorithms for elevated ICP, management of patients following thrombolysis for stroke, and algorithms for status epilepticus management. Protocols for nutrition, DVT prophylaxis, and infection control have also been instituted in successive years. 

Current State of Neurocritical Care

The current neurocritical care unit at Khoula Hospital was expanded to a 30-bed ICU with state-of-the-art facilities fully equipped with neuromonitoring technology last July. Each bed is equipped with advanced vital sign monitors, ventilators, and infusion pumps. There is dedicated bedside equipment for the monitoring of ICP, EEG, and cerebral oxygenation. The unit is also equipped with Transcranial Doppler (TCD) machines to aid in the detection of vasospasm in patients with aneurysmal subarachnoid hemorrhage (SAH). All invasive procedures like central venous catheter and arterial line insertion are performed under ultrasound guidance. All staff are well-trained across relevant areas of neurosciences and are exposed to a variety of clinical conditions, participating in regular training programs to update and encourage them in all aspects of patient management. Regular academic sessions are held in the department, and bedside discussions are held in conjunction with neurologists and neurosurgeons. The Department of Radiology also has specialists trained in neuro-intervention who are integral parts of the stroke program. Their support has allowed Khoula Hospital to intervene early in the management of stroke and vasospasm. The unit is further supported by other multidisciplinary specialists, including well-trained respiratory therapists, physiotherapists, clinical pharmacists, and clinical microbiologists.

Neuroscience services in Oman have come a long way to reach their current level, which is now on par with advanced centers across the globe. This is due to the continuous hard work and planning of everyone involved in their development. As the tertiary care referral center for stroke management, Khoula Hospital has adopted all international guidelines (with modifications to suit local logistics) pertaining to management of stroke, SAH, and traumatic brain injury, which has resulted in improved outcomes. The last five years have also seen exponential growth in the management of neuro-critically ill patients overall, with the number of patients treated in the last 5 years averaging about 500 cases per year. Implementation of continuous training programs and advanced monitoring has resulted in reduced rates of morbidity and mortality that continue to improve.

Along with other hospitals in Muscat, the intensive care unit at Khoula Hospital was one of the main ICUs managing critical ill patients during the COVID-19 pandemic. It was expanded to accommodate these patients alongside the neurointensivist care unit, and they were even sicker during the second wave of the pandemic. This translated to an average of nearly 250 COVID-19 patients treated during the period from February 2020 to September 2020 and was only possible due to the efforts of dedicated and highly-trained staff across specialties and departments, including nursing, respiratory therapists, physiotherapists, intensivists, and all other support staff. 

Future Directions

Over the last few years, anesthesiologists who graduated from Oman have proceeded to complete fellowships in neuroanethesiology and neurocritical care in the United Kingdom, Canada, and Germany, further strengthening the neurosciences team. The department of anesthesia and neurocritical care is working towards starting its own fellowship programs in neuro-anesthesia and neurocritical care, as well as establishing a Center of Excellence for the Neurosciences. In the meantime, the department has been training residents and encouraging them to conduct high-quality research in the field of brain injury, polytrauma, and stroke.

The neurointensivists and other intensivists across the country are in the process of creating a Neurocritical Care Society chapter in Oman and coordinating with other international societies to organize CME programs and conferences in neurocritical care.  As a commitment to progress for the society, we look forward to coordinating with the Neurocritical Care Society (NCS) on multi-center research trials and organizing ENLS® courses for nurses and clinicians to have uniform management of emergency neurological conditions across all units.  Over the next few years, the current team expects to be further strengthened with more trained neurointensivists to improve outcomes and the overall quality of care. 

Acknowledgement

The department acknowledges the contributions of Dr. Santosh Lad (former Senior Consultant and Head of Department, Neurosurgery), Dr. Neelan Suri (former Senior Consultant and Head of Department, Anesthesia and Critical Care), Dr. Naresh Kaul (Senior Consultant, Anesthesia and Critical Care), and Dr. Rashid Manzoor Khan (Senior Consultant, Anesthesia and Critical Care), Khoula Hospital, Muscat, Sultanate of Oman. 

References

1. Al-Ismaily, H.A., and Probert, D. Transport policy in Oman, Applied Energy. 1998; 61(2): 79-109.
2. Islam MM, Al Hadhrami AYS. Increased Motorization and Road Traffic Accidents in Oman. Journal of Emerging Trends in Economics and Management Sciences. 2012; 3(6): 907-14.
3. World Health Organization (WHO) 2018 data source.