An Intracerebral Hemorrhage Care Bundle Is Associated with Lower Case Fatality

Abstract

Objective: Anticoagulation reversal, intensive blood pressure lowering, neurosurgery, and access to critical care might all be beneficial in acute intracerebral hemorrhage (ICH). We combined and implemented these as the "ABC" hyperacute care bundle and sought to determine whether the implementation was associated with lower case fatality.

Methods: The ABC bundle was implemented from June 1, 2015 to May 31, 2016. Key process targets were set, and a registry captured consecutive patients. We compared 30-day case fatality before, during, and after bundle implementation with multivariate logistic regression and used mediation analysis to determine which care process measures mediated any association. Difference-in-difference analysis compared 30-day case fatality with 32,295 patients with ICH from 214 other hospitals in England and Wales using Sentinel Stroke National Audit Programme data.

Results: A total of 973 ICH patients were admitted in the study period. Compared to before implementation, the adjusted odds of death by 30 days were lower in the implementation period (odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.38-0.97, p = 0.03), and this was sustained after implementation (OR = 0.40, 95% CI = 0.24-0.61, p < 0.0001). Implementation of the bundle was associated with a 10.8 percentage point (95% CI = -17.9 to -3.7, p = 0.003) reduction in 30-day case fatality in difference-in-difference analysis. The total effect of the care bundle was mediated by a reduction in do-not-resuscitate orders within 24 hours (52.8%) and increased admission to critical care (11.1%).

Interpretation: Implementation of the ABC care bundle was significantly associated with lower 30-day case fatality after ICH. ANN NEUROL 2019;86:495-503.

Figure 1

Summary of patients admitted before, during, and after bundle implementation. ICH = intracerebral hemorrhage.

Figure 2

Survival after acute intracerebral hemorrhage at Salford Royal Hospital. Kaplan–Meier curve shows survival for the first 30 days after admission during the before implementation (solid line), during implementation (dashed line), and after implementation (dotted line) periods. Survival was more likely in the during implementation and after implementation periods (p < 0.001, log‐rank test).

Figure 3

Difference‐in‐difference analysis: Salford Royal Hospital (circles) compared to the rest of England and Wales (crosses, n = 32,295). Points signify 30‐day case fatality for patients admitted during each 2‐month period from June 1, 2013 to May 31, 2017. A regression line for each group (Salford Royal Hospital, solid line; the rest of England and Wales, dashed line) before and after bundle implementation from June 1, 2015 was fitted. SSNAP = Sentinel Stroke National Audit Programme. [Color figure can be viewed at www.annalsofneurology.org]