Adherence to Acute Care Bundle Improves Intracerebral Hemorrhage Mortality

Adrian R. Parry-Jones, PhD

The implementation of a hyperacute care bundle involving anticoagulation reversal, intensive blood pressure lowering, neurosurgery, and access to critical care (ABC) significantly lowers the rate of 30-day case fatality in patients with intracerebral hemorrhage (ICH).

Given that ICH is associated with some of the worst outcome rates among stroke subtypes, investigators led by Adrian R. Parry-Jones, PhD, of the University of Manchester, sought to evaluate the effect of improved implementation of a system of evidence- and guideline-based interventions. Results were published in Annals of Neurology.

As part of the system, providers were charged to adhere to the following process targets:

• Rapid anticoagulant reversal with either 4-factor prothrombin complex concentrate (PCC) or anti-Xa antagonists or idarucizumab within 90 minutes of arrival
• Intensive blood pressure lowering to a systolic blood pressure (SBP) target of 130-140 mmHg for patients arriving within 6 hours of symptom onset with an SBP >150 mmHg, with a needle-to-target time of <60 minutes
• Immediate neurosurgical referral for patients with modified Rankin Scale score ≤2, as well as any of the following characteristics: Glasgow Coma Scale <9, posterior fossa ICH, obstructed 3^rd/4^th ventricle, or hematoma volume >30 ml

Ultimately, data from 973 patients were included. Patients who were restricted to palliative care only and those who were note under the care of stroke or neurosurgery specialists were excluded from the initial analysis. Following exclusions, 353 patients were included in the before implementation group, 266 in the implementation group, and 241 in the after-implementation group.

Compared to the before implementation period, unadjusted 30-day fatality was significantly reduced during the implementation period (27.8% vs 21.4%, P =.07); this benefit continued through the after-implementation period (27.7% vs 15.4%, P <.001). Following multivariable adjustment, patients in the implementation group had lower odds of 30-day fatality (OR, 0.62, 95% CI, 0.38—0.97; P =.003), which was maintained in the after-implementation period (OR, 0.40, 95% CI, 0.24—0.61; P <.0001).

In an analysis of all patients (N=973), admission after implementation of the ABC protocol was significantly associated with reduced odds of 30-day fatality (OR, 0.41, 95% CI, 0.24—0.63; P <.0001) but not for those admitted during the implementation period. In a difference-in-difference analysis that included data from 32,295 patients with ICH, implementation of the ABC protocol was associated with a 10.8 percentage point reduction in 30-day fatality (95% CI, -17.9 to -3.7; P =.003).

“This study supports the hypothesis that consistent and effective delivery of evidence-based, guideline-recommended care to acute ICH patients may lead to a marked improvement in survival, suggesting that existing therapeutic nihilism may no longer be justified,” the study authors wrote.

REFERENCE

Parry-Jones AR, Sammut-Powell C, Paroutoglou K, et al. An intracerebral hemorrhage care bundle is associated with lower case fatality. Ann Neurol. Published online July 10, 2019. Doi: 10.1002/ana.25546.