Abstract Body: Background and Purpose: Intracerebral and subarachnoid hemorrhages comprise roughly 15% of all strokes but have a higher risk of mortality and morbidity than ischemic strokes. Controlling hypertension after a hemorrhage is the primary intervention to limit the risk of hematoma expansion (HE) and the sequelae of secondary injury. Practice guidelines recommend smooth and sustained BP control within the first 60 minutes to limit the risk of HE. Chart reviews revealed median time to BP control was above the 1-hour timeframe and hemorrhage order set use by ED providers was only 65% at baseline. These findings drove efforts to improve the BP control for both non-traumatic ICH and SAH patients within the first hour of ED presentation.
Methods: A multidisciplinary stakeholder group developed several interventions as part of this QI endeavor. A target SBP was defined as 130-150 mmHg for both ICH and SAH patients for the hyper-acute management phase. After a review of the literature for nicardipine titration practices, the ED hemorrhage order set was updated to allow for potentially faster BP control. An educational campaign was shared with ED nurses, providers, and other staff to broadly communicate project goals and changes made to the ED hemorrhage order sets. Target BP outlier cases were shared with ED and pharmacy leaders and reviewed via the Stroke Program’s quality improvement program meetings.
Results: During the data analysis period of November 2023 to July 2024, 66 non-traumatic ICH and SAH patients presented directly to our ED (comfort care in the ED, transferred patients and ICH related to metastasis excluded). Charts were reviewed for time of arrival (door) to time of achieving the target SBP of 130-150 mmHg. There were 54 ICH and 12 SAH patients; 47% were female and median age was 59. Of these 66 patients, 85% had the appropriate order set placed which improved from a baseline of 65% prior to the QI endeavor. BP data analysis for the 34 (51%) patients who presented with an SBP above 130-150, improved from 74 to 53 minutes.
Conclusions: BP control for ICH and SAH patients is a key intervention to limit rebleeding as well as associated morbidity and mortality. While this was a single center project with a limited number of patients, our QI program resulted in better use of the appropriate ED order set and improved median door-to target BP control times reflecting safe, effective, and evidenced-based care for our patients.