Abstract Body: Background: Rapid blood pressure reduction and anticoagulant reversal have been associated with lower mortality and improved outcomes in patients with acute spontaneous ICH, prompting the establishment of time-based quality measures for acute ICH care, similar to those for acute ischemic stroke. Multimodal systems of care interventions need to be developed and validated that drive organizational change to achieve these quality targets.
Methods: We developed a multimodal systems of care intervention to enhance attainment of 3 acute ICH care process outcomes: 1) door-to-treatment (DTT) time for initiation of an antihypertensive agent with initial SBP ≥160 mmHg, including targets of ≤60m, ≤45m, and ≤30m; 2) door-to-blood pressure control (DTC) time with goal SBP <160, including targets of ≤120m, ≤90m, and ≤60m; and 3) DTT for initiation of an anticoagulant reversal agent, including targets of ≤90m, ≤60m, and ≤45m. Quality improvement interventions included use of a specialized emergency hemostatic order set for ICH management, a post-case feedback form to all providers (Image 1), and serial care process analysis and refinement. Here we analyze results during the intervention development and pilot period at a single comprehensive stroke center between July 2022 and June 2024.
Results: During the study period, 77 adult, acute, non-transfer, ED-arriving ICH patients presented, including 42 (54.5%) with initial SBP ≥160 and 10 (13.0%) on anticoagulation. Outcomes for care process time metrics are shown in Images 2 and 3. Among the patients with initial SBP ≥160, median DTT time for initiation of an antihypertensive agent was 42 minutes (IQR 27-74), including 66.7% within 60m, 54.8% within 45m, and 28.6% within 30m. Median DTC time for first achievement of blood pressure control was 86 minutes (IQR 55-121), including 73.8% within 120m, 57.1% within 90m, and 31.0% within 60m. Among the patients with anticoagulation-associated ICH, median DTT time for initiation of an anticoagulant reversal agent was 76 minutes (IQR 64-113), including 60.0% of patients within 90m, 20.0% within 60m, and 20.0% within 45m. Patients with faster DTT times had higher NIHSS and ICH scores on presentation.
Conclusions: Development and pilot period implementation of a multimodal systems of care intervention resulted in achievement of ICH quality measures in a majority of patients. These findings support the establishment of national Target: Stroke initiatives to improve emergency ICH care.