ABC-ICH care bundle
The ‘ABC’ care bundle for intracerebral haemorrhage (ICH) was developed and implemented at Salford Royal Hospital and reduced 30-day case fatality in 2015-2016 by 35%. Implementation of the bundle was scaled out across the two other hyperacute stroke units (HASUs) in Greater Manchester from April 2017. A mixed-methods evaluation was conducted alongside. Support was given to link to datasets across the stroke pathway in GM through the CHC project; an ABC-ICH app and dashboard were developed in collaboration with the m-Health team at the University of Manchester to support implementation and capture process data.
A harmonised quality improvement register at each HASU captured consecutive ICH patients from 01/10/2016-30/03/2017 (pre-launch) and 01/04/2017-30/03/2018 (post-launch). Quantitative data are presented as median and interquartile range. Qualitative evaluation captured how the bundle was implemented across sites; it involved: 33 interviews with implementation teams/clinicians; 79 hours of non-participant observation; analysis of documents.
Unanticipated regulatory barriers delayed introduction of the app into clinical practice. Despite this, HASU1 significantly reduced anti-coagulant reversal door-to-needle time (134 min [120–392; n=14] pre-launch vs 72 min [63–108; n=21] post-launch; p<0.001) and intensive BP lowering door-to-target time 336.5 min [199-856, n=22] pre-launch vs 83.5 min [59.5-114.5, n=30] post-launch; p<0.001). 30-day case fatality at HASU1 fell from 34.3% (n=70) to 26.8% (n=97, 21.9% relative reduction), but was not statistically significant. No statistically significant changes in care process/ case fatality occurred at HASU2. Qualitative evaluation identified importance of facilitation: all-site quarterly meetings encouraged a learning culture between HASUs; robust planning before bundle launch contributed to early adoption at one site; close monitoring of data helped identify missed targets and provide early feedback to staff. Contextual changes overtime impacted upon implementation across sites, identifying a need for continued implementation support.
Lessons learnt from this project will be used to support an implementation strategy to test bundle in other areas outside of GM and to develop v.2 of the app and dashboard.