Challenge
To transform an established culture of nihilism to a ‘can do’, proactive approach in treating intracerebral haemorrhage (ICH) patients which is embraced by clinicians.

Solution
Applied the evidence in a simple, structured way Developed an accessible, realistic bundle of care processes called the “ABC care bundle”, which combined a number of evidence based treatments for ICH patients.
Adopted a standardised, measurable approach which established process targets for:

1. Anticoagulant (blood thinning drugs) reversal
2. Blood pressure (BP) lowering
3. Agreed care pathway to ensure rapid and timely referral to neurosurgery for those likely to benefit

Established a quick and steady flow of key data Collected just enough data to understand key processes.

Tested changes, measured impact, implemented findings Performed ‘Plan-Do-Study-Act’ cycles to test changes and met regularly to discuss findings. For example, after reviewing records of cases, we quickly realised that the need for a doctor to administer the first line drug (labetalol) for BP lowering was delaying treatment. Therefore, we predicted that using another type of BP lowering drug (GTN) instead would allow the nursing team to take ownership of the dosing. We tested this change, which led to a dramatic reduction in the time to reach target BP. We thus implemented this change with long-term benefit.

Impact

• Improvements in the speed of blood pressure lowering (median needle-to-target time reduced to 65 min after vs. 371 min before)
• Increased number of patients undergoing neurosurgery for ICH from 2 per month to 4 per month.
• An increase in supportive care, with more patients going to critical care (29.2% after vs. 18.4% before) and a reduction in early (<24h) do-not-resuscitate orders (22.8% after vs. 33.7% before). 
• The project was associated with a 31% reduction in 30-day mortality for patients admitted to our centre.

Next Steps
We are currently scaling this work up across the centralised stroke pathway in Greater Manchester and assessing the impact on both recovery and survival by collecting modified Rankin scale scores at 6 months.

This case study was written by Dr Adrian Parry-Jones; NIHR clinician scientist & honorary consultant neurologist; University of Manchester & Salford Royal NHS Foundation Trust.


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