Time for "Code ICH"? Workflow Metrics of Hyperacute Treatments and Outcome in Patients with Intracerebral Haemorrhage

Introduction: Knowledge about uptake and workflow metrics of hyperacute treatments in patients with non-traumatic intracerebral haemorrhage (ICH) in the emergency department is scarce.

Methods: Single-centre retrospective study of consecutive patients with ICH between 01/2018-08/2020. We assessed uptake and workflow metrics of acute therapies overall and according to referral mode (stroke code, transfer from other hospital, or other).

Results: We enrolled 332 patients (age 73 years, IQR: 63-81 and GCS 14 points, IQR: 11-15, onset-to-admission time 284 min, IQR: 111-708 min), of whom 101 patients (35%) had lobar haematoma. Mode of referral was stroke code in 129 patients (38%), transfer from other hospital in 143 patients (43%), and arrival by other means in 60 patients (18%). Overall, 143 of 216 (66%) patients with systolic blood pressure >150 mm Hg received IV-antihypertensive treatment, and 67 of 76 (88%) on therapeutic oral anticoagulation received prothrombin complex concentrate treatment (PCC). Forty-six patients (14%) received any neurosurgical intervention within 3 h of admission. Median treatment times from admission to first IV-antihypertensive treatment were 38 min (IQR: 18-72 min) and 59 min (IQR: 37-111 min) for PCC, with significant differences according to mode of referral (p < 0.001) but not early arrival (≤6 h of onset, p = 0.92). The median time in the emergency department was 139 min (IQR: 85-220 min), and among patients with elevated blood pressure, only 44% achieved a successful control (<140 mm Hg) during ED stay. In multivariate analysis, code ICH concordant treatment was associated with significantly lower odds for in-hospital mortality (aOR 0.30, 95% CI: 0.12-0.73, p = 0.008) and non-significant trends towards better functional outcome measured using the modified Rankin scale score at 3 months (aOR for ordinal shift 0.54, 95% CI: 0.26-1.12, p = 0.097).

Conclusion: Uptake of hyperacute therapies for ICH treatment in the ED is heterogeneous. Treatment delays are short, but not all patients achieve treatment targets during ED stay. Code ICH-concordant treatment may improve clinical outcomes. Further improvements seem achievable by advocating for a "code ICH" to streamline acute treatments.