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Published on: September 16, 2017
Effect of Onset-to-Admission Time and Care Bundle Achievement on Functional Outcomes in Patients With ICH: A
Álvaro Lambea-Gil1,2,3, Joan Marti-Fabregas1,2,3, Pere Cardona4
1Stroke Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
Insights
Timely application of the care bundle protocol (CBP) improves functional outcomes in patients with intracerebral hemorrhage (ICH), even beyond six hours. Earlier intervention is ideal, but expanding CBP use enhances patient recovery in stroke care.
Area of Science:
- Neurology
- Critical Care Medicine
- Public Health
Background:
- Intracerebral hemorrhage (ICH) is a major cause of death and disability with limited treatment options.
- Early care bundle protocol (CBP) implementation within 6 hours improves outcomes, but its efficacy beyond this window is unknown.
- Assessing the impact of onset-to-admission (OTA) time and CBP adherence on ICH patient outcomes is crucial.
Purpose of the Study:
- To evaluate the effect of onset-to-admission (OTA) time and care bundle protocol (CBP) achievement on functional outcomes and mortality in acute spontaneous intracerebral hemorrhage (ICH) patients.
- To determine if CBP benefits extend beyond the initial 6-hour window.
- To explore the interaction between OTA time and CBP achievement.
Main Methods:
- A population-based prospective cohort study of 1,821 acute spontaneous ICH patients in Catalonia, Spain (2020-2022).
- Inclusion criteria: age ≥18, OTA <24 hours, baseline modified Rankin Scale (mRS) ≤3.
- CBP achievement involved controlling blood pressure, glucose, temperature, and oxygen saturation within 24 hours, plus anticoagulation reversal if needed. Outcomes assessed via multivariable logistic regression.
Main Results:
- CBP was achieved in 27.7% of patients.
- Shorter OTA time correlated with poorer functional outcomes (aOR 1.04 per hour).
- CBP achievement significantly improved favorable functional outcomes at 3 months (aOR 1.66).
- A significant interaction (p=0.016) showed greater CBP benefits with earlier admission, particularly within the first 8 hours, extending up to 13.8 hours.
Conclusions:
- Timely CBP application is vital for improving functional outcomes in ICH patients, even after 6 hours from symptom onset.
- While early intervention is optimal, these findings support broader CBP implementation and "Code ICH" initiatives.
- Expanding CBP use can enhance patient outcomes within stroke care systems.
Background And Objectives:
Intracerebral hemorrhage (ICH) remains a leading cause of morbidity and mortality, with limited effective treatments. Early implementation of a care bundle protocol (CBP) within 6 hours of symptom onset has been shown to improve functional outcomes, although its effect beyond this time frame remains unclear. We assessed the impact of onset-to-admission (OTA) time and CBP achievement on functional outcome and mortality in patients with acute spontaneous ICH.
Methods:
We conducted a population-based study of a prospective cohort of consecutive patients diagnosed with acute spontaneous ICH between 2020 and 2022 in Catalonia, Spain. Inclusion criteria were patients aged 18 years or older, OTA time <24 hours, and a baseline modified Rankin Scale (mRS) score ≤3. CBP achievement was defined as attaining control in the first 24 hours of blood pressure (<140/90 mm Hg), glycemia (<150 mg/dL), body temperature (<37.5°C), and blood oxygen saturation (>92%) and, if required, anticoagulation reversal. The primary outcome was the proportion of patients with a favorable functional outcome, defined as mRS score ≤3 at 3-month follow-up. The effects of OTA time and CBP achievement on outcomes were evaluated using multivariable logistic regression. Potential interaction between OTA time and CBP achievement was assessed using the likelihood ratio test.
Results:
A total of 1,821 patients were included (mean age 70.3 ± 14.1 years, 37.7% women). CBP was achieved in 27.7% of patients. Shorter OTA time was independently associated with poorer functional outcome (adjusted odds ratio [aOR]x1h 1.04, 95% CI 1.02-1.06). CBP achievement was associated with a higher probability of favorable outcome at 3 months (aOR 1.66, 95% CI 1.29-2.15). An interaction between OTA time and CBP achievement was observed (p = 0.016), indicating greater CBP benefits for earlier admission. This interaction was evident up to 13.8 hours after symptom onset, with the CBP benefit concentrated in the first 8 hours.
Discussion:
Our findings highlight the importance of timely CBP application to improve functional outcome in patients with ICH, even beyond the first 6 hours after symptom onset. While earlier intervention remains ideal, our results support expanding CBP implementation and promoting "Code ICH" initiatives to enhance patient outcomes in stroke care systems.
Trial Registration Information:
Multicentre Registry of Patients With Spontaneous Acute Intracerebral Hemorrhage in Catalonia (HIC-CAT). ClinicalTrials.gov ID: NCT03956485. Registration submission: May 2019. First patient enrolled March 2020.
Classification Of Evidence:
This study provides Class III evidence that in patients with acute ICH, achievement of a standardized CBP is associated with better functional outcomes at 3 months.
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