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Code Intracerebral Hemorrhage: A Quality Improvement Pilot Study
Ehab Harahsheh1, Oana M Dumitrascu1, Katelyn Marsden2
1Department of Neurology, Mayo Clinic Arizona, Phoenix, AZ.
Insights
Implementing a Code ICH protocol improved adherence to acute intracerebral hemorrhage management guidelines, ensuring timely treatments and assessments for patients.
Area of Science:
- Neurology
- Quality Improvement Science
- Emergency Medicine
Background:
- Acute spontaneous intracerebral hemorrhage (ICH) management requires adherence to national guidelines.
- Existing care gaps may delay critical interventions in emergency department settings.
- Standardized protocols are essential for optimizing patient outcomes in acute neurological emergencies.
Purpose of the Study:
- To enhance adherence to guideline-recommended practices for acute spontaneous intracerebral hemorrhage (ICH) management.
- To implement and evaluate a quality improvement initiative within an emergency department setting.
- To reduce delays in antihypertensive treatment, anticoagulation reversal, and neurological assessments for ICH patients.
Main Methods:
- A Define-Measure-Analyze-Improve-Control (DMAIC) framework was employed for a quality improvement initiative.
- A standardized 'Code ICH' protocol and electronic medical record power plan were developed.
- Key performance indicators included timely antihypertensive administration, anticoagulation reversal, repeat CT scans, and specialist consultations.
Main Results:
- High adherence rates were achieved for antihypertensive treatment (92-100%) and anticoagulation reversal (100%).
- Repeat CT scans at 6 hours were completed in 93-100% of patients.
- Vascular neurology and neurosurgery assessments were prompt, with consultations occurring in 87% of cases.
Conclusions:
- A structured 'Code ICH' protocol significantly improved adherence to acute ICH management guidelines.
- The initiative facilitated prompt neurological assessments and timely interventions.
- Sustainability plans were developed to maintain protocol compliance and improve patient care.
Objective:
To improve adherence to current national guideline-recommended practices for managing acute spontaneous intracerebral hemorrhage (ICH) in patients presenting to Mayo Clinic Arizona emergency department.
Patients And Methods:
We launched a quality improvement initiative from April 1, 2024, to April 30, 2025, using the Define-Measure-Analyze-Improve-Control framework. Initial 6-month goals included: (1) administering antihypertensive treatment within 30 minutes of identifying ICH in ≥80% of patients with systolic blood pressure >150 mm Hg; (2) reversing anticoagulation within 45 minutes in ≥80% of anticoagulated patients; (3) performing repeat computed tomography head scans at 6 hours post-ICH identification in ≥80% of patients; and (4) initiating vascular neurology and neurosurgery assessments within 15 minutes of ICH recognition. Identified care gaps, informed by stakeholder feedback, led to the creation of a standardized Code ICH protocol and an emergency department-specific ICH electronic medical record power plan.
Results:
Twenty patients were included in the 1-6-month interval (Code ICH activated in 15/20 (75%) of eligible patients) and 12 patients in the 7-13 month interval (Code ICH activated in 8/12 [67%]). Antihypertensive medication administration within 30 minutes occurred in 92% (11/12) and 100% (3/3) of patients with systolic blood pressure >150 mm Hg. Anticoagulation reversal within 45 minutes was achieved in all eligible patients (100%, 2/2). Repeat computed tomography scans at 6 hours post-ICH identification were completed in 93% (11/12) and 100% (8/8) of patients at respective time points. Immediate vascular neurology evaluations were performed in all patients, and neurosurgery consultations occurred in 87% (20/23). A sustainability plan was developed postintervention to maintain continued Code ICH activation and compliance.
Conclusion:
Implementation of a structured Code ICH protocol facilitated prompt neurological assessments and adherence with current national acute ICH management guidelines.
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