Abstract
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.
Spontaneous intracerebral hemorrhage (ICH) accounts for 10% of the 795,000 strokes per year in the United States,1 and has higher associated morbidity and mortality compared with acute ischemic stroke (AIS) with early term mortality approaching 30%-40%.2,3 Mathematical models applying the “time is brain” concept to ICH demonstrate that the neuronal damage is more devastating when compared to AIS, with 2.2 billion neurons lost for every 33 mL of hematoma volume.3 Delayed ICH identification, higher systolic blood pressure (SBP), and early hematoma expansion are consistent predictors of worse outcomes.4 Despite the advances in management, there has been minimal improvement in ICH outcomes and a paucity of standardized quality care metrics for monitoring patients with ICH. Therefore, the cornerstone of ICH management is aimed at limiting hematoma expansion by rapid initiation of supportive management (ie, tight blood pressure control and anticoagulant reversal), which has been shown to improve functional outcomes and survival of these patients.5,6 The importance of these interventions is underscored in the 2022 American Heart Association (AHA)/American Stroke Association (ASA) spontaneous ICH management guidelines.7
In these updated most recent guidelines, it is recommended that patients with acute spontaneous ICH who present with a SBP of >150-220 mm Hg have their SBP lowered to a target of 140 mm Hg, within a range of 130-150 mm Hg, and minimal variation following acute ICH detection (Class 2b, level of evidence [LOE] B).7 Moreover, there is a warning that sudden lowering of SBP <130 mm Hg is potentially harmful (Harm Class 3, LOE B) and a proposal to initiate antihypertensive treatment within 2 hours of ICH onset and reaching the goal target within 1 hour. (Class 2a, LOE C).7 The guidelines continue to emphasize the importance of rapid reversal of anticoagulation to improve survival (Class 1, LOE C) and reiterate that serial head computed tomography (CT) can be useful within the first 6-24 hours after symptom onset to evaluate for hematoma expansion (Class 2a, LOE B)7 because most hematoma expansion occurs mostly within the first 3 hours after onset.8 Despite guideline-based recommendations emphasizing timely supportive interventions in acute ICH, their implementation remains limited across providers and institutions, primarily due to the absence of standardized protocols. Therefore, there has been an increasing interest and recent call to create Code ICH to help with rapid initiation of supportive measures in these patients.9, 10, 11
To address this gap and facilitate timely initiation of supportive care for acute ICH, a quality improvement (QI) initiative was launched at Mayo Clinic Arizona on April 1, 2024, using the Define-Measure-Analyze-Improve-Control methodology. The project aimed to establish a standardized Code ICH pathway and streamline emergency department (ED) workflows to ensure prompt evaluation and adherence to guideline-based management following ICH detection.
Patients and Methods
Define Project
The existing workflow was reviewed through didactic sessions, direct communication, and email outreach with key stakeholders, including vascular neurology, neurosurgery, emergency medicine, neurocritical care, neurology residents and fellows, Emergency department nurses (registered nurses), and the stroke coordinator at Mayo Clinic Arizona (MCA) (Supplemental Table 1, (available online at http://www.mcpiqojournal.org). Additional input was gathered from vascular neurologists at Mayo Clinic Rochester and Jacksonville. The target population included patients with acute spontaneous ICH presenting to the MCA ED. Initial assessments revealed limited awareness and adoption of the 2022 AHA/ASA ICH guidelines, with many stakeholders continuing to use outdated SBP targets (<140 mm Hg). Few had integrated the updated recommendations into routine practice. The identified barriers included delayed vascular neurology and neurosurgery stakeholder notification after ICH detection, nonstandardized workflows, and an outdated ICH order set that lacked alignment with current guidelines.
Based on stakeholder feedback, a consensus was reached to develop a Code ICH protocol at MCA. This included designing a streamlined workflow for patients presenting with acute ICH, modeled after existing stroke alert pathways for AIS. The initiative introduced a new ED-specific electronic health record (EHR) ICH power plan incorporating guideline-recommended orders, such as vital sign monitoring, neurological assessments, antihypertensive therapy, and anticoagulation reversal. In addition, a structured documentation template was created in the EHR to facilitate standardized care and enable ongoing QI monitoring (Supplemental Figure, available online at http://www.mcpiqojournal.org). Baseline data measurements were obtained from patients with acute ICH who presented to MCA ED prior to Code ICH implementation from January 1, 2022, to February 28, 2023. The implementation date of the novel Code ICH pathway was April 1, 2024, and subsequent data were evaluated until April 30, 2025.
For the first measurement in the ensuing 1–6-month interval after QI implementation, the goals were as follows: (1) at least 50% of patients with acute ICH presenting to MCA ED would have the Code ICH pathway activated with concomitant ED-specific ICH power plan initiation immediately after ICH detection; (2) at least 80% of patients with SBP >150 mm Hg would be started on antihypertensive agents within 30 minutes of ICH detection and at least 50% of them within 15 minutes; (3) at least 80% of patients would have anticoagulation reversal administered within 45 minutes of ICH detection, if indicated; (4) at least 80% of patients will have a repeat CT head at 6 hours after ICH identification; and (5) all patients would have an immediate assessment within 15 minutes by vascular neurology and neurosurgery teams on Code ICH activation. The second remeasurement was planned at a 7-13 month interval after QI implementation with similar goals. At its completion, the ownership of this project will be transitioned to the stroke coordinator, with goals for continued sustained improvement thereafter.
Project Measurement
The EHRs of consecutive patients presenting with acute spontaneous ICH to MCA ED from January 1, 2022, to February 28, 2023, were reviewed to obtain baseline (preimplementation) data measurements (n=19). Key time-based metrics were extracted, including time from ICH detection to (1) initiation of antihypertensive agents in patients with SBP >150 mm Hg, (2) anticoagulation reversal in eligible patients, and (3) the percentage of subjects that had repeat CT head at 6 and 24 hours. We calculated the percentage of patients meeting benchmarks for each measure. At baseline before the intervention (Table), 84% (16/19) had a SBP >150 mm Hg; of these, 44% (7/16) received antihypertensive treatment within 30 minutes and only 6% (1/16) within 15 minutes. Among patients requiring anticoagulation reversal (37% ,7/19), 57% (4/7) were administered within 45 minutes of ICH detection. Repeat CT head imaging was obtained in 32% (6/19) at 6 hours and 100% (19/19) at 24 hours.
Table 1.
| Variable/Group | Preintervention (From January 2022 to February 2023), n=19 | 1-6-Mo Postintervention (From April 2024 to October 2024), n=20 |
7-I3-Mo Postintervention (From November 2024 to April 2024), n=12 |
||
|---|---|---|---|---|---|
| Code ICH (n=15) | No Code ICH (n=5) | Code ICH (n=8) | No Code ICH (n=4) | ||
| Age (y), mean | 75.6 | 69.4 | 72 | 65 | 63.5 |
| Sex | M 53% (10) | M 80% (12) | M 80% (4) | M 38% (3) | M 50% (2) |
| NIHSS, median (IQR) | NA | 13 (5-23) | 1 (NA-NA) | 3 (2-15.5) | 2 (NA-NA) |
| SBP >150 mm Hg | 16 (84%) | 12 (80%) | 3 (60%) | 3 (38%) | 1 (25%) |
| <15 min ttt | 1 (6%) | 11 (92%) | 1 (33%) | 2 (67%) | 0 |
| <30 min ttt | 7 (44%) | 11 (92%) | 2 (67%) | 3 (100%) | 0 |
| Mean time to ttta | 57 min | 8.5 min | 32.3 min | 7.6 min | 48 min |
| Mean time to SBP control | NA | 44.5 min | 77.0 min | 29.3 min | 60 min |
| Anticoagulation reversal <45 min to ttt Mean time to ttt |
7 (44%) | 2 (13%) | 1 (20%) | 0 | 0 |
| 4 (57%) | 2 (100%) | 1 (100%) | |||
| 36 min | 27.5 min | 44.0 min | |||
| Repeat CT head | |||||
| 6 h | 6 (32%) | 14 (93%) | 4 (80%) | 8 (100%) | 4 (100%) |
| 24 h | 19 (100%) | 11 (73%) | 4 (80%) | 7 (88%) | 3 (75%) |
| Vascular neurology assessmentc | 17 (89%) | 15 (100%) | 2 (40%) | 8 (100%) | 2 (50%) |
| Neurosurgery assessmentc | 17 (89%) | 13 (87%) | 5 (60%) | 7 (88%) | 4 (100%) |
| Mean ICH volume (mL) | |||||
| Baseline CT head | NA | 22.2 | 15.8 | 23.5 | 7.7 |
| 6 h CT head | NA | 26.4 | 12.9 | 24.7 | 9.0 |
| 24 h CT head | NA | 18.2 | 9.5 | 55.4 | 9.9 |
| Hematoma expansion at 24 h | NA | 6 (40%) | 0 | 2 (25%) | 1 (25%) |
Abbreviations: CT, computed tomography; ICH, intracerebral hemorrhage; M, male; NA, non applicable; SBP, systolic blood pressure; ttt, treatment.
Mean times are all calculated from initial ICH detection time.
Neurology and neurosurgery assessment within 15 minutes of ICH detection in the postintervention 1-6-month and 7-13-month intervals.
Following implementation of the QI initiative, EHRs were reviewed at 1–6-month (n=20, April/ 1, 2024 to November 1, 2024), and 7–13-month (n=12, November 1, 2024 to April 30, 2025) intervals to assess process and outcome measures. Data collected included Code ICH activation, ED-specific power plan utilization, vascular neurology, and neurosurgery assessment within 15 minutes of ICH detection; time from ICH detection to initiation of antihypertensive therapy in patients with SBP >150 mm Hg; time to reach SBP target from ICH detection; time to anticoagulation reversal administration in eligible patients; and whether the patient had a repeat CT head at 6 and 24 hours. In addition, we performed automated ICH volumetric analysis on baseline and follow-up imaging, to assess the hematoma expansion. The ICH detection time was defined as the time the CT head was either reviewed by the on-call radiologist or documented by the vascular neurology team during stroke alerts or Code ICH activations. Time to SBP control was defined as the interval from the ICH detection to the first recorded SBP within the 130-150 mm Hg range that was subsequently sustained within the 130-150 mm Hg range with or without the use of antihypertensive agents. Hematoma expansion was defined as the relative growth of ICH volume by at least 33% on repeat CT heads at 6 or 24 hours when compared with baseline.12 At each time interval, we then calculated the percentage of patients with acute ICH who had Code ICH activation, the percentage of ED-specific power plan implementation in patients with Code ICH activation, the percentage of patients with acute ICH and SBP >150 mm Hg who had antihypertensive agents initiated within 15 and 30 minutes of ICH detection, the percentage of patients who had anticoagulation reversal within 45 minutes of ICH detection, the percentage of patients evaluated by vascular neurology and neurosurgery within 15 minutes of ICH detection, the percentage of patients who had repeat CT heads at 6 and 24 hours, and the percentage of patients who had hematoma expansion on subsequent imaging.
The process measures included compliance with target goals based on review of consecutive patient records at the 1-6 month and 7-13 month intervals postimplementation. Outcome measures focused on the percentage of patients with SBP >150 mm Hg who received antihypertensive treatment within 15 and 30 minutes of ICH detection, the percentage of patients who received anticoagulation reversal within 45 minutes, and the percentage of patients who had repeat neuroimaging at 6 hours.
The automated assessment of ICH volume on CT head was done using the Viola software.13 First, the initial CT head was registered to a CT head template in Montreal Neurologic Institute space, and subsequent CT head studies in the same subject were registered to the initial CT head. Registration was performed with ANTsPy 2.4 using type Rigid registration. The ICH segmentation was then performed with Viola. Volumes for each hemorrhage were calculated using NumPy 2.2.0.
Results
Analyze the Project
To identify gaps in acute ICH management and inform intervention planning, preintervention verbal interviews and didactic sessions were conducted with key stakeholders, including neurology trainees, the neurosurgery team, emergency medicine physicians, and the neurocritical care team. Although stakeholders universally prioritized acute ICH care, many were unaware of the updated 2022 AHA/ASA guidelines and the recommended changes. Several delays in care were identified, primarily due to the absence of a standardized workflow. First, ICH cases identified during routine stroke alerts were often deprioritized or downgraded under the false assumption that, in the absence of a reperfusion therapy, there was less urgency-resulting in postponed initiation of supportive measures (eg, antihypertensives, anticoagulation reversal, and neuro checks). Second, unlike AIS cases, ICH documentation lacked time-stamped metrics (eg, time to detection and treatment initiation), hindering measurement and quality monitoring. Third, ambiguity regarding admitting service responsibilities led to fragmented consultations and delayed care escalation. To address these issues, stakeholders agreed on the implementation of a standardized Code ICH pathway (Figure 1) paired with a new HER ED-specific ICH power plan (Figure 2) aligned with updated clinical practice guidelines to facilitate organized, timely, and appropriate care.
Figure 1.
Workflow for Code ICH activation at MCA ED. Once ICH is identified on CT head, either the ED or VN team will request ED team lead to activate Code ICH paging system with ED room and call back numbers. The ED, VN, NSGY, and critical care team will be immediately notified once paging system is activated. At the same time, ED team will order an ED-specific ICH power plan in the electronic health record. Following VN and NSGY immediate assessment, the admitting team and ICH level of care will be decided, and subsequent ICH quality metrics will be documented in the patient’s chart. CT, computed tomography; ED, emergency department; ICH, intracerebral hemorrhage; NSGY, neurosurgery; VN, vascular neurology.
Figure 2.
The creation of ED-specific ICH power plan entailed discussion among multiple stakeholders. The power plan ensures frequent BP monitoring initially Q15 minutes for the first 2 hours or until SBP goal (130s-150s) is achieved, then Q30 minutes for 6 hours followed by Q1hour for 16 hours. The arterial line was used for all patients admitted to the neurocritical care or progressive care units for BP monitoring and if needed, intravenous nicardipine or clevidipine infusions were used to help with BP control, though the former was the preferred antihypertensive agent, and the latter was used only in the ICU setting per our institutional policy. Patients with small ICH, normal BP at presentation, and admission to the medicine/surgical floor did not require an arterial line; instead, BP was monitored by cuff using the same time intervals. The power plan also includes neurological checks (level of consciousness, pupillary response, and gross motor assessment) on an hourly basis for the first 24 hours and includes details regarding anticoagulation reversal agents depending on the type of anticoagulant. BP, blood pressure; ED, emergency department; ICH, intracerebral hemorrhage; IV, intravenous; NSGY, neurosurgery; VN, vascular neurology; VK, vitamin K; VKA, vitamin K antagonist.
This QI initiative followed the Plan-Do-Study-Act methodology. The Plan phase included baseline data collection and stakeholder interviews, which informed the design of the Code ICH pathway. In the Do phase, the Code ICH protocol and ED-specific power plan were implemented. The Study phase involved postimplementation analysis of care metrics and trends. Finally, based on the improvements observed, the initiative transitioned into the Act phase, adopting Code ICH as an ongoing best practice.
Improvement Intervention
Several didactic sessions were conducted for each group of stakeholders (vascular neurology, neurosurgery, neurology and neurosurgery trainees and advanced practice providers, ED physicians and registered nurses, neuroradiology, neurocritical care, and the stroke steering committee). Updated 2022 AHA/ASA evidence-based guidelines for BP management, anticoagulation reversal and serial head imaging in ICH were reviewed and presented during each session. The institutional QI project goals and targets were also presented and reiterated. A Microsoft PowerPoint presentation was subsequently e-mailed to stakeholders for future reference, and PDFs of the Code ICH workflow were distributed among ED staff. With the assistance of the stroke center coordinator, there was the creation of a one-step Code ICH notification via the paging system, which ensured simultaneous notification of key stakeholders (on-call vascular neurology, neurosurgery, and critical care). An ED-specific ICH power plan was created to reflect updated clinical practice guidelines.
The first remeasurement was conducted for the 1-6 month interval after the implementation of Code ICH, based on a retrospective review of 20 consecutive cases of acute spontaneous ICH presenting to MCA ED. Patient medical records were identified through the MCA acute intracerebral hemorrhage database. Code ICH was activated in 75% (n=15) of cases, whereas 25% (n=5) did not undergo activation (Table). Among those with Code ICH activation, 73% (n=11) had the ED-specific ICH power plan initiated. Of the 15 patients with Code ICH activation, 80% (n=12) presented with SBP >150 mm Hg and 13% (n=2) were on anticoagulation. Repeat CT head imaging was performed in 93% (n=14) at 6 hours and 73% (n=11) at 24 hours. Among patients with SBP >150 mm Hg (n=12), 92% and 92% received antihypertensive therapy within 15 and 30 minutes of ICH detection, respectively—compared with 6% and 44%, respectively, at baseline preintervention. The mean time to antihypertensive initiation was 8.5 minutes compared with 57 minutes preintervention (Figure 3). Both patients on anticoagulation received reversal therapy within 45 minutes (100%) with a mean time of 27 minutes, an improvement from 57% preintervention with a mean time of 36 minutes. Hematoma expansion was observed in 40% (n=6) of patients.
Figure 3.
Graphic display of the interventions’ outcomes: antihypertensive agents’ initiation within 30 minutes of ICH detection before and after intervention (A), including mean time from ICH detection to starting antihypertensive treatment (B); anticoagulation reversal within 45 minutes (eligible patients with and without Code ICH activation postintervention were reversed within 45 minutes, no patients were on anticoagulants at 7–13-months postintervention) (C); and repeat CT head at 6 hours (D) before and after intervention for patients with and without Code ICH activation. CT, computed tomography; ICH, intracerebral hemorrhage; SBP, systolic blood pressure.
In contrast, among patients without Code ICH activation (n=5), 3 presented with SBP >150 mm Hg. Of these, 67% (2/3) received antihypertensive treatment within 30 minutes and 33% (1/3) within 15 minutes of ICH detection. The mean time from ICH detection to initiation of antihypertensive agents was 32.3 minutes. No cases of hematoma expansion were observed.
At the a 7-13 month interval (second remeasurement), 12 additional medical records of patients with acute ICH presenting to MCA ED were retrospectively reviewed. A Code ICH was activated in 67% (n=8) of cases, whereas 33% (n=4) did not undergo activation. Among patients with Code ICH activation, 88% (n=7) had the ED-specific ICH power plan initiated. SBP >150 mm Hg at the time of ICH detection was present in 38% (n=3), and none of the patients were on anticoagulation. All patients (100%) underwent repeat CT head imaging at 6 hours. Among patients with SBP >150 mm Hg (n=3), 100% received antihypertensive therapy within 30 minutes, and 67% (n=2) within 15 minutes. Mean times to antihypertensive initiation was 7.6 minutes. Hematoma expansion occurred in 25% (n=2).
In contrast, among patients without Code ICH activation (n=4), only one had SBP >150 mm Hg. In this case, the time to antihypertensive initiation was 48 minutes. Repeat CT head at 6 hours was performed in 100% (n=4), and hematoma expansion was observed in one patient (25%). Of note the median National Institutes of Health Stroke Scale (NIHSS) scores for patients with and without Code ICH activation throughout this project were 9 (3-22) and 1 (0.5-2.5), respectively. In addition, the mean time from ED arrival to CT head completion among patients with Code ICH activation was 33 minutes and 67 minutes during the 1–6-month and 7–13-month intervals, respectively.
Stakeholders were regularly engaged throughout the implementation process via didactic conferences and structured meetings, where they were encouraged to provide feedback and ask questions. The ED quality RN and the RN stroke coordinator reinforced project objectives through periodic email communications, emphasizing key targets such as timely BP control, rapid anticoagulant reversal, and serial neuroimaging, along with the rationale supporting these interventions.
Control Summary
Baseline data, implementation plans, and outcomes from the first and second re-measurements were shared with key stakeholders. To ensure long-term sustainability of the Code ICH protocol, the comprehensive stroke center leadership and stakeholder teams at MCA will continue to meet regularly to review workflow, monitor adherence to performance targets, and discuss any updates to clinical guidelines. The stroke nurse coordinator will maintain the acute intracerebral hemorrhage database and periodically review performance metrics. If target compliance falls below 80%, reintervention will include stakeholder re-education and targeted email reminders. In addition, stroke education for incoming neurology trainees will incorporate guideline-based BP management for ICH, the importance of timely neuroimaging and anticoagulation reversal, and the Code ICH workflow.
Discussion
This project demonstrated that targeted educational interventions, including didactic lectures and brief presentations, can effectively facilitate the adoption of guideline-based clinical practices. Equally important was the academic setting with availability of in-house 24 of 7 trainees and collaborative input from multidisciplinary stakeholders, which proved essential in the design and implementation of a novel Code ICH workflow. Our project reports that Code ICH is feasible and has the potential to streamline and expedite short-term care delivery for patients with ICH.
Although our predefined improvement targets and timelines were met, some barriers to implementation were identified (Supplemental Table 2, available online at http://www.mcpiqojournal.org). One challenge was the recent expansion of our ED, which led to rapid onboarding of new providers and contributed to suboptimal utilization of Code ICH during both the 1-6 month and 7-13 month remeasurement periods, especially given the novelty of the Code ICH concept. In addition, the mild neurological deficits in the nonactivation (median NIHSS 1.0 [IQR, 0.5-2.5]) versus activation cohorts (median NIHSS 9.0 [IQR, 3-23]) is another important factor that might have rendered ED physicians reluctant to activate and use Code ICH in these mildly affected patients. Although multiple didactic sessions and reminder emails were distributed, more frequent and targeted outreach to ED personnel—such as scheduled in-service education and direct communication—may improve Code ICH activation rates. Moreover, closed-loop communication following Code ICH activation is of extreme importance to ensure that the ED-specific ICH power plan with the appropriate order set is placed for all patients, which was 73% at the 1-6-month postimplementation and improved to 88% at the 7-13 month interval. In the high-acuity environment of neurological emergencies, failure to enter appropriate electronic orders is not uncommon. Delegation of responsibilities and improved communication are necessary to ensure consistent and complete protocol adherence.
This QI initiative holds promise for enhancing patient care, optimizing outcomes, improving staff efficiency, and supporting stroke center certification and quality recognition. Timely antihypertensive therapy and rapid anticoagulation reversal in acute ICH have been shown to reduce hematoma expansion and are associated with improved functional outcomes.5 Moreover, our Code ICH model may serve as a framework for implementation at other stroke centers nationally and globally, reinforcing the concept that 'time is brain' applies equally to ICH and AIS. Although the initiative does not yield direct financial benefits, indirect cost savings are anticipated through reduced hospital and rehabilitation lengths of stay as a result of timely interventions.14
The Define-Measure-Analyze-Improve-Control methodology provided a structured and effective framework throughout this project, from defining targets and engaging teams to implementing changes, evaluating impact, and strategizing for sustainability. Future directions include expanding the Code ICH pathway and power plan to hospitalized patients with in-hospital acute ICH, and exploring implementation across other Mayo Clinic sites, including Jacksonville and Rochester. Moreover, improving time metrics from ED arrival to CT head imaging should be another important goal for future consideration, given CT head completion among patients with Code ICH activation was 33 minutes and 67 minutes during the 1–6-month and 7–13-month intervals, respectively. This discovery results in a unique opportunity for further improvement and implementation of guideline-specific recommendations in this patient population.
Conclusion
Implementing a structured Code ICH protocol effectively facilitated timely neurological assessment and improved compliance with current clinical guidelines for acute ICH management in the ED.
Potential Competing Interests
The authors report no competing interests.
Acknowledgments
Ethics Statement
This project was conducted as a quality improvement initiative and did not require Institutional Review Board (IRB) approval or formal IRB review. However, this QI project was registered with the Mayo Clinic Quality improvement project committee. QI project number 6049 and title of registration is “Improving time to initiation of guideline based practices after identification of acute intracerebral hemorrhage patients in the Emergency Department”.
Footnotes
Supplemental material can be found online at http://www.mcpiqojournal.org. Supplemental material attached to journal articles has not been edited, and the authors take responsibility for the accuracy of all data.
Supplemental Online Material
Supplemental Figure.
References
- 1.Tsao C.W., Aday A.W., Almarzooq Z.I., et al. Heart disease and stroke statistics-2022 update: a report from the American Heart Association. Circulation. 2022;145(8):e153–e639. doi: 10.1161/CIR.0000000000001052. [DOI] [PubMed] [Google Scholar]
- 2.Jolink W.M., Klijn C.J., Brouwers P.J., Kappelle L.J., Vaartjes I. Time trends in incidence, case fatality, and mortality of intracerebral hemorrhage. Neurology. 2015;85(15):1318–1324. doi: 10.1212/WNL.0000000000002015. [DOI] [PubMed] [Google Scholar]
- 3.O’Carroll C.B., Brown B.L., Freeman W.D. Intracerebral hemorrhage: a common yet disproportionately deadly stroke subtype. Mayo Clin Proc. 2021;96(6):1639–1654. doi: 10.1016/j.mayocp.2020.10.034. [DOI] [PubMed] [Google Scholar]
- 4.Davis S.M., Broderick J., Hennerici M., et al. Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage. Neurology. 2006;66(8):1175–1181. doi: 10.1212/01.wnl.0000208408.98482.99. [DOI] [PubMed] [Google Scholar]
- 5.Anderson C.S., Heeley E., Huang Y., et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355–2365. doi: 10.1056/NEJMoa1214609. [DOI] [PubMed] [Google Scholar]
- 6.Sheth K.N., Solomon N., Alhanti B., et al. Time to anticoagulation reversal and outcomes after intracerebral hemorrhage. JAMA Neurol. 2024;81(4):363–372. doi: 10.1001/jamaneurol.2024.0221. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Greenberg S.M., Ziai W.C., Cordonnier C., et al. 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke. 2022;53(7):e282–e361. doi: 10.1161/STR.0000000000000407. [DOI] [PubMed] [Google Scholar]
- 8.Morotti A., Boulouis G., Dowlatshahi D., et al. Intracerebral haemorrhage expansion: definitions, predictors, and prevention. Lancet Neurol. 2023;22(2):159–171. doi: 10.1016/S1474-4422(22)00338-6. [DOI] [PubMed] [Google Scholar]
- 9.Hemphill J.C., Citerio G. Adopting Code ICH in intensive care. Intensive Care Med. 2024;50(12):2179–2181. doi: 10.1007/s00134-024-07655-6. [DOI] [PubMed] [Google Scholar]
- 10.Yakhkind A., Yu W., Goldstein J.N., Mayer S.A. Code-ICH: time is brain. Curr Opin Crit Care. 2025;31(2):112–116. doi: 10.1097/MCC.0000000000001244. [DOI] [PubMed] [Google Scholar]
- 11.Li Q., Yakhkind A., Alexandrov A.W., et al. Code ICH: a call to action. Stroke. 2024;55(2):494–505. doi: 10.1161/STROKEAHA.123.043033. [DOI] [PubMed] [Google Scholar]
- 12.Liu J., Xu H., Chen Q., et al. Prediction of hematoma expansion in spontaneous intracerebral hemorrhage using support vector machine. EBioMedicine. 2019;43:454–459. doi: 10.1016/j.ebiom.2019.04.040. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Liu Q., MacIntosh B.J., Schellhorn T., Skogen K., Emblem K.E., Bjørnerud A. Voxels intersecting along orthogonal levels attention U-Net for intracerebral haemorrhage segmentation in head CT. Preprint. Posted online August 12, 2022 doi: 10.48550/arXiv.2208.06313. arXiv 2208. [DOI] [Google Scholar]
- 14.Zhu Z., Bower M., Stern-Nezer S., et al. Early initiation of oral antihypertensives reduces intensive care unit stay and hospital cost for patients with hypertensive intracerebral hemorrhage. Neurocrit Care. 2020;32(3):707–714. doi: 10.1007/s12028-020-00951-1. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.