ObjectiveAnticoagulation reversal, intensive blood pressure lowering, neurosurgery, and access to critical care might all be beneficial in acute intracerebral hemorrhage (ICH). We combined and implemented these as the “ABC” hyperacute care bundle and sought to determine whether the implementation was associated with lower case fatality.MethodsThe ABC bundle was implemented from June 1, 2015 to May 31, 2016. Key process targets were set, and a registry captured consecutive patients. We compared 30‐day case fatality before, during, and after bundle implementation with multivariate logistic regression and used mediation analysis to determine which care process measures mediated any association. Difference‐in‐difference analysis compared 30‐day case fatality with 32,295 patients with ICH from 214 other hospitals in England and Wales using Sentinel Stroke National Audit Programme data.ResultsA total of 973 ICH patients were admitted in the study period. Compared to before implementation, the adjusted odds of death by 30 days were lower in the implementation period (odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.38–0.97, p = 0.03), and this was sustained after implementation (OR = 0.40, 95% CI = 0.24–0.61, p < 0.0001). Implementation of the bundle was associated with a 10.8 percentage point (95% CI = −17.9 to −3.7, p = 0.003) reduction in 30‐day case fatality in difference‐in‐difference analysis. The total effect of the care bundle was mediated by a reduction in do‐not‐resuscitate orders within 24 hours (52.8%) and increased admission to critical care (11.1%).InterpretationImplementation of the ABC care bundle was significantly associated with lower 30‐day case fatality after ICH. ANN NEUROL 2019;86:495–503

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BackgroundIntracerebral haemorrhage (ICH) accounts for 10%–15% of strokes in the UK, but is responsible for half of all annual global stroke deaths. The ABC bundle for ICH was developed and implemented at Salford Royal Hospital, and was associated with a 44% reduction in 30-day case fatality. Implementation of the bundle was scaled out to the other hyperacute stroke units (HASUs) in the region from April 2017. A mixed methods evaluation was conducted alongside to investigate factors influencing implementation of the bundle across new settings, in order to provide lessons for future spread.MethodsA harmonised quality improvement registry at each HASU captured consecutive patients with spontaneous ICH from October 2016 to March 2018 to capture process and outcome measures for preimplementation (October 2016 to March 2017) and implementation (April 2017 to March 2018) time periods. Statistical analyses were performed to determine differences in process measures and outcomes before and during implementation. Multiple qualitative methods (interviews, non-participant observation and project document analysis) captured how the bundle was implemented across the HASUs.ResultsHASU1 significantly reduced median anticoagulant reversal door-to-needle time from 132 min (IQR: 117–342) preimplementation to 76 min (64–113.5) after implementation and intensive blood pressure lowering door to target time from 345 min (204–866) preimplementation to 84 min (60–117) after implementation. No statistically significant improvements in process targets were observed at HASU2. No significant change was seen in 30-day mortality at either HASU. Qualitative evaluation identified the importance of facilitation during implementation and identified how contextual changes over time impacted on implementation. This identified the need for continued implementation support.ConclusionThe findings show how the ABC bundle can be successfully implemented into new settings and how challenges can impede implementation. Findings have been used to develop an implementation strategy to support future roll out of the bundle outside the region.