Early Stroke Recognition and Time-based Emergency Care Performance Metrics for Intracerebral Hemorrhage

Katharine Colton 1, Christopher T Richards 2, Peter B Pruitt 2, Scott J Mendelson 3, Jane L Holl 3, Andrew M Naidech 4, Shyam Prabhakaran 3, Matthew B Maas 5

Affiliations

PMID: 31839545
PMCID: PMC6954314 (available on 2021-02-01)
DOI: 10.1016/j.jstrokecerebrovasdis.2019.104552

Free PMC article

Abstract

Background and aim: Performance measures have been extensively studied for acute ischemic stroke, leading to guideline-established benchmarks. Factors influencing care efficiency for intracerebral hemorrhage (ICH) are not well delineated. We sought to identify factors associated with early recognition of ICH and to assess the association between early recognition and completion of emergency care tasks.

Methods: Consecutive patients with spontaneous ICH were enrolled in an observational cohort study conducted from 2009 to 2017 at an urban comprehensive stroke center, excluding patient transferred from other hospitals. We used stroke team activation as the indicator of early recognition and measured completion times for multiple ICH-relevant performance metrics including door to computed tomography (CT) acquisition and door to hemostatic medication initiation.

Results: We studied 204 cases. All stroke-related performance times were faster in patients managed with stroke team activation compared to no activation, including quicker door to CT acquisition (median 24 versus 48 minutes, P < .001) and door to hemostatic medication initiation (63 versus 99 minutes, P = .005). These associations were confirmed in adjusted models. Stroke codes were activated in 43% of cases and were more likely in patients with shorter onset-to-arrival times, higher National Institutes of Health Stroke Scale scores, and higher Glasgow Coma Scale scores.

Conclusions: Stroke team activation was associated with more rapid diagnostic and therapeutic interventions for patients with ICH, but activation did not occur in the majority of cases, implying absence of early recognition. A stroke team activation process improves care performance, but leveraging the advantages of existing systems will require improved triage tools to identify ICH in the acute setting.

Keywords: Performance; diagnosis; emergency; intracerebral hemorrhage; intracranial hemorrhage; stroke.