Scale-up of ABC care bundle for intracerebral haemorrhage across two hyperacute stroke units in one region in England: a mixed methods evaluation of a quality improvement project

• Published in: BMJ open quality Vol. 11; no. 2; p. e001601
• Main Authors: Brunton, Lisa, Sammut-Powell, Camilla, Birleson, Emily, Boaden, Ruth, Knowles, Sarah E, McQuaker, Clare, Cross, Stephen, Greaves, Natalie, Paroutoglou, Kyriaki, Alzouabi, Omran, Patel, Hiren C, Suman, Appukuttan, Kawafi, Khalil, Parry-Jones, Adrian R
• Format: Journal Article
• Language: English
• Published: England British Medical Journal Publishing Group 01.04.2022; BMJ Publishing Group LTD; BMJ Publishing Group
• Subjects: Anticoagulants; Blood pressure; Cerebral Hemorrhage - therapy; Data collection; Data processing; Disability; England; Evaluation methodology; Fatalities; Humans; Implementation science; Laboratories; Mixed methods research; Patient Care Bundles; Quality Improvement; Quality Improvement Report; Stroke; Stroke - therapy; Teams; England; United Kingdom > UK; Quality improvement; Evaluation methodology; Implementation science
• DOI: 10.1136/bmjoq-2021-001601
• ISSN: 2399-6641

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.