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

Abstract

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.

Advances in Stroke: Quality Improvement

“…2 Scaling QI interventions that were successful in one setting to other units requires attention to contextual factors that may inhibit or promote program implementation and may involve local adaptations. 4…”

“…Four studies successfully used external facilitation as part of a multicomponent intervention alongside other implementation strategies. 1,2,4,10 However, the professional backgrounds, core activities, mode of delivery, and the amount of involvement of the external facilitators varied. The external facilitation of the program implemented in 58 hospitals in China to improve acute stroke care included monthly videoconferencing with local hospitals.…”

“…Process mapping was used to describe either the current practice at a given site or the ideal workflow, identify potential pitfalls that inhibited care quality, or identify targets for QI activities. 4,12,13,20,25 For processes of care that involve many disciplines, process mapping ideally included staff members from all involved Education to reduce routine urinary screening…”

“…The research designs and reporting of stroke quality improvement (QI) studies that were published in 2022 continue to improve with the use of advanced implementation methods (eg, stepped-wedge trials 1,2 ), adherence to the Standards for Quality Improvement Reporting Excellence guidelines 3 for reporting results, and involvement of patients 4 in intervention development. The studies emerged from a diverse range of countries (Figure) and spanned the spectrum from single hospital reports to regional and national care evaluations.…”

Enterprise negotiation and communication management system under the guidance of the Internet of Things

“…The second is the comprehensive evaluation method of virtual enterprise partners. Commonly used evaluation methods include the Analytic Hierarchy Process (AHP), fuzzy comprehensive evaluation, fuzzy optimization, neural network, timing multi-objective decision-making method, trigonometric analysis-based AHP, packet network method, integer programming, and Genetic Algorithm (GA) [ 4 ]. However, these evaluation methods are based on a single-entity enterprise.…”