Supplementary Material for: Time for “code ICH”? – Workflow metrics of hyperacute treatments and outcome in patients with intracerebral haemorrhage

Introduction:
Knowledge about uptake and workflow metrics of hyperacute treatments in patients with non-traumatic intracerebral haemorrhage (ICH) in the emergency department are scarce.

Methods:
Single centre retrospective study of consecutive patients with ICH between 01/2018-08/2020. We assessed uptake and workflow metrics of acute therapies overall and according to referral mode (stroke code, transfer from other hospital or other).

Results:
We enrolled 332 patients (age 73years, IQR 63-81 and GCS 14 points, IQR 11-15, onset-to-admission-time 284 minutes, IQR 111-708minutes) of whom 101 patients (35%) had lobar haematoma. Mode of referral was stroke code in 129 patients (38%), transfer from other hospital in 143 patients (43%) and arrival by other means in 60 patients (18%).
Overall, 143 of 216 (66%) patients with systolic blood pressure >150mmHG received IV antihypertensive and 67 of 76 (88%) on therapeutic oral anticoagulation received prothrombin complex concentrate treatment (PCC). Forty-six patients (14%) received any neurosurgical intervention within 3 hours of admission.
Median treatment times from admission to first IV-antihypertensive treatment was 38 minutes (IQR 18-72minutes) and 59 minutes (IQR 37-111 minutes) for PCC, with significant differences according to mode of referral (p<0.001) but not early arrival (≤6hours of onset, p=0.92). The median time in the emergency department was 139 minutes (IQR 85-220 minutes) and among patients with elevated blood pressure, only 44% achieved a successful control (<140mmHG) during ED stay. In multivariate analysis, code ICH concordant treatment was associated with significantly lower odds for in-hopsital mortality (aOR 0.30, 95%CI 0.12-0.73, p=0.008) and a non-significant trends towards better functional outcome measured using the modified Rankin scale score at 3 months (aOR for ordinal shift 0.54 95%CI 0.26-1.12, p=0.097).

Conclusion:
Uptake of hyperacute therapies for ICH treatment in the ED is heterogeneous. Treatment delays are short but not all patients achieve treatment targets during ED stay. Code ICH concordant treatment may improve clinical outcomes. Further improvements seem achievable advocating for a “code ICH” to streamline acute treatments.

研究背景：目前针对急诊室（emergency department, ED）中非创伤性脑出血（intracerebral haemorrhage, ICH）患者超急性治疗的接受率与流程相关指标的相关研究仍较为匮乏。

研究方法：本研究为单中心回顾性研究，纳入2018年1月至2020年8月期间收治的所有连续性ICH患者。我们整体评估了急性治疗的接受率与流程指标，并根据患者的转诊方式（卒中绿色通道（stroke code）、院外转诊及其他方式）进行分层分析。

研究结果：本研究共纳入332例患者（年龄中位数73岁，四分位间距[IQR] 63~81岁；格拉斯哥昏迷量表（Glasgow Coma Scale, GCS）评分中位数14分，IQR 11~15分；发病至入院时间中位数284分钟，IQR 111~708分钟），其中101例（35%）为脑叶血肿。
转诊方式方面，129例（38%）患者通过卒中绿色通道就诊，143例（43%）为院外转诊，60例（18%）通过其他方式抵达急诊。
整体而言，216例收缩压＞150mmHg的患者中，143例（66%）接受了静脉降压治疗；76例接受治疗性口服抗凝治疗的患者中，67例（88%）接受了凝血酶原复合物浓缩剂（prothrombin complex concentrate, PCC）治疗。
46例（14%）患者在入院后3小时内接受了神经外科干预。
从入院至首次静脉降压治疗的中位时间为38分钟（IQR 18~72分钟），PCC治疗的中位给药时间为59分钟（IQR 37~111分钟）；上述治疗时长差异在不同转诊方式间具有统计学意义（p＜0.001），但在早就诊组（发病至入院时间≤6小时）与非早就诊组间无统计学差异（p=0.92）。
患者在急诊室的中位滞留时间为139分钟（IQR 85~220分钟）；在血压升高的患者中，仅44%在急诊滞留期间实现了血压达标（＜140mmHg）。
多因素分析结果显示，接受符合ICH急救绿色通道规范的治疗的患者，其院内死亡风险显著降低（校正比值比[aOR] 0.30，95%置信区间[CI] 0.12~0.73，p=0.008）；同时在3个月时采用改良Rankin量表（modified Rankin Scale, mRS）评估的功能预后方面，虽未达到统计学显著性，但呈现出更优预后的趋势（有序转移校正aOR 0.54，95%CI 0.26~1.12，p=0.097）。

研究结论：急诊室内针对ICH的超急性治疗接受率存在显著异质性。治疗延误时间整体较短，但并非所有患者均能在急诊滞留期间实现治疗目标。符合ICH急救绿色通道规范的治疗或可改善患者临床预后。推广“ICH急救绿色通道”以简化急性治疗流程，有望进一步提升诊疗质量。