Rapid feedback on my Emergency Department Hemorrhagic Stroke care? It Improves Telestroke and In-person treatment times

Background: Rapid time to treatment of intracerebral hemorrhage (ICH) is important yet not consistently achieved in some emergency departments (EDs). The concept of CODE-ICH, similar to Code Ischemic Stroke, is now well-described, yet mechanisms to change provider and system behavior to improve treatment times is lacking. Objective: We aim to evaluate ICH treatment time metrics before and after a standardized ICH provider feedback intervention, individualized for each patient with a spontaneous acute ICH in the ED. Methods: A multicenter retrospective cohort of consecutive patients ≥ 18 years old with acute ICH were identified from March 1, 2022 to January 1, 2025 within a network of an integrated not-for profit healthcare system in the U.S. A rapid feedback intervention for all providers involved in the patient case was developed to contain specific treatment times compared to goals. Patients were grouped into pre- and post-intervention cohorts. The primary endpoint was CT scout time to antihypertensive agent and anticoagulation reversal agent administration. Secondary outcomes were: ICH orderset utilization, in-person daytime versus telehealth nighttime coverage, length of stay, and discharge disposition. Results: A total of 226 patients met inclusion criteria, 108 pre- and 118 post-intervention, with similar age (median: 68 vs. 69 years) and 54% were female. Pre- to post-intervention median NIHSS was the same (10; p=0.25), as were median ICH scores (pre: 2.0, interquartile range, IQR, 0-3 vs. post: 1.0, IQR 1-3; p=0.90). Median post-intervention CT to antihypertensive treatment was faster (pre: 21, IQR 23-52 min vs. Post: 14, IQR 7-26 min; p=0.0012), as well as median CT to anticoagulation reversal agent administration (pre: 40, IQR 30-64 min vs. Post: 29, IQR 18-40 min; p=0.03). The intervention was associated with increased orderset usage (54% to 96%; p=0.0001). Conclusions: A standardized ICH feedback intervention improved treatment times for blood pressure and anticoagulation reversal following detection of ICH on CT head imaging in the ED.