Implementation of a Goal-Directed Care Bundle for Intracerebral Hemorrhage Shows Promise
The Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT3) has shown promising results in improving functional recovery for patients suffering from acute intracerebral hemorrhage (ICH). This trial implemented a goal-directed, multi-faceted Care Bundle that included protocols for managing physiological variables such as systolic blood pressure (SBP), glucose levels, body temperature, and the rapid reversal of warfarin-related anticoagulation.
- Systolic Blood Pressure (SBP): Target <140mmHg
- Glucose Control: Target 6.1–7.8 mmol/L for non-diabetics and 7.8–10.0 mmol/L for diabetics
- Anti-pyrexia Treatment: Target body temperature ≤37.5°C
- Anticoagulation Reversal: Target international normalized ratio <1.5
An embedded process evaluation was conducted to understand the implementation of the Care Bundle across seven low- and middle-income countries (LMICs) and one high-income country. The evaluation used a mixed-methods approach, including interviews, focus group discussions, and surveys, to assess implementation outcomes such as fidelity, dose, reach, acceptability, appropriateness, adoption, and sustainability.
Despite the Care Bundle being generally well-received and delivered as planned, several challenges were identified, including difficulties in reaching SBP and glycemic targets, staff shortages, limited availability of antihypertensive drugs, and delayed care processes. Facilitators of successful implementation included good communication and collaboration with emergency department staff, the development of care pathways within available resources, and regular training and monitoring.
The study highlights the importance of addressing contextual barriers for the effective scale-up of the Care Bundle implementation globally. It also underscores the need for strategies to overcome medication limitations, improve public awareness of stroke symptoms, and ensure timely hospital admission to enhance the delivery of stroke care in LMICs.
Trial registration: INTERACT3 is registered at Clinicaltrials.gov (NCT03209258) and the Chinese Clinical Trial Registry (ChiCTR-IOC-17011787).