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Quality Improvement in the Management of Subarachnoid Hemorrhage: Current State and Future Directions

  • Secondary Headache (M Robbins, Section Editor)
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Abstract

Purpose of Review

Aneurysmal subarachnoid hemorrhage carries high mortality and morbidity. Quality improvement (QI) efforts in the management of this disease process are growing as the field of neurocritical care matures. This review provides updates in QI in subarachnoid hemorrhage (SAH) and discusses gaps and future directions.

Recent Findings

Literature published on the topic over the past 3 years were evaluated. An assessment of current QI practices pertaining to the acute care of SAH was conducted. These include processes surrounding acute pain management, inter-hospital coordination of care, complications during the initial hospital stay, role of palliative care, and quality metrics collection, reporting, and monitoring.

Summary

SAH QI initiatives have shown promise by decreasing ICU and hospital lengths of stay, health care costs, and hospital complications. The review reveals substantial heterogeneity, variability, and limitations in SAH QI protocols, measures, and reporting. Uniformity in QI research, implementation, and monitoring will be crucial as disease-specific QI develops in neurological care.

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References

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  1. Modi S, Shah K, Schultz L, Tahir R, Affan M, Varelas P. Cost of hospitalization for aneurysmal subarachnoid hemorrhage in the United States. Clin Neurol Neurosurg Elsevier. 2019;182:167–70.

    Article  Google Scholar 

  2. Chan V, Lindsay P, McQuiggan J, Zagorski B, Hill MD, O’Kelly C. Declining admission and mortality rates for subarachnoid hemorrhage in Canada between 2004 and 2015. Stroke Am Heart Assoc. 2019;50:181–4.

    Google Scholar 

  3. Bederson JB, Awad IA, Wiebers DO, Piepgras D, Haley EC Jr, Brott T, et al. Recommendations for the management of patients with unruptured intracranial aneurysms: a statement for healthcare professionals from the Stroke Council of the American Heart Association. Circulation Am Heart Assoc. 2000;102:2300–8.

    CAS  Google Scholar 

  4. Mukhtar TK, Molyneux AJ, Hall N, Yeates DR, Goldacre R, Sneade M, et al. The falling rates of hospital admission, case fatality, and population-based mortality for subarachnoid hemorrhage in England, 1999–2010. J Neurosurg. American Association of Neurological Surgeons. 2016;125:698–704.

  5. Taylor TN, Davis PH, Torner JC, Holmes J, Meyer JW, Jacobson MF. Lifetime cost of stroke in the United States. Stroke Am Heart Assoc. 1996;27:1459–66.

    CAS  Google Scholar 

  6. Samuels O, Webb A, Culler S, Martin K, Barrow D. Impact of a dedicated neurocritical care team in treating patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care Springer. 2011;14:334–40.

    Article  Google Scholar 

  7. Fargen KM, Neal D, Rahman M, Hoh BL. The prevalence of patient safety indicators and hospital-acquired conditions in patients with ruptured cerebral aneurysms: establishing standard performance measures using the Nationwide Inpatient Sample database. J Neurosurg. American Association of Neurological Surgeons. 2013;119:1633–40.

  8. Wolf SJ, Byyny R, Carpenter CR, Diercks DB, Gemme SR, Gerardo CJ, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med Elsevier. 2019;74:e41–74.

    Article  Google Scholar 

  9. Perry JJ, Sivilotti ML, Sutherland J, Hohl CM, Émond M, Calder LA, et al. Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache. CMAJ Can Med Assoc. 2017;189:E1379–85.

    Article  Google Scholar 

  10. Gorelick PB, Hier DB, Caplan LR, Langenberg P. Headache in acute cerebrovascular disease. Neurology AAN Enterprises. 1986;36:1445–1445.

    CAS  Google Scholar 

  11. Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. Publishing Group. 1968;28:14–20.

  12. Glisic EK, Gardiner L, Josti L, Dermanelian E, Ridel S, Dziodzio J, et al. Inadequacy of headache management after subarachnoid hemorrhage. Am J Crit Care AACN. 2016;25:136–43.

    Article  Google Scholar 

  13. Singh M, Guth JC, Liotta E, Kosteva AR, Bauer RM, Prabhakaran S, et al. Predictors of 30-day readmission after subarachnoid hemorrhage. Neurocrit Care Springer. 2013;19:306–10.

    Article  Google Scholar 

  14. Huckhagel T, Klinger R, Schmidt NO, Regelsberger J, Westphal M, Czorlich P. The burden of headache following aneurysmal subarachnoid hemorrhage: a prospective single-center cross-sectional analysis. Acta Neurochir (Wien). Springer; 2020;162:893–903.

  15. Langley T, Hampton D, Wiggins A, Fraser J. Evaluation of headache intensity and treatment associated with subarachnoid hemorrhage. J Nurse Pract: Elsevier; 2021.

    Book  Google Scholar 

  16. • Hile GB, Cook AM. Treatment of headache in aneurysmal subarachnoid hemorrhage: multimodal approach. Interdiscip Neurosurg. Elsevier. 2020;22:100857. No single pharmacologic agent reduced subarachnoid-associated headaches, highlighting need for non-systemic treatment alternatives and multi-modal approaches.

  17. Jaffa MN, Podell JE, Smith MC, Foroutan A, Kardon A, Chang W-TW, et al. Association of refractory pain in the acute phase after subarachnoid hemorrhage with continued outpatient opioid use. Neurology. AAN Enterprises. 2021;96:e2355–62.

  18. Viswanathan V, Lucke-Wold B, Jones C, Aiello G, Li Y, Ayala A, et al. Change in opioid and analgesic use for headaches after aneurysmal subarachnoid hemorrhage over time. Neurochirurgie: Elsevier; 2021.

    Book  Google Scholar 

  19. Dhakal LP, Turnbull MT, Jackson DA, Edwards E, Hodge DO, Thottempudi N, et al. Safety, tolerability, and efficacy of pain reduction by gabapentin for acute headache and meningismus after aneurysmal subarachnoid hemorrhage: a pilot study. Front Neurol. 2020;11:744.

  20. Lionel KR, Sethuraman M, Abraham M, Vimala S, Prathapadas U, Hrishi AP. Effect of pregabalin on perioperative headache in patients with aneurysmal subarachnoid hemorrhage: a randomized double-blind, placebo-controlled trial. J Neurosci Rural Pract. Thieme Medical and Scientific Publishers; 2019;10:438–43.

  21. Venkatesulu KB, Nandhakumar A, Cherian M, Mehta P, Kalingarayar S, Shanmugam S. Scalp block for management of subarachnoid hemorrhage (SAH)-induced headache. J Neurosurg Anesthesiol LWW. 2019;31:356–7.

    Article  Google Scholar 

  22. Smith CR, Fox WC, Robinson CP, Garvan C, Babi M-A, Pizzi MA, et al. Pterygopalatine fossa blockade as novel, narcotic-sparing treatment for headache in patients with spontaneous subarachnoid hemorrhage. Neurocrit Care. Springer. 2021;241–8.

  23. Dietzel J, Eck T, Usichenko T. Treating therapy-resistant headache after aneurysmal subarachnoid hemorrhage with acupuncture. Neurocrit Care Springer. 2019;31:434–8.

    Article  Google Scholar 

  24. Kardon A, Murray RS, Khalid M, Colloca L, Simard JMarc, Badjatia N, et al. Pain control and anxiolysis after subarachnoid hemorrhage using immersive virtual reality: a case report. The Neurohospitalist. 2022;12:563–6.

  25. Diringer MN, Bleck TP, Hemphill JC, Menon D, Shutter L, Vespa P, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care Springer. 2011;15:211–40.

    Article  Google Scholar 

  26. Talahma M, Alkhachroum AM, Alyahya M, Manjila S, Xiong W. Takotsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage: institutional experience and literature review. Clin Neurol Neurosurg Elsevier. 2016;141:65–70.

    Article  Google Scholar 

  27. Solenski NJ, Haley ECJ, Kassell NF, Kongable G, Germanson T, Truskowski L, et al. Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Crit Care Med LWW. 1995;23:1007–17.

    Article  CAS  Google Scholar 

  28. Creutzfeldt CJ, Hough CL. Get out of bed: immobility in the neuro ICU. Crit Care Med. NIH Public Access. 2015;43:926.

  29. Indicators AQ. Guide to patient safety indicators. Rockv MD Agency Healthc Res Qual. 2003.

  30. Agency for Healthcare Research and Quality, United States Department of Health and Human Services. Toolkit for using the AHRQ quality indicators: how to improve hospital quality and safety. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/combined_toolkit.pdf. Published January, 2012. Updated March, 2017. Accessed 1 Oct 2021.

  31. • Revilla-Pacheco F, Calderón-Juárez M, Lerma A, Herrada-Pineda T, Lerma C. Efficacy of an intervention program to prevent patient safety indicators in aneurysmal subarachnoid haemorrhage. Br J Neurosurg. Taylor & Francis. 2021;0:1–6. Intervention program that reduced incidence of common nosocomial complications of subarachnoid hemorrhage.

  32. Collins CI, Hasan TF, Mooney LH, Talbot JL, Fouraker AL, Nelson KF, et al. Subarachnoid hemorrhage “fast track”: a health economics and health care redesign approach for early selected hospital discharge. Mayo Clin Proc Innov Qual Outcomes. 2020;4:238–48.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Mohan M, Islim A, Dulhanty L, Parry-Jones A, Patel H. CT angiogram negative perimesencephalic subarachnoid hemorrhage: is a subsequent DSA necessary? A systematic review. J Neurointerventional Surg. Br Med J Publishing Group. 2019;11:1216–21.

  34. Marquardt G, Niebauer T, Schick U, Lorenz R. Long term follow up after perimesencephalic subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. BMJ Publishing Group Ltd; 2000;69:127–30.

  35. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. The Lancet Elsevier. 2009;373:1874–82.

    Article  Google Scholar 

  36. Hale C, Wong K, Pennings A, Rnic A, Tobali B, Hawke C, et al. Practice patterns of Canadian physiotherapists mobilizing patients with external ventricular drains. Physiother Can. University of Toronto Press Incorporated. 2013;65:365–73.

  37. Moyer MT, Hinkle JL, Mendez JD. An integrative review: early mobilization of patients with external ventriculostomy drains in the neurological intensive care unit. J Neurosci Nurs LWW. 2021;53:220–4.

    Article  Google Scholar 

  38. Xu J, Wu J, Yan H. Application of inter-professional care model in patients with aneurysmal subarachnoid haemorrhage. J Nurs Manag Wiley Online Library. 2020;28:797–803.

    Google Scholar 

  39. • Alaraj A, Hussein AE, Esfahani DR, Amin-Hanjani S, Aletich VA, Charbel FT. Reducing length of stay in aneurysmal subarachnoid hemorrhage: a three year institutional experience. J Clin Neurosci Off J Neurosurg Soc Australas. 2017;42:66–70. Multidisciplinary intervention that reduced hospital length of stay and associated costs in subarachnoid hemorrhage.

    Google Scholar 

  40. Wallace DJ, Mohan D, Angus DC, Driessen JR, Seymour CM, Yealy DM, et al. Referral regions for time-sensitive acute care conditions in the United States. Ann Emerg Med Elsevier. 2018;72:147–55.

    Article  Google Scholar 

  41. Bardach NS, Zhao S, Gress DR, Lawton MT, Johnston SC. Association between subarachnoid hemorrhage outcomes and number of cases treated at California hospitals. Stroke. 2002;33:1851–6.

    Article  PubMed  Google Scholar 

  42. Cross DT, Tirschwell DL, Clark MA, Tuden D, Derdeyn CP, Moran CJ, et al. Mortality rates after subarachnoid hemorrhage: variations according to hospital case volume in 18 states. J Neurosurg. 2003;99:810–7.

    Article  PubMed  Google Scholar 

  43. Manser T. Fragmentation of patient safety research: a critical reflection of current human factors approaches to patient handover. J Public Health Res. PAGEPress. 2013;2:194–7.

  44. Catalano AR, Winn HR, Gordon E, Frontera JA. Impact of interhospital transfer on complications and outcome after intracranial hemorrhage. Neurocrit Care Springer. 2012;17:324–33.

    Article  Google Scholar 

  45. Zepeski A, Rewitzer S, Leira EC, Harland K, Faine BA. Interhospital transfer delays anticoagulation reversal in warfarin-associated intracranial hemorrhage. J Stroke Cerebrovasc Dis Elsevier. 2018;27:3345–9.

    Article  Google Scholar 

  46. Nuño M, Patil CG, Lyden P, Drazin D. The effect of transfer and hospital volume in subarachnoid hemorrhage patients. Neurocrit Care. 2012;17:312–23.

    Article  PubMed  Google Scholar 

  47. Naval NS, Chang T, Caserta F, Kowalski RG, Carhuapoma JR, Tamargo RJ. Impact of pattern of admission on outcomes after aneurysmal subarachnoid hemorrhage. J Crit Care. 2012;27:532.e1–532.e7.

    Article  PubMed  Google Scholar 

  48. Drazin D, Rosner J, Nuño M, Alexander MJ, Schievink WI, Palestrant D, et al. Type of admission is associated with outcome of spontaneous subarachnoid hemorrhage. Int J Stroke. 2015;10:529–33.

    Article  PubMed  Google Scholar 

  49. Kaleem S, Lutz MW, Hernandez CE, Kang JH, James ML, Dombrowski KE, et al. A triage model for interhospital transfers of low risk intracerebral hemorrhage patients. J Stroke Cerebrovasc Dis. 2021;30: 105616.

    Article  PubMed  Google Scholar 

  50. Finn EB, Campbell Britton MJ, Rosenberg AP, Sather JE, Marcolini EG, Feder SL, et al. A qualitative study of risks related to interhospital transfer of patients with nontraumatic intracranial hemorrhage. J Stroke Cerebrovasc Dis. 2019;28:1759–66.

    Article  PubMed  PubMed Central  Google Scholar 

  51. United States Department of Defense. Procedures for performing a Failure Mode, Effects and Criticality Analysis. US MIL-STD 1629 (1974), US MIL-STD 1629A (1980), US MIL-STD 1629A/Notice 2 (1984). Washington, DC. 1974.

  52. Briggs LJ. Interservice procedures for instructional systems development. Five Vol Fort Monroe VA US Army Train Doctrine Command. 1975.

  53. Press D. Guidelines for failure mode and effects analysis (FMEA), for automotive, aerospace, and general manufacturing industries. CRC Press. 2003.

  54. Commission AJ. Comprehensive accreditation manual, CAMH for Hospitals; 2017.

  55. Thornton E, Brook OR, Mendiratta-Lala M, Hallett DT, Kruskal JB. Application of failure mode and effect analysis in a radiology department. Radiographics Radiological Society of North America. 2011;31:281–93.

    Google Scholar 

  56. Battles JB. Improving patient safety by instructional systems design. BMJ Qual Saf. BMJ Publishing Group Ltd. 2006;15:i25–9.

  57. Chilakamarri P, Finn EB, Sather J, Sheth KN, Matouk C, Parwani V, et al. Failure mode and effect analysis: engineering safer neurocritical care transitions. Neurocrit Care. 2021;35:232–40.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Sather J, Littauer R, Finn E, Matouk C, Sheth K, Parwani V, et al. A multimodal intervention to improve the quality and safety of interhospital care transitions for nontraumatic intracerebral and subarachnoid hemorrhage. Jt Comm J Qual Patient Saf. 2021;47:99–106.

    PubMed  Google Scholar 

  59. Tran LN, Back AL, Creutzfeldt CJ. Palliative care consultations in the neuro-ICU: a qualitative study. Neurocrit Care Springer. 2016;25:266–72.

    Article  Google Scholar 

  60. Souter MJ, Blissitt PA, Blosser S, Bonomo J, Greer D, Jichici D, et al. Recommendations for the critical care management of devastating brain injury: prognostication, psychosocial, and ethical management. Neurocrit Care Springer. 2015;23:4–13.

    Article  Google Scholar 

  61. Creutzfeldt CJ, Wunsch H, Curtis JR, Hua M. Prevalence and outcomes of patients meeting palliative care consultation triggers in neurological intensive care units. Neurocrit Care Springer. 2015;23:14–21.

    Article  Google Scholar 

  62. Mehta AK, Wright SM, Wu DS, Harris CM. Palliative care involvement in patients hospitalized in the united states with aneurysmal subarachnoid hemorrhage. J Palliat Med. Mary Ann Liebert, Inc. 2021;24:1555–60

  63. Lele A, Cheever C, Healey L, Hurley K, Kim LJ, Creutzfeldt CJ. Operationalization of the transition to comfort measures only in the neurocritical care unit: a quality improvement project. Am J Hosp Palliat Care. 2019;36:38–44.

    Article  PubMed  Google Scholar 

  64. McAndrew NS, Leske JS. A balancing act: experiences of nurses and physicians when making end-of-life decisions in intensive care units. Clin Nurs Res. 2015;24:357–74.

  65. Xian Y, Fonarow GC, Reeves MJ, Webb LE, Blevins J, Demyanenko VS, et al. Data quality in the American Heart Association Get With The Guidelines-Stroke (GWTG-Stroke): results from a national data validation audit. Am Heart J. Elsevier. 2012;163:392–398. e1.

  66. The Joint Commission. Comprehensive stroke certification: standardized performance measures. https://www.jointcommission.org/performance_measures_for_comprehensive_stroke_centers/. Published 2018. Accessed 2 Sep 2021.

  67. Rooij NK de, Linn FHH, Plas JA van der, Algra A, Rinkel GJE. Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry. BMJ Publishing Group Ltd. 2007;78:1365–72.

  68. National Healthcare Safety Network, Centers for Disease Control and Prevention. 2019 National and State Healthcare-Associated Infections Progress Report [Internet]. Centers for Disease Control and Prevention; 2020 [cited 2021 Sep 1]. Available from: https://www.cdc.gov/hai/data/portal/progress-report.html

  69. Rosenbaum BP, Vadera S, Kelly ML, Kshettry VR, Weil RJ. Ventriculostomy: frequency, length of stay and in-hospital mortality in the United States of America, 1988–2010. J Clin Neurosci Elsevier. 2014;21:623–32.

    Article  Google Scholar 

  70. Lele AV, Quality Committee of the Neurocritical Care Society, Moheet AM. Neurocritical care quality improvement practices: a survey of members of the Neurocritical Care Society. Neurocrit Care Springer. 2020;32:295–301.

  71. Alunpipatthanachai B, Thirapattaraphan P, Fried H, Vavilala MS, Lele AV. External ventricular drain management practices in Thailand: results of the EPRACT study. World Neurosurg. 2019;126:e743–52.

    Article  PubMed  Google Scholar 

  72. Taran S, Trivedi V, Singh JM, English SW, McCredie VA. The use of standardized management protocols for critically ill patients with non-traumatic subarachnoid hemorrhage: a systematic review. Neurocrit Care Springer. 2020;32:858–74.

    Article  Google Scholar 

  73. Wang Y, Li Z, Wang Y, Zhao X, Liu L, Yang X, et al. Chinese Stroke Center Alliance: a national effort to improve healthcare quality for acute stroke and transient ischaemic attack: rationale, design and preliminary findings. Stroke Vasc Neurol. 2018;3:256–62.

    Article  PubMed  PubMed Central  Google Scholar 

  74. •• Rao CPV, Suarez JI, Martin RH, Bauza C, Georgiadis A, Calvillo E, et al. Global survey of outcomes of neurocritical care patients: analysis of the PRINCE study part 2. Neurocrit Care Springer. 2020;32:88–103. First global database of neurocritical care delivery and mortality outcomes.

    Article  Google Scholar 

  75. Spertus JA, Eagle KA, Krumholz HM, Mitchell KR, Normand S-LT. American College of Cardiology and American Heart Association methodology for the selection and creation of performance measures for quantifying the quality of cardiovascular care. Circulation. Am Heart Assoc. 2005;111:1703–12.

  76. Josephson SA, Ferro J, Cohen A, Webb A, Lee E, Vespa PM. Quality improvement in neurology: Inpatient and emergency care quality measure set: executive summary. Neurology. 2017;89:730–5.

    Article  PubMed  Google Scholar 

  77. The Neurocritical Care Society, Livesay S, Fried H, Gagnon D, Karanja N, Lele A, et al. Clinical performance measures for neurocritical care: a statement for healthcare professionals from the Neurocritical Care Society. Neurocrit Care Springer. 2020;32:5–79.

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  1. Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, NY, New York, USA

    Aaron Kaplan, Safa Kaleem & Margaret Huynh

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Kaplan, A., Kaleem, S. & Huynh, M. Quality Improvement in the Management of Subarachnoid Hemorrhage: Current State and Future Directions. Curr Pain Headache Rep 27, 27–38 (2023). https://doi.org/10.1007/s11916-022-01097-9

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