Nontraumatic Intracranial Hemorrhage Research Articles

Burden-of-Illness Associated with Bleeding-Related Hospitalizations in Atrial Fibrillation Patients: Findings from the Nationwide Readmission Database.

Introduction A paucity of contemporary data examining bleeding-related hospitalization outcomes in atrial fibrillation (AF) patients exists. Methods Adults in the Nationwide Readmissions Database (January 2016–November 2016) with AF and hospitalized for intracranial hemorrhage (ICH), gastrointestinal, genitourinary, or other bleeding were identified. Association between bleed types and outcomes were assessed using multivariable regression (gastrointestinal defined as referent) and reported as crude incidences and adjusted odds ratios (ORs) or mean differences with 95% confidence intervals (CIs). Results In total, 196,878 index bleeding-related hospitalizations were identified in this AF cohort (CHA2DS2VASc score ≥2 in 95.1%), with 70.8% classified as gastrointestinal. The overall incidences of in-hospital mortality, need for post-discharge out-of-home care, and 30-day readmission were 4.9, 50.8, and 18.2%, respectively. Multivariable regression suggested traumatic and nontraumatic ICHs were associated with higher odds of in-hospital mortality (OR = 3.99, 95% CI = 3.79, 4.19; OR = 13.09, 95% CI = 12.24, 13.99) and need for post-discharge out-of-home care (OR = 2.92, 95% CI = 2.83, 3.01; OR = 2.74, 95% CI = 2.59, 2.90), and increases in mean index hospitalization length-of-stay (8.31 days, 95% CI = 8.03, 8.60, 6.27 days, 95% CI = 5.97, 6.57) versus gastrointestinal bleeding. Genitourinary and other bleeds were associated with lower mortality (OR = 0.37, 95% CI = 0.25, 0.55; OR = 0.59, 95% CI = 0.53, 0.64) and reduced length-of-stays (−2.84 days, 95% CI = − 2.91, −2.76; −2.06 days, 95% CI = − 2.11, −2.01) versus gastrointestinal bleeding. Genitourinary bleeds were also associated with a reduced need for post-discharge out-of-home care (OR = 0.86, 95% CI = 0.77, 0.97). Conclusion The burden of bleeding-related hospitalizations was notably driven by relatively rare but severe and life-threatening ICH, and less morbid but more frequent gastrointestinal bleeding. There is need for continued research on bleeding risk factors and mitigation techniques to avoid bleeding-related patient hospitalizations.

Sulfonylureas and Metformin Were Not Associated With an Increased Rate of Serious Bleeding in Warfarin Users: A Self-Controlled Case Series Study.

Drug interactions between warfarin and sulfonylureas are suggested by pharmacokinetic information and prior studies. However, clinical evidence on the association of such interactions and the risk of bleeding is lacking. Using healthcare claims data from 5 US Medicaid programs from 1999-2011 and a self-controlled case series design with warfarin as an object drug, we calculated confounder-adjusted rate ratios (RRs) for concomitant use of sulfonylureas and metformin for 3 outcomes separately: (i) serious bleeding as a composite outcome of gastrointestinal bleeding (GIB) and nontraumatic intracranial hemorrhage (ICH); (ii) GIB; and (iii) ICH. In 6,463 warfarin users experiencing serious bleeding, an increased rate of serious bleeding was not associated with concomitant use of glimepiride (RR: 0.93; 95% confidence interval (CI) 0.75-1.15), glipizide (RR: 0.97; 95% CI 0.84-1.13), glyburide (RR: 0.89; 95% CI 0.76-1.06), or metformin (RR: 0.85; 95% CI 0.76-0.96), nor was the occurrence of the component outcomes of GIB or ICH. These results suggest that use of sulfonylureas or metformin was not associated with an increased rate of serious bleeding in warfarin users.

CT Scanning in Suspected Stroke or Head Trauma: Is it Worth Going the Extra Mile and Including the Chest to Screen for COVID-19 Infection?

Chest CT may be used as a tool for rapid coronavirus disease 2019 (COVID-19) detection. Our aim was to investigate the value of additional chest CT for detection of coronavirus 19 (COVID-19) in patients who undergo head CT for suspected stroke or head trauma in a COVID-19-endemic region. Our study included 27 patients (mean age, 74 years; range, 54-90 years; 20 men) who underwent head CT for suspected stroke (n = 21) or head trauma (n = 6), additional chest CT for COVID-19 detection, and real-time reverse transcriptase polymerase chain reaction testing in a COVID-19-endemic region. Sensitivity, specificity, and negative and positive predictive values of chest CT in detecting COVID-19 were calculated. Final neurologic diagnoses were ischemic stroke (n = 11), brain contusion (n = 5), nontraumatic intracranial hemorrhage (n = 2), brain metastasis (n = 1), and no primary neurologic disorder (n = 8). Symptoms of possible COVID-19 infection (ie, fever, cough, and/or shortness of breath) were present in 20 of 27 (74%) patients. Seven of 27 patients (26%) had real-time reverse transcriptase polymerase chain reaction confirmed-COVID-19 infection. Chest CT results were 6 true-positives, 15 true-negatives, 5 false-positives, and 1 false-negative. Diagnostic performance values of chest CT were a sensitivity of 85.7%, specificity of 75.0%, negative predictive value of 93.8%, and positive predictive value of 54.6%. The sensitivity of additional chest CT is fairly high. However, a negative result does not exclude COVID-19. The positive predictive value is poor. Correlation of chest CT results with epidemiologic history and clinical presentation, along with real-time reverse transcriptase polymerase chain reaction, is needed for confirmation.

Optimal Initial Blood Pressure in Intensive Care Unit Patients with Non-Traumatic Intracranial Hemorrhage.

Blood pressure (BP) control is crucial for minimizing the risk of mortality and hematoma growth in patients with acute intracranial hemorrhage (ICH). We aimed to determine the optimal BP range associated with improved patient outcomes. From the Medical Information Mart for Intensive Care-III database, we identified 1493 patients (age, 18–99 years) admitted to the intensive care unit (ICU) with non-traumatic ICH. The 3-day and 14-day mortality of ICU admissions were compared at different BP ranges. Generalized additive models were used to assess the optimal range of initial mean arterial pressure, systolic blood pressure (SBP), and diastolic blood pressure, and these were identified to be 70–100, 120–150, and 60–100 mmHg, respectively. The 3-day or 14-day mortality showed U-shaped correlations with BP ranges. Our results show that an initial SBP between 120 and 150 mmHg is associated with minimal risk of mortality risk. This recommendation can assist physicians to achieve better outcomes for patients with ICH.

Oral Substitution of Melatonin in Critical Care: A Pharmacokinetic Study in Patients with Intracranial Hemorrhage

Background: Intracranial hemorrhage (ICH) is a devastating condition with a high mortality and morbidity rate. Neuroprotective agents protect surrounding brain tissue from the toxic effects of hematoma and can result in better outcomes. There is evidence demonstrating the neuroprotective benefits of melatonin in experimental animal models of ICH. Reduced melatonin levels have been reported in the intensive care unit (ICU) patients. The aim of this study was to evaluate baseline melatonin levels and pharmacokinetic profile of melatonin in ICH patients.
 Methods: This was a randomized clinical trial in which 24 patients with non-traumatic ICH were divided into melatonin and control groups. Subjects in the melatonin group received 30 mg of melatonin for 5 days. Another group of 12 healthy volunteers also were recruited for the study. Baseline serum melatonin levels were measured for all groups. For the pharmacokinetic study, sampling intervals were 0.25, 0.5, 0.75, 1.5, 3, 6 and 10 hours after melatonin administration. Samples were analyzed using an HPLC system with fluorescence detection.
 Results: Serum melatonin concentrations found to be decreased in all patients. Patients showed a significant increase in levels by the third day but still lower than healthy volunteers. By day 5, the melatonin group reaches melatonin levels, statistically similar to healthy volunteers, but the control group didn't reach normal levels even on the seventh day of study.
 Conclusion: Our study suggests that monitoring melatonin levels and supplementing with exogenous melatonin can correct the reduced levels. Further studies focused on melatonin administration in ICH patients can be helpful in evaluating clinical outcomes in these patients.
 J Pharm Care 2020; 8(1): 3-10.

Analyses of Mortality and Prevalence of Cerebrovascular Disease in Colombia, South America (2014-2016): A Cross-Sectional and Ecological Study

Background: Stroke is the second cause of death and the first cause of disability worldwide. However, although numerous reports regarding stroke epidemiology in Latin America have been published, they differ widely in terms of employed methods and end points. This is the first of a series of articles that describes the epidemiology of stroke and other cerebrovascular diseases (CVD) in the nation, as well as their correlation with recognized risk factors and social variables. Methods: Descriptive analyses were performed using the Colombian vital registration system and social security information system as primary data sources. Rates and ratios were calculated, corrected for under-registration, and standardized. Secondary analyses were made using data from national surveys and government organizations on hypertension, diabetes mellitus, sedentarism, obesity, tobacco and alcohol consumption, and unsatisfied basic needs. Factorial multivariate multiple regression analyses were performed to evaluate correlations. Concentration curves and indices were calculated to evaluate for inequities in the distribution of events. Results: Global CVD had a national mortality rate and a prevalence ratio of 28 and 142 per 100,000 persons, respectively. Nontraumatic intracranial hemorrhage had the highest mortality rate (ie, 15 per 100,000), while cerebral infarction and transitory cerebral ischemia had the highest prevalence ratios (ie, 28 and 29 per 100,000, respectively). Hypertension and tobacco use were the most relevant risk factors for most of the simple and multiple models, and cerebral amyloid angiopathy and nonpyogenous intracranial venous thrombosis were the disease categories with the most socially unequal distribution of deaths and cases (ie, concentration indices of .34 and .29, respectively). Conclusions: CVDs are a cause for concern in Colombia and a marker of healthcare inequality and social vulnerability. Nationwide control of risk factors such as hypertension and tobacco use, as well as the design and conduct of public policy focused on the vulnerable and medically underserved regions and on standardizing mandatory CVD registries might ease its burden.

459: Trends in stroke-related maternal mortality in the United States

We conducted a retrospective analysis of maternal mortality data in the United States from 1979-2017 in order to evaluate trends in stroke- related deaths. A retrospective cohort study was performed of all maternal live births and deaths as reported by the Center for Disease Control and Prevention from 1979-2017. Maternal mortality was defined as any death occurring in a pregnancy or within 42 days of the end of a pregnancy (including termination, miscarriage, and birth). Stroke-related causes of death were determined by ICD-9 codes from 1979-1998 and ICD-10 codes from 1999-2017. Maternal mortality ratios (MMR) per 100,000 live births were calculated for each year for the overall population as well as by race. There was a total of 270 maternal deaths due to stroke-related disease from 1979-2017, accounting for 1.1% of total deaths. Forty percent of these deaths were attributed to non-traumatic intracranial hemorrhage followed by 29% due to a stroke cause- not otherwise classified. Over this time period, there was an overall 91% decrease in mortality due to stroke-related disease with a decrease in the MMR from 0.57 per 100,000 live births in 1979 to 0.03 in 2017 (Adjusted rate ratio 2016-2017 versus 1979-1980 0.09, 95% CI 0.04-0.21). As shown in Table 1, when evaluated by race, the proportion of deaths due to stroke-related disease mimicked overall mortality data with 63.3% of stroke-related deaths occurring in whites as compared to 33.0% in blacks. Figure 1 displays how this trend is consistent across all subtypes of stroke-related death evaluated. Despite lower numbers, overall higher MMRs were noted in the black population which accounted for all stroke-related mortality in 2017. Despite fluctuations over time, the maternal mortality rate due to stroke-related disease has decreased significantly over time. Non-traumatic intracranial hemorrhage is the major contributing etiology of these cases. The distribution of stroke-related deaths by race is similar to overall mortality data with lower absolute numbers, but higher MMRs in black as compared to white patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Validation of SUSPEKT Score in Predicting One-month Mortality of Patients with Hemorrhagic Stroke; a Diagnostic Accuracy Study.

Predicting the outcome of patients with intracranial hemorrhage (ICH) is the area of interest for in charge physicians as well as patients and their associates. This study aimed to evaluate the accuracy of SUSPEKT score in predicting one-month outcome of patients with hemorrhagic stroke. This prospective cross sectional study was conducted on > 18 years old patients with non-traumatic supra-tentorial ICH admitted to emergency department, from February 2017 to January 2018. SUSPEKT score was measured for each patient and its screening performance characteristics in prediction of one-month mortality were calculated. 169 cases with the mean age of 63.09± 15.45 (21 - 96) years were studied (56.8% male). After one month follow up 47 (27.8%) cases had died, 30 (17.7%) cases were bed ridden, and 72 (42.6%) could walk without help or with a cane. Non-survived patients had significantly larger intra-ventricular hemorrhage (IVH) (p < 0.001) and hematoma (p < 0.001) volume, higher serum glucose (p < 0.001) and blood pressure (p = 0.028), higher frequency of IVH (p < 0.001), and higher WBC count (p = 0.037). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of SUSPEKT score at the 65 cut point were 82.97% (95% CI: 68.65% - 91.86%), 74.59% (95% CI: 65.76% - 81.84%), 55.71% (95% CI: 43.38% - 67.40%), and 91.91% (95% CI: 84.23% - 96.16%), respectively. Total accuracy of SUSPEKT score in predicting one-month mortality of non- traumatic ICH patients is in good range and it has 82% sensitivity and 92% NPV in this regard. It seems that we need further studies before applying the score in routine practice.

Factors Associated With DNR Status After Nontraumatic Intracranial Hemorrhage.

We explored factors associated with admission and discharge code status after nontraumatic intracranial hemorrhage. We extracted data from patients admitted to our institution between January 1, 2013, and March 1, 2016 with nontraumatic intracerebral hemorrhage or subarachnoid hemorrhage who had a discharge modified Rankin Scale (mRS) of 4 to 6. We reviewed data based on admission and discharge code status. Of 88 patients who met inclusion criteria, 6 (7%) were do not resuscitate (DNR) on admission (aDNR). Do not resuscitate on admission patients were significantly older than those who were full code on admission (P = 0.04). There was no significant difference between admission code status and sex, marital status, active cancer, premorbid mRS, admission Glasgow Coma scale (GCS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, or bleed severity. At discharge, 66 (75%) patients were full code (dFULL), 11 (13%) were DNR (dDNR), and 11 (13%) were comfort care. African American and Hispanic patients were significantly more likely to be dFULL than Asian or white patients (P = .01) and less likely to be seen by palliative care (P = .004). Patients with less aggressive code status had higher median APACHE II scores (P = .008) and were more likely to have active cancer (P = .06). There was no significant difference between discharge code status and sex, age, marital status, premorbid mRS, discharge GCS, or bleed severity. Limitation of code status after nontraumatic intracranial hemorrhage appears to be associated with older age, white race, worse APACHE II score, and active cancer. The role of palliative care after intracranial hemorrhage and the racial disparity in limitation and de-escalation of treatment deserves further exploration.

Resistant Pseudomeningocele following Craniotomy for Non-Traumatic Acute Intracranial Haematoma in Very Young Children: Report of Four Cases

Background: The incidence of non-traumatic intracranial haemorrhage among neonates is less than among adults. However, the outcomes are generally poor, with high rates of morbidity and mortality. Non-traumatic intracranial haemorrhage can cause a sudden increase in intracranial pressure, requiring emergency craniotomy for evacuation. Methods: We report 4 cases following craniotomy for non-traumatic acute intracranial haematoma in very young children. The surgical technique and postoperative course are discussed, with emphasis on dural repair to avoid resistant pseudomeningocele. Results: Despite successful management of the acutely raised intracranial pressure, all patients afterwards developed tense pseudomeningoceles and required formal dural repair. This led to a change in institutional practice and modifications to the surgical technique. Conclusion: The authors highlight the postoperative occurrence of resistant pseudomeningoceles in young children after clot evacuations and leaving the dura open. They describe the surgical procedures to avoid these pseudomeningoceles.

The susceptibility ring.

The susceptibility ring.

Intracranial hemorrhage in patients taking oral anticoagulants. Current possibilities for therapy

The paper reviews an update on the possibilities of providing care for patients with spontaneous non-traumatic intracranial hemorrhage (ICH) developing in patients with atrial fibrillation who use oral anticoagulants. The incidence of ICH is shown to be considerably lower when nonvitamin K-dependent anticoagulants (NOACs) are used, but the hematoma evolution scenarios do not differ between the groups of patients receiving vitamin K antagonists or NOACs. The results of studies assessing hypertension therapy in patients with ICH are compared. The possibilities of using various reversal agents for various oral anticoagulants are also discussed. Since one of the main problems associated with increased mortality and severe disabilities is the progression rate of ICH, the possibility of using a specific antagonist can determine the choice of an anticoagulant for the primary prevention of ischemic stroke in a patient with atrial fibrillation.

A Qualitative Study of Risks Related to Interhospital Transfer of Patients with Nontraumatic Intracranial Hemorrhage

Goal: Interhospital transfer (IHT) facilitates access to specialized neurocritical care but may also introduce unique risk. Our goal was to describe providers’ perceptions of safety threats during IHT for patients with nontraumatic intracranial hemorrhage. Materials and Methods: We employed qualitative, semi-structured interviews at an academic medical center receiving critically-ill neurologic transfers, and 5 referring hospitals. Interviewees included physicians, nurses, and allied health professionals with experience caring for patients transferred between hospitals for nontraumatic intracranial hemorrhage. Interviews continued until data saturation was reached. Coding occurred concurrently with interviews. Analysis was inductive, using the constant comparative method. Findings: The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. Insufficient communication highlights the unique communication challenges specific to IHT, which overlay and compound known intrahospital communication barriers. Gaps in clinical practice revolve primarily around the provision of neurocritical care for this patient population, often subject to resource availability, by receiving hospital emergency medicine providers. Lack of structure outlines providers’ questions that emerge when institutions fail to identify process channels, expectations, and accountability during complex neurocritical care transitions. Conclusions: The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. These themes serve as fundamental targets for quality improvement initiatives. To our knowledge, this is the first description of challenges to quality and safety in high-risk neurocritical care transitions through clinicians’ voices.

Abstract WP438: Hematoma Expansion and Outcomes in Vitamin K versus Non-Vitamin K Antagonist Oral Anticoagulation Related Intracerebral Hemorrhages

Background: There is mounting evidence that functional outcome after intracranial hemorrhage (ICH) related to non-vitamin K antagonist oral anticoagulation (NOAC-ICH) is similar if not better as compared to vitamin K antagonist (VKA)-related ICH (VKA-ICH). This has been partially attributed to a smaller initial hematoma volume (HV). However, the association with other hematoma characteristics such as hematoma expansion (HE) are not well understood. Methods: We retrospectively analyzed 102 consecutive patients with acute non-traumatic ICH on oral anticoagulation therapy to compare HV and HE, and their relation to the 90-day modified Rankin scale (mRS) score. Results: A specific reversal agent was used in 72 (93.5%) VKA-ICH versus two (8%) NOAC-ICH. In unadjusted analyses, VKA-ICH (n=77) and NOAC ICH (n=25) had a similar admission HV (p&gt;0.05) and HE (p&gt;0.05), and NOAC-ICH patients more frequently had lower 90-day mRS scores than VKA-ICH patients (p=0.017). After adjustment, an unfavorable 90-day functional outcome (mRS 4-6) was independently associated with lower admission Glasgow coma scale score (OR 1.63; 95%-CI 1.26-2.10; p&lt;0.001) and greater HV (OR 1.03; 95%-CI 1.00-1.05; p=0.046), but not the oral anticoagulant strategy (OR 2.85; 95%-CI 0.69-11.86; p=0.15). After exclusion of patients without follow-up head CT to allow for adjustment by the HE, VKA-ICH was associated with an approximately 3.5 times greater odds for a poor 90-day outcome (OR 3.64; 95%-CI 1.01-13.09; p=0.048). Conclusions: Our observations support the notion that NOAC does not relate to a worse ICH extent and post-ICH functional outcome, information that may aid clinical decision making if confirmed in prospective studies.

Clinical and Radiological Characteristics of Vitamin K Versus Non-Vitamin K Antagonist Oral Anticoagulation-Related Intracerebral Hemorrhage

Recent studies indicated that functional outcome after intracranial hemorrhage (ICH) related to direct oral anticoagulation (DOAC-ICH) is similar, if not better, than vitamin K antagonist (VKA)-related ICH (VKA-ICH) due to a smaller initial hematoma volume (HV). However, the association with hematoma expansion (HE) and location is not well understood. We retrospectively analyzed 102 consecutive patients with acute non-traumatic ICH on oral anticoagulation therapy to determine HV and HE stratified by hematoma location, and the relation to the 90-day outcome. DOAC-ICH (n = 25) and VKA-ICH (n = 77) had a similar admission HV and HE (unadjusted p > 0.05, each). Targeted reversal strategies were used in 93.5% of VKA-ICH versus 8% of DOAC-ICH. After adjustment, an unfavorable 90-day functional outcome (modified Rankin scale score 4-6) was independently associated with alower admission Glasgow Coma Scale score (OR 1.63; 95% CI 1.26-2.10; p < 0.001) and greater HV (OR 1.03; 95% confidence interval (CI) 1.00-1.05; p = 0.046). After exclusion of patients without follow-up head computed tomography to allow for adjustment by occurrence of HE, VKA-ICH was associated with an approximately 3.5 times greater odds for a poor 90-day outcome (OR 3.64; 95% CI 1.01-13.09; p = 0.048). However, there was no significant association of the oral anticoagulant strategy with 90-day outcome in the entire cohort (OR 2.85; 95% CI 0.69-11.86; p = 0.15). DOAC use did not relate to worse HE, HV, and functional outcome after ICH, adding to the notion that DOAC is a safe alternative to VKA even in the absence of access to targeted reversal strategies (which are still not universally available).

Comparison of 3% vs. 23.4% Hypertonic Saline in Traumatic Brain Injury

Background: Hypertonic saline (HTS) is an effective treatment for patients with increased intracranial pressure (ICP) secondary to traumatic brain injury (TBI). The ideal concentration for use in these patients is not well defined. The aim of our study was to compare Glasgow coma scale (GCS) and mortality of patients after administration of 3% vs. 23.4% HTS in the initial resuscitation. Methods: We performed a retrospective analysis of patients admitted to the surgical intensive care unit (ICU) under the trauma service with a diagnosis of TBI who received HTS during initial resuscitation. Patient medical records were reviewed to collect data including in-hospital mortality, ICU length of stay, hospital length of stay, GCS at the time of admission and discharge, serum sodium and serum osmolality values at 24, 48 and 72 h after arrival, acute kidney injury and severe hypernatremia. Results: Patients >= 18 years of age admitted to trauma ICU with a diagnosis of TBI. Pregnant, incarcerated, or non-traumatic intracranial hemorrhage patients were excluded. Thirty-one patients were included in the study. The 3% arm included 21 patients, and 23.4% arm had 10 patients. All patients received 3% HTS continuous infusion following initial bolus. Median injury severity scores (ISS) were 22 vs. 25 in the 3% vs. 23.4% HTS groups, respectively (P = 0.37). There was no difference in in-hospital mortality between the two groups (52.4% vs. 50.0%, P = 0.45). There was a significant improvement in GCS at discharge, 8.3% vs. 44.4% in 3% HTS vs. 23.4% HTS arms, respectively (P = 0.029). Patients reaching goal serum sodium and serum osmolality at 24 h was significantly higher in the 23.4% group (33.3% vs. 70.0%; P = 0.028 and 35.7% vs. 77.8%; P = 0.026, respectively). Significant increase in incidence of severe hypernatremia in the 23.4% arm was noted (0.0% vs. 40.0%, P = 0.009). Conclusion: This study demonstrates no significant difference in in-hospital mortality for patients who received 3% vs. 23.4% HTS. Significantly higher percentage of patients receiving 23.4% HTS reached goal serum sodium and osmolality levels at 24 h with a concomitant significantly increased rate of severe hypernatremia. J Curr Surg. 2019;9(4):39-44 doi: https://doi.org/10.14740/jcs389 Â

57 Improving the Safety and Quality of Inter-Hospital Transfer for Nontraumatic Intracerebral and Subarachnoid Hemorrhage

Patients with nontraumatic intracranial hemorrhage (ICH, including intracerebral or subarachnoid hemorrhage) often require inter-hospital transfer (IHT) for subspecialty care. IHT involves multiple care transitions that harbor safety threats and quality gaps, yet few studies have implemented and evaluated interventions to improve this process. We re-engineered the IHT process at our institution for patients with nontraumatic ICH and implemented a multi-modal intervention that standardized clinical care goals and enhanced inter-disciplinary communication. We examined the impact of this intervention on process metrics, communication during transition periods, and the timeliness/effectiveness of care. Robust pre-intervention problem analysis identified several safety threats in this patient population. Guided by these results, we instituted a multi-modal intervention in May 2017 that included: 1) statewide clinical guideline dissemination, 2) standardization of the IHT acceptance process, 3) implementation of a patient arrival notification system, and 4) EMR enhancements. The intervention was evaluated through an EMR-based dashboard, case-by-case audit and feedback, and content analysis of IHT calls. We performed pre/post-intervention descriptive statistics analysis. The primary outcomes were a set of quality and safety measures: 1) process outcomes (ED length of stay [LOS], time to admit order, and ED boarding), 2) inter-departmental coordination/communication (% of times consulting services were notified upon patient arrival, % of times an ED attending to NICU attending conversation occurred), and 3) timeliness/effectiveness outcomes (adequate blood pressure control, and time to reversal of anticoagulation). The interventions resulted in significant improvements in the process of care: ED LOS (300 to 149 minutes, p<.01), ED time to admission order (66 to 20 minutes, p<.05) and ED boarding time (218 to 92 minutes, p<.01). Inter-departmental communication was enhanced: the percentage of IHT in which consult services were notified upon patient arrival improved from 38% to 91% (p < .05); additionally, a NICU attending discussed the care plan with the ED attending before the patient arrived in 64% of transfers post-intervention compared to 10% pre-intervention (p < .05). Timeliness/effectiveness improvements were noted in the reduction of time to anticoagulation reversal, though this was not statistically significant (217 to 165 minutes, p = 0.53). There was no significant difference in blood pressure control (86% to 80% with adequate BP control, p = 1). Decreased mortality was noted, though this was not statistically significant (27% to 14%, p = 0.26) The implementation of a large-scale multi-modal intervention significantly improved process and communication metrics associated with IHT for patients with nontraumatic ICH and resulted in a trend towards improvement in the timeliness and effectiveness of clinical care. Future research should explore the relationship between process improvement and more rare clinical outcomes, as our study was not powered to detect such differences. Our approach may be scalable to other critical care entities and achieve greater impact on the overall safety and quality threats related to the IHT process at large.

Altitude and Variable Effects on Infant Mortality in the United States

To explore whether altitude has different effects on infant mortality from newborn respiratory distress, nontraumatic intracranial hemorrhage, and necrotizing enterocolitis. Infants born in the US Mountain Census Division (AR, CO, ID, NV, NM, UT, and WY) had lower mortality from newborn respiratory distress (p < 0.001, mortality rate ratios [MRR] = 0.5 for non-Hispanic blacks and non-Hispanic whites and 0.6 for Hispanic whites) relative to infants born elsewhere in the United States, while Mountain Division non-Hispanic white infants had significantly higher mortality from nontraumatic intracranial hemorrhage (MRR = 1.3 [1.1, 1.6] p < 0.001). After adjustment for state average birth weight, gestational age, and income inequality, a statistically significant, inverse association remained between state average altitude and non-Hispanic white infant mortality from newborn respiratory distress. County altitude (3058 counties in 9 categories from ≤0 to ≥7000 feet) was negatively correlated with newborn respiratory distress (r = -0.91, p < 0.001) and necrotizing enterocolitis (r = -0.81, p = 0.006) at ≤0 to ≥7000 feet and positively correlated with nontraumatic intracranial hemorrhage at ≤0 to 6000-6999 feet (r = 0.78, p = 0.02). These data show variable cause-specific effects of altitude on infant mortality. Analytic epidemiologic research is needed to confirm or refute the hypotheses generated by these descriptive data.

P5138Resuming anticoagulation in patients with atrial fibrillation experiencing hemorrhage stroke or nontraumatic intracranial hemorrhage

P5138Resuming anticoagulation in patients with atrial fibrillation experiencing hemorrhage stroke or nontraumatic intracranial hemorrhage

Intracerebral Hemorrhage in Women: A Review with Special Attention to Pregnancy and the Post-Partum Period

Non-traumatic intracranial hemorrhage includes subarachnoid hemorrhage, subdural hemorrhage, and intracerebral hemorrhage (ICH), which can be classified as primary or secondary. Primary ICH is due to arterial hypertension or cerebral amyloid angiopathy, and secondary ICH is due to cerebral vascular malformations, coagulopathies, infectious complications, brain tumors, and illicit stimulant drug use. This review explores the epidemiology and management of non-traumatic ICH in women, with a focus on pregnancy and the post-partum period, defined as 6weeks post-delivery.