What did we do?

We looked at how the ABC-ICH care bundle was used in hyper-acute stroke units across 6 regions in the North of England. These are hospital units that provide urgent specialist care for people soon after a stroke. We did this by collecting and studying information from interviews, meetings and documents.

 

 

Why was it important?

About 1 in 10 strokes are caused by bleeding into the brain, known as intracerebral haemorrhage.  About a third of people with this type of stroke do not survive beyond one month and many that do survive are dependent on others for their care. 

 

A bundle of care called the ABC-ICH bundle was developed at Salford Royal Hospital between 2015 and 2016 to try to improve care for these patients. It combines national and international guidelines that allow clinicians to provide systematic care to patients. The bundle comprises:

 

• Rapid reversal of blood thinning drugs
• Delivery of intensive blood pressure lowering
• A care pathway for quick referral to brain surgery teams when indicated.

 

At Salford Royal hospital, the care bundle was shown to save around 2 lives per month. 

 

The care bundle was then scaled out to the other hyper-acute stroke units in Greater Manchester. We investigated how well it worked in different settings so we could learn lessons for future roll-out.  

 

A quality improvement (QI) project then began in August 2021 to introduce the ABC-ICH care bundle into stroke units across 6 different regions in the North of England.  An app was developed to guide clinicians on how to deliver the care bundle and collect data. 

 

We needed to understand what helped or made it harder for different hospitals to use the ABC-ICH care bundle. We wanted to know:

 

• what local things affected how well the bundle was used in different hospitals.
• what lessons could help improve plans for using the bundle more widely in the future.

 

 

How did we do it?
We did 45 online interviews (29 first interviews and 16 follow-up interviews) with 30 key stakeholders (6 Quality Improvement (QI) project regional leads, 15 QI project nurse leads, 4 QI project consultant leads and 5 nurses delivering the ABC-ICH care bundle) at different hospital trusts across 6 regions in the North of England. We also observed 6 regional collaborative meetings and collected 9 project documents.  

 

 

What we found

 

What worked well?

Staff liked the ABC-ICH care bundle because it gave them clear steps to follow when caring for people with bleeding in the brain. It helped staff know what to do quickly and made this type of stroke care feel more active and organised.

 

The care bundle worked best when hospitals could adapt it to fit their own local systems, while keeping the same main aims: faster treatment, clear steps for staff and more consistent care for patients.

 

 

What were the challenges?

Some hospitals had delays because of staffing pressures and the time needed to get approvals before the app could be used. The app was difficult to use in everyday care. Staff often had to enter the same information into more than one system, so the app was later stopped.

 

Hospitals did not always have a simple way to check if the care bundle was being used as planned. This made it harder to see what was working well, what needed to change and whether care was improving.

 

One important challenge was deciding which patients needed advice from brain surgery teams. Some staff were not confident doing the checks needed for this, so many patients were still referred for advice even when this was not always needed.

 

 

What does this mean for future care?

• Hospitals will need clear local leaders and enough staff time to support the ABC-ICH care bundle properly.
• Staff need simple training, especially on how to work out which patients need advice from brain surgery teams.
• Hospitals need easy ways to check if the care bundle is being used as planned. This will help staff see what is working well and what still needs to change.
• These findings will help us improve how the care bundle is used in other hospitals in the future and will be used to improve plans for national roll out across the NHS. 

 

 

Who did we working with?

• Stroke Association

 

 

Downloadable resources

• Publications
  • Brunton L, Wilson P, Parry-Jones AR. (2026) Rollout of a care bundle for intracerebral haemorrhage across the North of England: a qualitative study. BMJ Open Quality.
  • Brunton L, Sammut-Powell C, Birleson E, Boaden R, Knowles SE, McQuaker C, et al. (2022) Scale-up of ABC care bundle for intracerebral haemorrhage across two hyperacute stroke units in one region in England: a mixed methods evaluation of a quality improvement project. BMJ Open Quality

 

 

More information

 

 

Senior Programme Lead

Mike Spence
michael.spence@manchester.ac.uk