Authors (including presenting author) :
Hau FC (1), Wu HF (2), Sheng B (2), Chin LSA (1), Lam MW (1), Wong KC (1)
Affiliation :
(1) Department of Neurosurgery, Princess Margaret Hospital (2) Department of Medicine and Geriatrics, Princess Margaret Hospital
Keyword 1: :
Intracerebral Haemorrhage Care
Keyword 2: :
Standardized Nurse-Led Protocol
Introduction :
Acute intracerebral haemorrhage (ICH) is a critical neurological emergency associated with high morbidity and mortality. Conventional management at Princess Margaret Hospital traditionally focuses on blood pressure control. Emerging evidence, however, supports a comprehensive, protocol-driven approach to optimize patient trajectories. A standardized nurse-led protocol was introduced at Princess Margaret Hospital, designed to systematically integrate evidence-based interventions—including stringent blood pressure control, targeted glycaemic management, fever prevention and timely anticoagulant reversal within the critical early therapeutic window. This coordinated protocol aims to translate clinical evidence into structured practice, thereby enhancing care quality and improving long-term functional outcomes.
Objectives :
1.To embed bundled interventions into routine ICH care workflow
2.To monitor the rates of achieving targets to drive for continuous quality improvement
3.To enhance adherence to time and target-based interventions within prespecified time windows
4.To improve the six-month functional outcome and reduce mortality.
Methodology :
The standardized nurse-led protocol for acute ICH care has been implemented since July 2025. This protocol is applied during the critical initial 12-hour period following admission and comprises the following bundled interventions—involving the timely administration of anticoagulant reversal within one hour of protocol initiation; meticulous blood pressure management using prescribed intravenous antihypertensives, with the infusion rate adjusted by nurses to achieve tiered targets—aiming for a systolic blood pressure (SBP) target of < 200 mmHg in the initial hour, then adjusting the goal to 140-160 mmHg if the initial SBP exceeds 220 mmHg or if CT scan shows signs of mass effect or midline shift or targeting SBP < 140 mmHg if the initial SBP is ≤220 mmHg; Blood glucose level will be closely monitored every four hours, with subcutaneous insulin administered as needed to maintain < 7.8 mmol/L for non-diabetic patients or < 10 mmol/L for diabetic patients. Body temperature will be controlled to maintain below 37.5°C using oral or rectal paracetamol.
This study employs a quantitative approach for evaluation and is classified as a prospective study. Adherence to the protocol and achievement of physiological targets (blood pressure, blood glucose, temperature and anticoagulant reversal) are assessed from electronic vital sign and medication order systems. Patient outcomes are evaluated at six-months after protocol implementation using the modified Rankin Scale (mRS) through clinical record review or structured telephone follow-up with patients or caregivers to determine the mRS scores.
Result & Outcome :
As of 16 December 2025, the implementation of the standardized nurse-led protocol was applied to 37 patients. The blood pressure target within one hour was achieved in 62% of patients, and 80% of patients received anticoagulant reversal within one hour. Under the intervention, 67% of patients achieved blood glucose control to target range within 4 hours and 71% patients achieved temperature control to target range within 4 hours. The six-month functional outcome data remain under collection. The mortality rate for the same period last year was 39.6%, while this year's rate during the intervention was 36.6%. No cases of protocol-associated hypoglycaemia were observed.
