Rollout of a care bundle for intracerebral haemorrhage across the North of England: a qualitative study.

backgroundA care bundle was developed and implemented at a hospital in North West England to improve the management of intracerebral haemorrhage (ICH) and was associated with a 44% reduction in 30-day case fatality. It was scaled out to the other hyperacute stroke units (HASUs) in the region. Findings showed the bundle could be successfully implemented into new settings, but challenges impeded its implementation. The findings were used to develop an implementation strategy to support roll-out outside the region. The ABC-ICH care bundle was then scaled up as a quality improvement initiative across six regions in the North of England. This paper reports on the qualitative process evaluation that was conducted in parallel.

methodsMultiple qualitative methods (45 interviews, six meeting observations and a document analysis) were used to capture how the bundle was implemented in HASUs across the six regions. We used the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to theoretically inform the study.

findingsKey facilitators in the uptake of the bundle were the clarity of the intervention, its compatibility with clinicians' values, its perceived relative advantage compared with current ICH care and the ability to locally tailor protocols. Key barriers to implementing the care pathway (judicious referral to neurosurgery) included lack of recipients' skills and confidence and prevailing organisational cultural norms which meant that most clinicians continued to refer all patients regardless of whether they met eligibility criteria. Lack of routine monitoring of process targets by local implementation teams impeded use of plan-do-study-act cycles to further improve care. Local contextual issues impeded or enabled effective facilitation.

conclusionThe findings recognise the importance of understanding what happens when the bundle is introduced into new settings outside of its local context and identifies lessons for future national roll-out.