Perceived, predicted and actual 6-month functional outcome of adult patients following acute spontaneous intracerebral haemorrhage treated in a neurocritical care setting: a mixed methods study

Background: Acute spontaneous intracerebral haemorrhage (ICH) is a devastating form of stroke with high rates of mortality and disability in survivors. There is uncertainty about the clinical benefit of admission to specialty and non-specialty critical care with limited research on the long-term outcome. Aim: To explore perceived, predicted and actual 6-month functional outcome of adult patients following acute spontaneous ICH and neurocritical care. Methods: Mixed method. Phase one, a secondary analysis of the multicentre prospective observational CROMIS-2 ICH study, explored characteristics associated with critical care admission and 6-month functional outcome for 825 patients with ICH. Phase two comprised 21 semi-structured interviews with clinicians (doctors and nurses) in a neurocritical care department. In phase three, 324 predictions for 52 patients with ICH were collected from neurocritical care clinicians then compared to actual patient 6-month functional outcome. Results: Treatment in critical care (compared to non-critical care settings) was significantly associated with a poor 6-month functional outcome but not with death. There was concordance between doctors and nurses when predicting patient outcome after ICH at 6-months however death was underestimated at 6-months suggesting early optimism for survival after neurocritical care. Prognostic uncertainty is a key feature in the acute phase. Caring for severely-affected patients with ICH in neurocritical care is challenging and can cause emotional distress. Contribution to knowledge: Neurocritical care appears to offer patients who have experienced ICH the best chance of survival despite the risk of major disability at 6months. Experienced clinicians’ perceptions and predictions of 6-month functional outcome after neurocritical care were mainly realistic, concordant and reflect actual 6month functional outcome. There is a role for subjective clinical judgment to support shared decision-making for patients who have experienced an ICH. Findings highlight a need for more patient-centred outcome measures to reduce prognostic uncertainty and enhance shared decision-making. Caring for this devastating form of stroke risks disabling clinician well-being and all involved in the provision of neurocritical care should provide support to mitigate the risk of emotional distress.