title: Early Therapy Intensity Level (TIL) Predicts Mortality in Spontaneous Intracerebral Hemorrhage.
abstract: BACKGROUND
  Outcome from spontaneous intracerebral hemorrhage (sICH) may depend on patient-care variability. We developed as ICH-specific therapy intensity level (TIL) metric using evidence-based elements in a high severity sICH cohort.
  
  
  METHODS
  This is a cohort study of 170 patients with sICH and any intraventricular hemorrhage treated in 2 academic neuroICUs. Pre-defined quality indicators were identified based on current guidelines, scientific evidence, and likelihood of care documentation in first 72 h of hospital admission. We assessed performance on each indicator and association with discharge mortality. Significant indicators were aggregated to develop a TIL score. The predictive validity of the best fit TIL score was tested with threefold cross-validation of multivariate logistic regression models of in-hospital survival and good outcome (modified Rankin score 0-3).
  
  
  RESULTS
  Median ICH score was 3; discharge mortality was 51.2%. Five/19 tested variables were significantly associated with lower discharge mortality: no DNR/withdrawal of treatment within 24 h of admission, target glucose within 4 h of high glucose, no recurrent hyperpyrexia, clinical reversal of herniation/intracranial pressure >20 mmHg within 60 min of detection, and reversal of INR (<1.4) within 2 h of first elevation. One point was given for each or if not applicable. Median TIL score was significantly higher in survivors versus non-survivors (5[1] vs. 3[1]; P < 0.001). A 4-point aggregated TIL score was most predictive of discharge survival (area under receiving operating characteristic curve 0.85, 95% CI 0.80-0.90) and good outcome (AUC 0.84) and was an independent predictor of both (survival: OR 7.10; 95% CI 3.57-14.11; P < 0.001; good outcome: OR 3.10; 95% CI 1.06-8.79; P < 0.001).
  
  
  CONCLUSIONS
  A simplified TIL score using evidenced-based patient-care parameters within first 3 days of admission after sICH was significantly associated with early mortality and good outcome. The next step is prospective validation of the simplified TIL score in a large clinical trial.
authors.affiliation: Division of Neurosciences Critical Care, Departments of Neurology, Anesthesiology/Critical Care Medicine, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 Wolf Street/Phipps 455, Baltimore, MD, 21287, USA, weziai@jhmi.edu.
authors.forename: Wendy C
authors.initials: WC
authors.lastname: Ziai
authors.forename: Aazim A
authors.initials: AA
authors.lastname: Siddiqui
authors.forename: Natalie
authors.initials: N
authors.lastname: Ullman
authors.forename: Daniel B
authors.initials: DB
authors.lastname: Herrick
authors.forename: Gayane
authors.initials: G
authors.lastname: Yenokyan
authors.forename: Nichol
authors.initials: N
authors.lastname: McBee
authors.forename: Karen
authors.initials: K
authors.lastname: Lane
authors.forename: Daniel F
authors.initials: DF
authors.lastname: Hanley
mesh_terms: D000368:Aged; D002543:Cerebral Hemorrhage / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000379:methods*; D010351:Patient Discharge; D011379:Prognosis; D012720:Severity of Illness Index