Code ICE: Development and Pilot Analysis of a Protocol to Improve Response Time in Non-Traumatic Intracranial Hemorrhage and Tumor Emergencies

Introduction: Rapid intervention is a critical pillar of managing non-traumatic intracranial hemorrhage and tumor emergencies, including in pediatric patients. At our institution, we developed "Code Intracranial Emergencies (ICE)"; this multidisciplinary, multi-staged protocol emphasizes synchronized roles, communication, and streamlined assessment.

Methods: 69 total patients from January 2016-August 2022 (control) and September 2021-January 2023 (Code ICE/treatment) were retrospectively analyzed; cases were further stratified by emergency type and urgency (elective, semi-urgent, urgent, or emergent). All control and treatment cases were closely age- and pathology-matched. Control and treatment groups were compared across time intervals including: time from emergency department (ED) arrival to initial imaging, initial page to neurosurgery to operating room (OR) admission, ED admission to OR admission, and total length of hospital stay. Mann-Whitney U tests were employed and the threshold for significance was set at p< 0.05.

Results: Across all tumor cases, the protocol significantly reduced page to OR time (p = 0.0252), with ED to OR time approaching significance (p = 0.0597); time from ED admission to initial imaging was also lower on average for Code ICE patients, albeit not significant (196.36 vs. 326.83 min.) For hemorrhage cases across all urgency levels, no significant differences were observed, though the average time between treatment and control cohorts for page to OR time (392.13 vs. 713.25 min.) varied. When excluding elective cases, the protocol showed a significant reduction in page to OR time for hemorrhage cases (p = 0.0245) and lower average ED to initial imaging time (56 vs. 71.33 min). In non-elective tumor cases, significant improvements were once again seen in page to OR (p = 0.0038) and ED to OR (p = 0.0472) times along with a general decrease in average length of stay at the hospital.

Conclusion : Implementation of Code ICE reduced response times across several key points, particularly in urgent hemorrhage and tumor cases. While we expand our cohort for more robust evaluation, this analysis highlights the potential for similar protocols to improve outcomes in neurosurgical emergency care.