Barriers to Achieving a Time-toTarget Temperature Goal in Post
Cardiac Arrest Patients Treated
with Therapeutic Hypothermia
Sarah Shepherd Carriere, BSN RN
ICU – St. Paul’s Hospital
Out-of-hospital VF Cardiac Arrest
Survival rate <5%
55% in Hypothermic Group:
Favorable Neurological Outcome
39% in Normothermic Group:
Favorable Neurological Outcome
1 hour delay: further
decreases favorable
neurological
outcome
Every 5 minute
delay:
Greater odds for
poor outcome
p
STANDARD OF CARE
AT SPH
Feedback from ICU staff
Cooling goal
times extend
past four hour
window
Delays after
patient
admission
Supported by
current
literature
The p
purpose
p
of examining
g the pathway…
p
y
Identify in-hospital barriers that delay
Achieving target temperature
Number of patients achieving the
goal time-to-target temperature
Therapeutic Hypothermia treatment for OHCA
patients
Create inhospital
timelines of
treatment
Chart review of
identified cases
Filtered search of the
ICU database
Direct vs.
vs non
nondirect transfer of
care route from
ROSC to cooling
achieved
Identify in-hospital barriers that delay TH
Our baby:
y the database
 Basic patient demographics.
Identifiers
Patient
Pt. #
086DI
081DC
077CY
075CW
073CU
Diagnosis
Male/female DOB
male
male
male
male
female
16‐Oct‐46
06‐Jan‐45
01‐Apr‐42
31‐Jul‐64
01‐Oct‐66
Time
Hosp admit dAdmitting Dx Type of arres ROSC
09‐Sep‐08 ST elevation ‐Vfib
7.38
12‐Feb‐09 Cardiac arresAystole 16.30pm
21‐Dec‐08 Cardiac arresVT‐VF
2213pm
03‐Dec‐08 Cardiac arresPolymorph
y p V 0936AM
22‐Nov‐08 Cardiac arresVT/VF
0735AM
Vitals
ER Admission temp
35.5
38.8
38.9
36.3
36.1
Database: ED pathway
p
y
Emerg
Locale
Service
A i ER
Arrive
ER MD arriva
i ICU MD notifi
tifi ICU MD arrivaCCU
i CCU MD notifCCU
tifCCU MD arrivDepart
i D t ER
8.08
16.49pm
2255pm
1002am
0809am
8.08am
1650pm
2255pm
1002am
0809AM
Service
nul
17.10PM
2348pm
1020am
1045am
Service
0941am
1815pm
0100am
1035am
1100am
Service
8.19am
17.10PM
2317pm
nul
n/a
Service
16.40pm
1815pm
2330pm
1145am
n/a
Locale
0820am
2100pm
0125pm
1345pm
1330pm
Database: CT/Intervention Catheterization
pathway
CT
Locale
Procedure
CT Y/N
Arrive CT
NO
YESS
No
No
Yes
Locale
Cath
Locale
Locale
locale
Depart CT
Cath Y/N
Arrive cath
Suscessful Depart cath
Yes
Noo
No
No
No
8.20am
Yes
1730pm
30p
1753pm
53p
1030am
1045am
Locale
0857am
Database: ICU pathway
p
y
ICU
L l
Locale
service
i
P d Procedure
Procedure
P d Procedure
P d Procedure
P d Procedure
P d Procedure
P d
Arrive ICU pre-cooling teCooling starteCooling achieArt line starteArt line compCVC started CVC completed
9.20am
35.5 10.40am 13.15pm
p 8.30am 8.30am 13.30p.p 13.30pm
p
2207PM
0135am
1415
1415pm
1325pm
38.1 2210PM
35.6 0015am
35 6 1230pm
35.6
1230
37 1445pm
0420AM
0500am
1715
1715pm
2300pm
nul
0240am
1100
1100am
nul
nul
0350am
1130
1130am
1100am
19.50PM
2315pm
1320
1320pm
nul
20.20PM
2330pm
1345
1345pm
1000am
Database: extra info
(because we can)
Yes=1 No=0 Procedure Procedure Cooling pathwPathway to ICCooling target maintained
Consult: Add Cooling modeInterrupted coTolerated cooDirect/non-di YES/NO
0
0
1 NO:
NO aborted
b t d 03 direct
No (below 32)
0
1
0 Yes
direct
No (below 32)
0
0 n/a
No: aborted 08direct
No (below 32)
0
1
0 Yes
direct
No (below 32)
0
1
0 Yes
non‐direct No (above 34)
More to come for future studies…
72% Male
VF arrest
60 years old
Basic
Information
Direct vs. non-direct transfer of care route to the ICU from time of
ROSC to cooling achievement
10 pts.
22 pts.
Let us break this down further:
Possible barriers to delaying
y g cooling.
g
arrival to ER:
Mean time: 25 minutes
ICU MD notified to arrival of
ICU MD responding to
page:
Mean time: 56 minutes
Patient arrives to ED to
ICU MD arrival time:
Mean time: 82 minutes
DELA
AYED CO
OOLING
P
POSSIBL
LE BARR
RIERS
Time between ROSC and
460 MINUTES
More Barriers Found
Time taken from
arrival
i l to ED to d
depart
ED
113.2
minutes
ICU MD arrival in ED to
arrival of patient in ICU
102.6
minutes
Depart ED to arrive in ICU
65
minutes
Time spent in CT
Scan
30
minutes
Time spent in
Interventional
Catheterization
44
minutes
Time spent
between ICU
arrival and
initiation of TH
37.81
37
81
minutes
Under the joint direction of the ED and ICU, could
we
e mo
move
e the patient thro
through
gh q
quicker?
icker?
Neither time of day / day of
week associated with time
taken to cool
TH initiated by ICU MDs…no
ED Ownership
DISCUSSION
Initiation of
TH by
y ED
could have a
large impact
on reducing
wasted time
Patients spending significant
time with separate groups,
groups
with no progression towards
TT
Range of temperature
changes noted between ED
stay a
and
d ICU
CU a
arrival
a
What we can say with confidence is that the handover process is not
streamlined.
Not portable
Sedation/para
lysis
Cooling
during PCI
Cooling
modality
Initiation-to-target mean time:
222 minutes
The Next Step
Information Shared
BCPSQC
ED OHCA Order Set
Dream Big
“C l it Protocol”
“Cool-it
P t
l”
Thank You
♥
Kevin Carriere
♥
Aggie Black and the Research
Challenge Initiative
♥
Janice Leonard – Operations
Leader, ICU
♥
Miriam Stewart – Director, Acute
S
Services
i
♥
Najib Ayas – Medical Director
♥
Shelly
y Fleck – Database Q
Queen
Sarah Carriere
sezshep@gmail.com