From the 2024 HVPA National Conference
Rabie Kilan, Master (JHAH)
Introduction
Cardiovascular-related deaths from cardiac arrest incidences are significant and are associated with the risk of neurological injury, poor quality of life, and survival rate. Targeted temperature management, also known as therapeutic hypothermia, is a therapeutic intervention that is intended to limit neurologic injury after a patient’s resuscitation from cardiac arrest (Liao et al., 2020). As per the American Heart Association chain of survival guidelines, targeted temperature management (TTM) plays an important role post-resuscitation in controlling the core body temperature and protecting neurological status.
Background
Johns Hopkins Aramco Health Care (JHAH) had been using and monitoring the TTM protocol for years. Data from January 2022 through March 2023 showed a low compliance rate for using the TTM protocol for patients with Return of Spontaneous Circulation (ROSC). It was also found that the current protocol is outdated, and there is no clear process for determining which patient category a TTM protocol should be applied to. Moreover, there was no clear flowsheet in the JHAH electronic health record – EPIC platform where healthcare providers could access consistent, appropriate documentation. Noncompliance, inconsistent TTM use, and an outdated TTM protocol decrease the opportunity to provide patients with the best possible treatment for better neurological outcomes post-cardiac arrest. The data showed only 12.4% compliance for TTM documentation, 26% compliance for order placement, and 24% compliance for inclusion/exclusion review.
Objectives
The project aimed to increase the chances of better neurological outcomes post-cardiac arrest by ensuring compliance with the TTM protocol using either a surface cooling or endovascular cooling approach. The goal was to improve compliance with the protocol through a best-evidence practice approach and reach a target of 100% compliance by ensuring that an updated inclusion and exclusion criteria framework is utilized by physicians for post-ROSC patients. A structured flow process and flow sheet documentation were also implemented. Additionally, the objective was to decrease the time required to reach the targeted temperature to 45-60 minutes from the onset of the order entry in the system.
Methodology
A project charter was designed to document the current process (Process Map), conduct root cause analysis (RCA), plan interventions, and sustain improvements. The researchers used a cross-sectional retrospective chart review to gather data, focusing on four domains: TTM planning and initiation, documentation, evidence of using inclusion and exclusion criteria, and the availability of resources to initiate TTM treatment. The initial data was collected for post-ROSC patients (n=59), followed by a second data collection (n=95). Through analysis, reflection, and group discussions, the data indicated an improvement in utilizing pre-order inclusion and exclusion criteria and TTM documentation by introducing a new TTM protocol, nursing flow sheet, and TTM flow process.
Result
The initial results showed a gap between current practice and best practices. The action plan was implemented in June 2023, which included designing a new TTM protocol for all critical care areas, implementing a new nursing flow sheet to ensure all TTM elements were captured, completing training and skill verification, and enhancing EPIC documentation. The second data set showed significant improvement in implementing the new protocol. The results showed that 100% of inclusion and exclusion criteria were reviewed, TTM start time was documented 70% of the time, initial patient temperature was documented 60% of the time, targeted temperature setting was documented 70% of the time, TTM temperature achievement was documented 70% of the time, TTM 24-hour monitoring was documented 60% of the time, rewarming start time was documented 60% of the time, rewarming achievement was documented 70% of the time, and TTM completion was documented 80% of the time.