Hypothermia program yields quick results
Cardiac patients' neuro functions restored
Less than two weeks after instituting a Post-Arrest Hypothermia program for heart attack patients, Providence (CA) Tarzana Medical Center has applied the body-cooling treatment in three cases, and each patient showed remarkable neurologic recovery. The program has been simultaneously implemented in the ED and the ICU.
"In the hospital, only one out of 10 [cardiac arrest) patients survive, and of those, how many survive without neurological damage is not known," notes James de la Torre, MD, MMM, associate director of emergency services.
Also showing excellence is the "number needed to treat," or how many patients have to receive a therapy before the provider sees the outcome he or she is looking for, adds G. Scott Brewster, MD, FACEP, medical director of the ED. 'Some of the best drugs for acute MI have a number needed to treat of 20-25, while this therapy has a number of seven or eight," Brewster notes. De la Torre adds, "That's why it's such an attractive therapy."
After reviewing studies on the therapy, Brewster and de la Torre decided to go ahead with a protocol, even though their research revealed a poll of physicians in which only 13% said they were using hypothermia in this manner. Brewster says some "doubters" felt new studies were needed, while others were deterred by the logistics needed to create a protocol because it's time-consuming and difficult. "But there's very little downside," he says. "There are not a whole lot of drugs to use, and 'number needed to harm' is so high we felt we should start looking at this." The American Hospital Association gave the procedure a Class IIA recommendation about 18 months ago, he says. (A Class IIa recommendation means that the weight of evidence or opinion is in favor of usefulness and efficacy.)
Brewster and de la Torre brought together a multidisciplined team to develop the protocol, including everyone from EMS pre-hospital care paramedics to discharge planners, neurologists, and follow-up providers, de la Torre says. "Chain of survival is key, and all of those links have to be in place. Intensivists, cardiologists, neurologists — they all have to be on the same page. A lot of it involved education, because this is a relatively new modality."
So, for example, when the EMS providers call and says they are bringing in a patient who has arrested, "the ED doc needs to be aware of the protocol, initiate orders, and have them continued on in the ICU, where they have to understand how to rewarm the patient, because you do not want to do it too quickly," says de la Torre.
A 'relatively simplistic protocol'
The protocol itself, says Brewster, is "relatively simplistic," involving inclusion and exclusion. For example, to be included, the patient must be 18 or older, have had cardiac arrest with return of spontaneous circulation, be unresponsive after that, have to be intubated and ventilated, and blood pressure must be maintained to at least 90 systolic. For exclusion, the patient could have another reason to be comatose (stroke), be pregnant, have a temperature of less than 30° C after the arrest, or have a do-not-resuscitate order.
"After that, the protocol is for us to put you on our machine as quickly as possible and bring your temperature down," Brewster continues. The protocol also includes some monitoring characteristics, such as making sure the patient is paralyzed and that sedation is "on board," he says. The team treating the patient also use BIS [bispectral index] monitors to help guide sedation. "It indicates how much neurologic function is going on," Brewster explains.
"We have preprinted order sheets hanging off every one of the [cooling] units — order sets, inclusion and exclusion criteria, and wraps," he adds. "You just pull the machine over. It's very efficient and exciting."
Several hypothermia options available A new Post-Arrest Hypothermia program for heart attack patients in the ED and ICUs at Providence (CA) Tarzana Medical Center has achieved significant success in just a couple of weeks. The body-cooling treatment has been applied in three cases, and each patient showed remarkable neurologic recovery. For EDs considering this modality, there are several options, notes G. Scott Brewster, MD, FACEP, medical director of the ED. "You can use the 'poor man's' method using materials every ED has: cool saline and ice packs," he says. "The problem is that it is difficult to be accurate [about the patient's temperature], and you can overshoot," such as cool the patient down too much, Brewster says. There are also several cooling systems available from vendors, with prices ranging from about $8,000 a unit to $25,000 a unit. Brewster says his ED uses three units from Gaymar Industries of Orchard Park, NY. "It's a noninvasive method," he explains. "The patient is wrapped in [blankets containing] gel foams, and you put cool saline around the chest and legs and sometimes the head and neck, and it regulates the temperature to a perfect degree." |
Bedside nurses give vital input One of the reasons that the Post-Arrest Hypothermia program at Providence Tarzana (CA) Medical Center has been so successful was the intimate involvement of bedside nurses in the planning and education processes, says Holly Nagatoshi, RNC, MSN, EdD, CEN, CPEN, manager of emergency services. "Patricia Jackson, RN, a staff nurse in our ED, was an integral part of the program development as part of the multidisciplinary team," she says. "She has led the implementation and education of not only the staff in our department, but the ICU and ICU [cardiovascular ICU]." Jackson set up six training sessions and inservices, Nagatoshi continues. "She also taught components of the program side by side with the doctors," she says. The nursing department also helped put together the packets, supplies, and protocols, and it came up with some of the key processes in the program, says Nagatoshi. Jackson continues to be involved in ongoing education and process improvement feedback to the staff, and she follows the progress of patients who have been successfully treated. "With any new process or change there are always challenges, but by getting staff nurses at the bedside involved, we were able to see it from a clinical bedside perspective," says Nagatoshi. "We found very few, if any issues, where we felt we would not be able to rapidly implement if we ended up in an emergency situation. They were knowledgeable about what they were doing, and we were able to access equipment immediately. It was flawless." When faced with the "real thing," she adds, "we were able to initiate everything in the first hour because we were so prepared and we communicated between teams. That's what made it really successful." |
Hypothermia has several key elements Successful application of post-arrest hypothermia involves several key steps, says James de la Torre, MD, MMM, associate director of emergency services at Providence Tarzana Medical Center, Providence, CA. "The decision to initiate cooling and therapeutic hypothermia is important," de la Torre says. "Once that decision has been made, time to target temperature [without overshooting] is critical to slow down the cellular processes, which have been set in motion." Finally, he says, maintaining a steady therapeutic hypothermic phase at 32°-34° C and having a controlled rewarming phase, without rebound, is crucial to optimizing therapeutic hypothermia benefits. "So far, our surface cooling techniques have enabled us to achieve all of the above with great clinical results in our patients," de la Torre says. |
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