Evidence-Based Practice Project

1. Evidence-Based Practice Project Timing of Implementation of Therapeutic Hypothermia Post Cardiac Arrest OHSU School of Nursing – Monmouth NRS 322 – Acute Nursing II Instructors – Bret Lyman & Allison Kooistra Senior Student Nurse (Project Leader) – Kira Biron Junior Student Nurses - Sarah Aulerich, Kylee Bell, John Brun, Melissa Knudsen, Amy Pieren, Oscar Ramos, Megan Vorderstrasse & Kimberly Washburn

2. RELEVANCE OF TOPIC • Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality and severe neurological disability. • Recent literature suggests that therapeutic hypothermia can improve survival and neurological outcome in some groups of comatose patients after cardiac arrest. • Uncertainty exists over the best way (method) and at what point to implement this treatment to assure best outcomes.

3. Salem Hospital & Therapeutic Hypothermia (TH) Therapeutic Hypothermia is already implemented in the ICU using the Alsius endovascular cooling system, but some talk has been done to possibly start the process sooner & consistently in the ED with other bridging methods.

4. What is Therapeutic Hypothermia (TH) Is a process of systematically & safely lowering a patient’s overall body temperature to a target of 33 C (91.4 F) degrees to slow down cell death which can increase the chance of full neurological recovery.

5. Reasons to Make a Patient Hypothermic • Decreases free radical production & dangerous buildup of calcium levels • Decreases intracranial pressure • Decreases cerebral metabolic rate as well as its need for oxygen and glucose • Decreases the damage that cerebral reperfusion injury can produce on patients with ROSC • Prevents mitochondrial damage & breakdown, reducing tissue necrosis and/or apoptosis • Prevents immune system attack on cells due to abnormal ion levels • Provides a better chance of recovery with intact neurological function

7. Cerebral Reperfusion Injury

8. EBP – PICOT Acronym

9. EBP – PICOT Question “For patients with return of spontaneous circulation (ROSC) after cardiopulmonary arrest who remain comatose upon admission, does sooner implementation of Therapeutic Hypothermia in the pre-hospital or ED setting as compared to later implantation in the ICU, make a difference in neurological outcomes over time”

10. EBP – Locating the Evidence The following key variables/terms provided to us by our Senior Student Nurse (Project Leader) were located via online research using CINAHL(EBSCO), MEDLINE (Ovid), PubMED (OHSU) & Nursing Reference Center: • Inclusion criteria: When should hypothermia be initiated and for which patients? • Cardiac arrest • Comatose • Within 6 hours of arrest • Exclusion criteria: Which patients should not get hypothermia therapy? • Head trauma • Overdose • Adverse effects/prevention • Sedation/shivering prevention • Electrolyte imbalances • Hyperglycemia • Cardiovascular/hemodynamic effects • Positive effects • Neurological outcomes • Statistics • Decreased metabolism • Decrease in excitatory amino acids • Suppresses inflammatory response • Decreases free radical production • Prevention of apoptosis

11. EBP – Critiquing the Evidence (1) The located articles where first given a rating of strength for the evidence, based on this evidence-leveling hierarchy provided to us by our Project Leader which she retrieved from the American Association of Critical Care Nurses (American Journal of Critical Care)

12. EBP – Critiquing the Evidence (2) First, the articles were critiqued with the following topics provided by our Project Leader: • Sample size • Research Methods • Findings • Study Limitations * These articles were then synthesized to provide preliminary recommendations to our Project Leader as she prepared to present to information to a Salem Hospital EBP meeting.

13. EBP – Critiquing the Evidence (3) Second, the articles were critiqued with the following topics provided by our Instructor: • Qualifications of author(s) • Quality of the source • Currency of the work • Evidence that suggests bias • Methods used to generate information or source from which information was obtained • Primary findings, suggestions and/or recommendations & extent to how they are supported by the information previously presented • Overall quality of the document as compared to other sources • Original contribution the article makes to the field of nursing knowledge and/or to our nursing practice

14. EBP – Synthesizing the Evidence • Next the findings suggestions, and/or recommendations that were well-supported in the evidence where identified. • These findings suggestions, and/or recommendations were then synthesized into coherent statements that a clinician could incorporate into his/her practice. • Statements were then qualified by the strength of the evidence supporting them.

15. Overall Quality of Evidence Team Response

16. Worldwide Evidence • Extensive worldwide evidence has demonstrated that early implementation of TH, reduces mortality and leads to better neurological outcomes for patients with return of spontaneous circulation (ROSC) post cardiac arrest while they were comatose.

17. AHA Recommendation • Even a stronger recommendation now exists to implement TH early in ROSC post cardiac arrest as the AHA has included TH as an option in their 2010 Guidelines for Cardiopulmonary Resuscitation & Emergency Cardiovascular Care.

18. Evidence-Based Recommendation The recommendation from the EBP research team is therefore is to start therapeutic hypothermia immediately after ROSC following cardiac arrest in the ED (or pre-hospital care if on radio control of EMS), for all patients that remain comatose and who do not meet certain exclusion categories.

19. Remaining Questions not Addressed by Evidence Team response

20. Therapeutic Hypothermia Not like this More like this

21. Salem Hospital TH in ED Implementation - Approved Excerpts from recently approved policy following presentation of recommendations from our Project Leader to SH EPB Staff: Steps & Key Points I – Identification of Eligible Patients • Emergency Department physicians, and nurses evaluate for treatment eligibility in collaboration with cardiology, critical care intensivists, neurology and neurosurgery

22. I – Identification of Eligible Patients • INCLUSION CRITERIA • Cardiac arrest with ROSC • Neurological status is unresponsive after ROSC (GCS <8) • MAP maintained at least 60mmHg spontaneous or with fluids/pressors • Time from initiation of hypothermia is less than 6 hours after ROSC

23. I – Identification of Eligible Patients • EXCLUSION CRITERIA • Hypotension (MAP< 60 mmHg for more than 30 minutes after return of spontaneous circulation with the use of fluids/pressors) • Conflict with DNR/Advanced Directive • Sepsis as suspected cause of cardiac arrest • Uncontrolled bleeding: Should be controlled before initiating therapeutic hypothermia

24. II - Location of Implementation • INITIATE COOLING AS SOON AS POSSIBLE. COOLING CAN BE INITATED UP TO SIX HOURS POST EVENT. • DO NOT DELAY CARDIAC CARE TO INITIATE COOLING.

25. II - Location of Implementation • Emergency department must continue therapeutic hypothermia if EMS initiates treatment in the field if emergency department physician determines eligibility per hospital protocol (See Identification of Eligible Patients, I) • Emergency Department physician must determine eligibility and initiate hypothermia as soon as possible if EMS has not initiated hypothermia. (See Procedure for induction and maintenance of cooling, III) • Cooling must be continued in the cardiac procedural lab.

26. III. Procedure for induction and maintenance of cooling • MAINTAIN TEMPERATURE BETWEEN 32-34 DEGREES CELSIUS. • AVOID OVER COOLING.

27. III. Procedure for induction and maintenance of cooling • Emergency Department • Obtain baseline CBC, CMP, Magnesium, Phosphate, Cardiac enzymes, DIC Panel Vital Signs and neurologic signs as directed by physician • Foley catheter placement with temperature probe. (Oesophageal/ventral venous temperature better reflects core temperature, especially with rapid cooling.

28. A - Emergency Department • Notify Critical Care charge nurses early of eligible hypothermia therapy patients • Administer analgesia, sedation, paralytics, shivering agents as directed • Wrap hands and feet with dry towels to decrease shivering stimulus

29. A - Emergency Department • Administer bolus of 30ml/kg (not exceeding 2 Liters) of 1-4 degree Celsius Normal Saline/Lactated Ringers in Second IV site over 30 minutes. Limit IV fluids with dextrose, or control blood sugar with insulin. Consider hypertonic fluid to limit extravasation. • Place surface cooling blankets until endovascular catheter placement is possible

30. A - Emergency Department • Place ice packs on axilla, groin and neck until endovascular placement is possible. • Endovascular cooling: Physicians and nurses trained and competent in endovascular cooling must be present when this method is selected. Follow manufacturers guidelines. • Monitor the skin carefully

31. IV. Monitoring • Metabolic Effects – While most metabolic effects will be more apparent during ICU, some may present during the initial induction process done in the ED: • Potassium: Hypothermia commonly causes hypokalemia, which may be exacerbated by insulin administration. • Glucose: Hypothermia causes insulin resistance resulting in hyperglycemia. Blood glucose monitoring may be required hourly. Arterial/central catheter blood may be more accurate than fingersticks due to vasoconstriction in extremities. • Drug Clearance: Hypothermia decreases drug metabolism. Titrate accordingly.

32. IV. Monitoring • Cardiovascular/Hemodynamics • Blood Pressure: Vasoconstriction may occur during cooling. monitor blood pressure frequently, set a target MAP with the team dependant upon patient circumstances. • Heart Rate: Hypothermia can induce initial tachycardia followed by bradycardia. • Arrhythmias: Risk increases as temperature drops. AVOID OVERCOOLING. • Cardiac Output: CO will decrease. Usually supply equals demand due to metabolism reduction. • Electrocardiogram: Prolonged PR intervals, increased QT interval, and widening of the QRS complex. • Coagulation: Mild hypothermia can induce mild coagulopathy.

33. Therapeutic Hypothermia Any questions?