Post-cardiac arrest therapeutic hypothermia: overcoming the barrier of workplace culture and other implementation lessons.

ABSTRACT

BACKGROUND: Therapeutic hypothermia (TH) is associated with improved neurologically intact survival after out-of-hospital cardiopulmonary arrest. Because of its complex multidisciplinary nature, many hospitals in the United States have resisted implementing TH. A post-cardiac arrest (post-arrest) TH program was implemented at a major urban academic medical center. IMPLEMENTING THE THERAPEUTIC HYPOTHERMIA PROGRAM After initial efforts at TH at the University of Alabama at Birmingham Hospital nearly failed, the leaders restructured the TH program. Key elements included frequent multidisciplinary meetings involving all stakeholders, development of TH protocols and techniques consistent with customary institutional practices, introduction of cooling technology, and implementation of a TH physician rapid response system. RESULTS: During its first 21 months, the program initiated TH on 93 post-arrest patients. Of the 83 patients who achieved goal hypothermia temperature, 30 (36%; 95% confidence interval [CI] 26%-47%) survived to hospital discharge. Care teams successfully managed expected complications. Of two patients with TH-associated coagulopathy, one required TH termination. CONCLUSIONS: The program illustrates key lessons for successful TH program implementation, such as the difficulty of organizing and coordinating complex interventions in complex institutions, the importance of overcoming workplace culture, the value of technology, the need for mid-course corrections, and the advantages of a physician-based rapid response system. Many of these lessons are applicable to any quality improvement intervention.