Targeted Temperature Management in Nursing Care

Targeted temperature management has become a standard of care in many intensive care settings. The role of nursing is critical as we consider the use of these new approaches to maintaining temperature control and inducing hypothermia in our patient populations. Indeed, the successful use of various new cooling devices many times falls on the nursing staff to maintain strict guidelines for use as well as troubleshooting problems. A series of state-of-the-art lectures presented at the 2014 Therapeutic Hypothermia and Temperature Management meeting in Miami brought together several experts to discuss their experiences with utilizing therapeutic hypothermia and temperature management strategies at their institutions and hospitals. Dr. Justin Lundbye, chief of cardiology at the Hospital of Central Connecticut, moderated this session. Mr. Mark Adams, Virginia Health System, University of Virginia, discussed collaborative efforts for the use of therapeutic hypothermia on injured patients. A major point of discussion was whether therapeutic hypothermia medicine is a nurse's therapy. Dr. Kelly Sawyer, Department of Emergency Medicine, William Beaumont School of Medicine, discussed targeted temperature management and out-of-hospital cardiac arrest in survivors undergoing therapeutic hypothermia. Ms. Deborah Klein, Cleveland Clinic, spoke on therapeutic hypothermia after cardiac arrest and strategies for a successful program. Specific issues discussed included steps in the implementation of a therapeutic hypothermia program as well as strategies for changing clinical behavior. A team approach in terms of recruiting members to work together as well as emphasizing various methods for cooling were discussed. Based on the information presented during this roundtable discussion, it is clear that therapeutic hypothermia is being used, and a growing number of different types of caregivers are responsible for the successful implementation of the programs and beneficial results.

Question: When you were going over your talk, some of your inclusion criteria were witnessed cardiac arrest, and it included VFib and pulseless VTach. I just recently rewrote the order sets for all seven of our hospitals. I removed that as an inclusion criterion because I didn't want to come across a physician who says, “Oh, it is a pulseless electrical activity (PEA) and now we have ROSC [return of spontaneous circulation],” but that didn't meet the criteria. So I am curious as to why you have VFib (VF) and pulseless VTach (VT) other than that's what the literature supports.

Ms. Deborah Klein: When working with new hospitals that have never used therapeutic hypothermia before, I have found it easier to start off with the things that are very clear and are supported by the American Heart Association/American College of Cardiology (AHA/ACC) guidelines. We include in our protocol to consider therapeutic hypothermia for asystole, PEA, and for in-hospital cardiac arrest. We don't want to limit therapeutic hypothermia to just the patients we know benefit (witnessed VF and pulseless VT). At the beginning of a program development especially, you want to provide clear guidelines. Criteria for patient inclusion are witnessed VF and pulseless VT and to consider in-hospital cardiac arrest, asystole, and PEA.

Question: Another phrase that we were getting hung up on was “within 6 hours.” So we changed that to be “ideally within 6 hours ” or something that would capture, somebody potentially out to 10 hours. It wasn't an absolute cutoff because, if they were 6 hours and 1 minute, what would you do?

Ms. Deborah Klein: The AHA/ACC guidelines support initiating therapeutic hypothermia as soon as possible after return of spontaneous circulation (ROSC). In conversations with the medical director of the Coronary ICU at Cleveland Clinic (main campus), we revised our protocol to state within 6–12 hours. We give ourselves that flexibility because we also have to consider transport time. The majority of our patients coming into the Coronary ICU are coming from outside facilities and are being flown via helicopter to us. Sometimes we don't meet the 6-hour criterion, and we are comfortable extending out to 12 hours.

Question: Then, finally, as far as your order work, my hospital accepts patients from the Keys. So it's about 3–4-hour prolonged transport time. With the order sets at Cleveland Clinic, do you have separate order sets for the ICU and then separate orders for just the ER to deploy? That was a large obstacle because, the reality is, I'm an ER nurse, and I really don't care about the maintenance and rewarming phase, but I do care about induction.

Ms. Deborah Klein: I respect your struggle, as this is an issue for the Cleveland Clinic Health System. We developed one therapeutic hypothermia order set for the Cleveland Clinic Health system. Not all hospitals have, for example, the capability to do continuous electroencephalography (EEG) monitoring. So in that hospital, continuous EEG monitoring was removed from the order set. On the main campus, we made a decision that the CICU (coronary intensive care unit) service would initiate and manage these patients. We don't have that many patients coming from the emergency department (ED), and, as a result, our ED really is not involved. We have actually gone down to the ED to help facilitate some of the initial management of these patients. It really needs to be one order set, one service. It is so much easier when time is of the essence.

Dr. Kelly Sawyer: I would add that I consolidated our order sets into one, as well, to reduce redundancy and because I hardly know anyone who would only order the ED one. I think we have more consistency by having just one order set.

Question: I just wanted to ask a kind of open-ended question to everyone here that several people have already touched on. How do we convince medical teams to intervene from multidisciplinary care when we have the neurostatus that is uncertain for 1 week or so? It's a broad question for everyone to think about maybe.

Dr. Kelly Sawyer: I'll start. I think we all recognize that we don't really understand neuroprognostication after cardiac arrest and temperature management. With a buy-in for a program, you really have to push for everyone to sort of agree to wait. It's a battle depending on the consultant for the day; I find that challenge still but I am hoping to find a designated neurologist to consult on all our patients. I'm not sure if other people have had better success doing that.

Mr. Mark Adams: I think one thing you should do is trust your nurse's serial assessments. You may have a neurology consultant who is observing once every 24 hours who sees a snapshot in time. But when you have a documented series of evaluations of limb movement or other activities that could or could not be significant, I think that's very important. One of the things that we've worked on is creating a standardized flow sheet so that a neurologist, cardiologist, emergency physician, or whomever can look at that and see the serial assessments—moving this, not moving that; eyes open, eyes not open. So I think it's very important that you look at the total and not just the one snapshot.

Dr. Kelly Sawyer: The only other thought is that we've been able to wait longer in some patients and actually had good outcomes. The more the (nursing) staff sees that, the more they push to wait as well. They aren't so quick to point out potential poor prognosticator signs to the family and instead are wonderful advocates for patience with this population.

Ms. Deborah Klein: One of the things that we have, and I know we're fortunate, is that we have a neurocritical care attending in the hospital 24/7. Our protocol includes that when we have a patient coming in who is a potential therapeutic hypothermia patient, the neurocritical care team is notified and we are at the bedside when the patient arrives. The intent is that a neuroassessment is performed before the patient is sedated. Sometimes the patient is sedated en route because of agitation. But more importantly, the neurocritical care physician can help distinguish seizure activity or purposeful or unpurposeful movement. Our neurocritical care physicians prefer to see the patient before therapeutic hypothermia is initiated. It provides them a baseline, plus they are initially involved in the care of the patient. They are not usually consulted in 2–4 days after the arrest when the patient has already been successfully rewarmed.

Question: I have a question. I'll direct it at Dr. Sawyer, but it's for everybody, regarding anticoagulation in the cooled patients. I'm interested in hearing what you use. We have used an IV prophylactic heparin protocol to avoid deep venous thrombosis (DVT). Some patients have gone on the extracorporeal membrane oxygenation (ECMO) machine, and so they have a considerable amount of anticoagulation and we have gotten away with using that. But I am curious to see what other institutions are doing. Dr. Sawyer, what you are using for DVT prophylaxis?

Dr. Kelly Sawyer: I think that the majority of ours get just sub-Q.

Mr. Mark Adams: I would say the same except for those who are on Impella or balloon pump support, and they all get unfractionated IV heparin.

Ms. Deborah Klein: We also use an anticoagulant with intravenous heparin if indicated.

Question: A modified IV or sub-Q?

Ms. Deborah Klein: It's very individualized. Sometimes, they are on IV heparin infusion. If they already have a stent, we want to keep them anticoagulated. It is interesting because the decision is made with our pharmacist as well as with our physicians together as a team to determine if a patient meets the criteria for anticoagulation and what should it be.

Question: I have just a few questions. Do you have any recommendations on what the total code time should be to initiate hypothermia? Especially in patients who have multiple arrests? Right now, in our protocol, we have 1 hour. If they've had three arrests, and total code time is less than 1 hour, we'll initiate. If it is greater than an hour, we won't.

Mr. Mark Adams: This is a soft call. We do have the 1 hour, but I can tell you at least anecdotally that when you have multiple arrests, it is confounding as to where you start your clock. Second, almost all those have a poor outcome.

Question: My next question is, do you have a recommendation on what degree of body temperature to stop central venous punctures, arterial lines, or central lines. Our main concern is when our team comes together sometimes, whoever is putting the central line in may be a little late, and so we don't want to delay cooling for that. So, once they get to 34, should we stop or does it matter?

Ms. Deborah Klein: We try to get all of our central lines in before we start cooling. We'll spend the extra 15 minutes getting lines in before we start cooling. Because most of our patients are transferred in from outside hospitals, our critical care transport team often will pack them in ice to start the cooling process.

Comment: I'm at a small community-based hospital, and 15 minutes would be fantastic, but what I'm really looking at is probably like 2 hours. But what we'll do is initiate iced saline infusions in the meantime, then get the lines in, and then start.

Dr. Kelly Sawyer: I'd say starting some things is better than nothing. Our staff tends to get concerned about vasoconstriction, causing trouble getting lines placed. Not so much a coagulopathy issue. So I'd say, as soon as possible, but start something early.

Dr. Justin Lundbye: So, my thinking is to get the cooling started as soon as possible. I'm not that concerned about bleeding and coagulopathies. There are a lot of trauma data that support that cooled people bleed more but that hasn't really been translated into what we are doing with therapeutic hypothermia. If you have vascular compromise, if you control that, you should not have any problems. We do percutaneous coronary intervention on patients who are at the target temperature all the time, and it hasn't been a big issue. So I would advocate for getting them to the target temperature as quickly as possible and getting the lines in when you can.

Question: What has been your experience with balloon pump and therapeutic hypothermia? We've had some issues with what we are assuming is helium gas expansion upon the rewarming portion. Have you had any issues with that? As the patient rewarms, do you get pressure alarms from the balloon pump because of the helium gas expanding?

Mr. Mark Adams: No. That is the first I've heard of that. We've had a number of patients with balloon pumps and cooling, and we've not had that.

Question: Our team is nurse-initiated. We have an established protocol, and so I don't have to call, as of right now, a physician to initiate. We initiate and then use our consults. In your presentation, you talked about having a physician-ordered therapy. How do you feel about that?

Mr. Mark Adams: That physician order could say, “Mark, let's start cooling.” Done, because we can translate a verbal order into a full set of protocols with 40 orders with just a verbal like that.

Question: I promise my last question is quick for Dr. Sawyer. For the 30-year-old pulmonary embolism patient that you talked about, did you start the cooling process before going into the operating room for the embolectomy?

Dr. Kelly Sawyer: Yes, an intravascular catheter was placed in the ER.

Dr. Justin Lundbye: What's the maximum age that you have cooled? Is there such a thing as minimum age?

Mr. Mark Adams: No restriction. The youngest was 21.

Question: All three of you have mentioned involvement of emergency medical services (EMS) and prehospital providers. As an emergency medicine physician and also someone running a prehospital service and conducting an induced hypothermia service, how do you put all of those components together. I'm sure you all have various prehospital organizations. Do you have a unified system that has unified protocols, or do you have to approach each system individually? Do you find problems in those individual systems?

Ms. Deborah Klein: We have multiple systems, and yes, each one has to be approached individually.

Mr. Mark Adams: I have the advantage of being a 15-year paramedic veteran and a regional EMS council director where I practice. So I actually sat with the medical directors of one region and we created the protocol. In the region, some competition came along. So we have two almost identical protocols that cover almost a 4,000-square-mile area with over 19 municipalities. It's not perfect.

Question: I would just have to congratulate all of you. It appears like you really have your acts together in terms of developing the infrastructure, personnel, communication, and the multifactorial approach attacking this problem. Do you get asked to go and speak at places to help people initiate these very complex programs, because it is clear that you know what does work and what does not work? We appreciate how much work and effort it takes to initiate a successful program and get different departments and divisions speaking together. What is your experience? Do you go out and teach, mentor other groups, and does it work?

Mr. Mark Adams: I've received phone calls and e-mails following this last year from people who know that we've had a program since 2006. A lot of it's done by phone and e-mail exchange and as I said earlier, all of our documents that we've created are available to anyone who asks. As Debbie alluded to, the person who calls up and says, “We're starting in a week,” that's horrifying. Great, let me ship you six things if you haven't written them already. Here, put your name on it and incorporate it into your system. But it's quite enjoyable and rewarding when you get calls back, saying that they had their first cooled patient, and it was successful.

Ms. Deborah Klein: I have a very similar experience with e-mails and phone calls. We want to start a program, but we're not sure where to start. How did you do it? I've actually gotten calls from bigger hospital systems who are just trying to improve their process. How are you addressing a specific issue? How are you managing shivering? Who completes the order set? What's the role of the ED in the process?

Question: And is there a critical mass of people that have to be on board to get this done?

Mr. Mark Adams: One from each discipline, at least. You have to have the enthusiasm, if you will, the cheerleaders. The physician, nurse, respiratory therapist, and pharmacy champions who are going to go back to their respective departments and talk up the evidence. The evidence is overwhelming. Yes, we are going to hear more about the actual temperatures, I'm sure. But the therapy in total is effective. We just need to bring that back to folks who are so busy they don't have time to do the research that we've done.