PC1213: An Effective Strategy for Targeted Temperature Management in Pediatric Patients Who Experience Cardiac Arrest

Purpose/Objectives: Optimizing functional neurologic outcomes in survivors of pediatric cardiac arrest is a major goal in critical care units. Fevers that occur following resuscitation can lead to worse outcomes. Targeted temperature management (TTM) with strict avoidance of fever has been shown to improve favorable neurologic outcomes and is an essential component of post cardiac arrest care. A review of patients with cardiac arrest at our institution revealed an average febrile time (>38 C) of 6.7 hours/patient and fevers occurred in 76% of post arrest patients. The goal of this project was to reduce total febrile hours by 50% to 3.3 hours.

Design/Methods: We utilized Lean-Six-Sigma methodology. We examined patients with cardiac arrest ≥2 minutes, who required mechanical ventilation post arrest, and had a post arrest motor GCS score ≤ 5. Baseline period occurred between February, 2019 - April, 2021 and intervention between April - December, 2021. Baseline analysis included a survey of nurses and clinical practitioners to identify barriers to TTM and interviews with nurses to understand how they deployed existing fever prevention tools. Cause and Effect and Key Driver Diagrams guided the improvement work. Identified barriers included 1) lack of a TTM protocol, 2) knowledge gaps in the use of cooling blankets, 3) difficulty managing shivering, and 4) poor communication of temperature goals. We developed and implemented a “TTM Bundle” (Figure 1) as our main intervention which included standard goal temperatures, cooling blanket use, temperature monitoring, and a post arrest order set. Nurses and clinical practitioners received training on the bundle prior to implementation. Our primary outcome was the number of febrile hours in the first 72 hours post cardiac arrest. Our process measure was the proportion of patients who had a cooling blanket ordered in compliance with the TTM bundle.

Results: We examined 29 patients in the baseline period and 26 in the intervention period. The intervention reduced average fever time per patient by 4.7 hours (95% CI 1.5-7.9) to 2 hours (SD 3.8), meeting the primary goal. Figure 2 displays the run chart of total fever hours/patient. The percent of patients with any fever was reduced from 76% to 46% (p = 0.03). Use of a cooling blanket immediately post arrest increased from 3% to 78% (p < 0.01).

Conclusion/Discussion: Consistent and effective TTM can be difficult to achieve without a regimented approach. This quality improvement project demonstrated that development and implementation of a protocolized approach to TTM can substantially reduce the frequency of fevers and the length of time fevers occur in patients who survive cardiac arrest.