Hospital Variation in the Utilization and Implementation of Targeted Temperature Management in Out-of-Hospital Cardiac Arrest

Abstract

Background Targeted temperature management (TTM) for out-of-hospital cardiac arrest is associated with improved functional survival and is a class I recommendation in resuscitation guidelines. However, patterns of utilization of TTM and adherence to recommended TTM guidelines in contemporary practice are unknown. Methods and Results In a multicenter, prospective cohort of consecutive adults with non-traumatic out-of-hospital cardiac arrest in the Resuscitation Outcomes Consortium in 2012 to 2015, we identified all adults (≥18 years) who were potential candidates for TTM. Of 37 898 out-of-hospital cardiac arrest patients at 186 hospitals across 10 Resuscitation Outcomes Consortium sites, 8313 survived for ≥4 hours after hospital arrival, of which, 2878 (34.6%) received TTM. Mean age was 61.5 years and 36.3% were women. Median hospital rate of TTM use was 27% (interquartile range [IQR]: 14%, 45%), with an over 2-fold difference across sites after accounting for differences in presentation characteristics (median odds ratio, 2.10 [1.83–2.26]). Notably, TTM utilization decreased during the study period (57.5% [2012] to 26.5% [2015], P <0.001) including among shockable out-of-hospital cardiac arrest (73.4% to 46.3%, P <0.001). When administered, the median rate of deviation from one or more recommended practices was 60% (IQR: 40%, 78%). The median rate for delayed onset of TTM was 13% (IQR: 0%, 25%), varying by 70% for identical patients across 2 randomly chosen hospitals (median odds ratio 1.70 [1.39–1.97]). Similarly, the median rate for TTM <24 hours was 20% (IQR: 0%, 34%) and for achieved temperature <32°C was 18% (IQR: 0%, 39%), with marked variation across sites (median odds ratios of 1.44 [1.18–1.64] and 1.98 [1.62–2.31], respectively). Conclusions There has been a substantial decline in the utilization of TTM with significant variation in its real-world implementation. Further standardization of contemporary post-resuscitation practices, like TTM, is critical to ensure that their potential survival benefit is realized.

Temporal trends in the use of targeted temperature management after cardiac arrest and association with outcome: insights from the Paris Sudden Death Expertise Centre

“…In the USA, where this treatment was historically less employed as compared with European countries, TTM use was shown to further decrease in many centers, as revealed by recent administrative data [8]. In parallel, Khera et al found that TTM use dropped in all subgroups of CA survivors (both shockable and non-shockable) [9]. On the whole, these uncertainties prompted to perform new large randomized trials testing this treatment in CA patients.…”

Hospital‐level variation in outcomes after in‐hospital cardiac arrest in Denmark

“…In the United States, substantial variation has been shown in post-resuscitation care across hospitals including targeted temperature management. 11,34 It is unclear to what extent differences in post-resuscitation care exist in Denmark, and whether hospital-level variation in outcomes will decrease as potential disparities in resuscitation care are diminished. Additional research is warranted to inform on hospital-level variation in resuscitation care and its influence on variation in outcomes after IHCA in Denmark.…”

Association Between Hospital Recognition for Resuscitation Guideline Adherence and Rates of Survival for In-Hospital Cardiac Arrest

“…Moreover, excellence in post-resuscitation care among patients who survive the acute resuscitation likely plays a large role, [22][23][24][25][26] given wide variations in post-resuscitation expertise across hospitals. [27][28][29][30][31][32] This is a critical issue with the current award system for inhospital cardiac arrest, as the process-of-care measures which comprise the award measure relate to best practices for conducting acute resuscitation but do not capture excellence in the delivery of post-resuscitation care in intensive care units among patients who achieve ROSC. Finally, hospital systems for resuscitation care may play a large role in higher facility-level survival rates for in-hospital cardiac arrest, 30 and these unmeasured factors include a focus on hospital culture towards iterative quality improvement in resuscitation performance, organized care teams, experienced and motivated staff, recurrent training and frequent use of resuscitation simulations, and a non-threatening method to assess system failures.…”