Transcript Video How to Assess, Review and Improve TTMDr. Justin Ratnasingham < Back to Boundaries of Temperature Session 6: Choices How to Assess, Review and Improve TTM Presented by Dr. Justin Ratnasingham Next talk will be given by Dr Justin Rattner juan. Um He's the clinical director of the Liverpool heart and chest institute. He's an anesthesiologist and internist. And he will give us a talk on how to assess review and improve T. T. M. So the stage is yours please. Hello thank you for the invite to come and speak here on this topic. I'll be covering how to assess review and improve T. T. M. So I stated I work at Liverpool heart and chest hospital. We're a large cardiothoracic center and I've got a high exposure to these kind of patients. So what is ideal T. T. M. First of all we need to decide who which patients we want to treat. We need to stick to our local protocols because with all the trials that have been taking place there's a lot of interpretation and then we need to make sure that patients get consistent care and we need to make sure we do no harm. So you've seen this slide a few times now over the last few days. This is the guidance that's come out just recently in March and I think we need to make sure that our protocols follow this or at least are consistent with it. So I think we can all agree that continuous monitoring of core temperature is vital in patients who are comatose after cardiac arrest. We know we need to avoid fever and we're finding that as a temperature greater than 37.7 in these patients. And then we need to maintain this protection for at least 72 hours. We should expose the patients and use antibiotic drugs or if that's not sufficient, use a cooling device to meet with the target temperature 37.5. And as we've just discussed, there's insufficient guidance at the moment to target anywhere between 30-36 and we're awaiting more research. But what we are all in agreement hours, we mustn't be warming these patients. So the patient selection should be fairly straightforward. All patients to remain comatose from cardiac arrest. There's there's a greater evidence in the hospital setting. Um, and but we do still use it for in patients if they've had prolonged arrests, we need to make sure and we need to measure ourselves according to our local protocols. We need to evaluate all parts of the pathway and that includes the initiation, maintenance and rewarming phases. And if we don't look at this, there's no way of knowing if we're improving or not. I feel really strongly about the consistent care aspect um, patients. Whatever time of the day they come in, they must get the same care and certainly within UK practice, the consultant workforce is generally there during the daytime. So care needs to happen. Whoever is providing it. And that means that means that if you want to be successful, you need to embed T T. M. Into the culture of the critical care unit and I think as you know, as as following from the nursing presentation yesterday, nurse leading implementation definitely improves compliance. We need an engaged and effective education team so we can't build a protocol around the left hand picture when you've got your experience critical care consultant during the daytime it needs to work at night with the tires workforce when I think about care of critical of these out of hospital cardiac arrest patients that are presenting to the health care system. I feel like we are on a journey and different units will be along in different places along this pathway. In some units there's still a lack of us that acceptance. That term is actually important. Next. We need to make sure we're doing continuous temperature monitoring. We need to make sure we're not doing any harm. So not warming patients inappropriately in some units it's just basic cooling methods and in some there's active server controlled temperature management and I think the nirvana will be with more research that a patient can come in and get a very individualized temperature target and duration. But we're not there yet. So how do we assess our T. T. M. We need to look at patient selection and if our colleagues aren't using it appropriately, we need to challenge them. We need to analyze the treatment phases and we need to do regular audit ideally continue and we need to create a feedback so that T. T. M becomes the standard of care. I'm sure you've all seen this this this uh phrase culture eats strategy for breakfast. But what does it really mean? So to me it means that when I'm on a busy night shift and I come in with two out of hospital cardiac arrest patients, I'll go to my intensive care, you know, and I see a picture of something um there was something else instead of that bag of ice but I've been that's been removed. Um But what's ready is that the the presented to work? There are two out of hospital cardiac arrest patients waiting to come to the unit and I go to the intensive care and the machines already there ready to go patients not even there yet. That's me is culture. So building that culture, you need to make it so that T. T. M. Is the norm. We need to do frequent data analysis. You need to have the whole M. D. T. United and you need a really strong education team. So where are we in terms of L. H. Ch as I've said, we're a large standalone quick arthritic center were primary PC. I. Center and and a heart attack center really like a lot of places in following the 2013. T TM one trial. There was a big reduction in T. T. M usage In 2017. There was a local to the UK policy called resuscitation to recovery. And this really highlighted that patients who are comatose need to have the same pathway as patients who are awake. So they should get the PC I their primary PC I at the same time and with the same eligibility. Doing that in our region was really quite difficult and we had to pilot a direct access by the ambulances to our center and then find a way of being able to deal with patients after the procedure being done. But that meant that document and and the result of it really increased our exposure to these patients. At the time we had an intravascular cooling device um In 2018 both machines really were failing and needed significant repairs and costs. And so this was we viewed this as an opportunity to reevaluate what we were doing and how we're doing it. When we looked at the patient pathway, as I've said when the when out of hours, the number of people that can insert intravascular catheter is limited. We're a large 32 bedded units and we're often needed in multiple places. So the decision to go for a surface cooling device that could be Nurse led rapid application, no medic needed. Apart from the decision for T. T. M just seemed like a no brainer. I've been coming to these T T. M. Conferences for a while and I think I've really taken on board that we need to keep things simple for if we want things to be effective. We need things to be simple. So just to algorithms on the machine norma hermia and hypothermia. We used the hypothermia protocol from the T. T. M. One treatment arm 36 degrees. And the the new product came with significant support and analysis that we hadn't experienced before. The protocol is fairly straightforward. Um As a cardiac center I'm well versed with brain protection. I do in my anesthesia, I do aortic surgery and we have to do brain protection quite a lot and it's well recognized that nasal pharyngeal temperature is the best surrogate for brain temperature. So that was done in the protocol one button. Nothing else to do. So then we have been using this for a little while and we had a review of where we are and we found that we were very good at the That um the initiation phase and maintaining patients at the target temperature of 36°. But there seemed to be a problem with the following 48 hours. So taking them up to the three day period and this is the same data displayed graphically. So we sat down and looked through individual cases and we found that there was quite a few times that we were using pads that weren't covering enough surface area. So the machine was having to work too hard and actually one of the decisions we made was to stop ordering the medium sized pads which had been incorrectly used on a lot of adult males. We increased education about use of universal parts if struggling with temperature control. We fed back with positive bit about good induction and maintenance phase and then we really wanted to understand what's going on about the normal hermia at the time. We only had two of the virtue of the bags of ice and they weren't um enough of the patients. These patients are a bit like busses sometimes they all come at once. And so we found that actually that reasonably clinicians were deciding well these patients in the 1st 24 hours so they're gonna have to take priority over say a patient's last 24 hours of this into our block. And we're having to take a machine off someone and put it on someone else. So we liaised with the company. We ended up having four of these machines. The nasal pharyngeal temperature was actually a problem because it's very user dependent. And often it ends up in the back of the pharynx. And so we've moved to blood temperature. And we did notice that there were times that the T. T. M. was being started at below 36°. So we adapted the protocol really to highlight those issues. So big red sign don't start the arctic sun until the patient gets reaches 36 degrees. We moved to bladder bladder probe as the first line with tim panic as being the check. And we also put counter one measures a standard because we found that it's more effective to treat shivering before it happens. We then reviewed where we were uh in the next six months And we found that we maintained our good maintenance at 36° and we have seen an improvement in the normal thermal phase. There were still times that the machine was coming off. But that when we looked at it, there were times when patients, for example had been woken up and they were appropriate and and it wasn't appropriate to keep them to keep the machine on that phase. And so that that that I think will always have that period a bit shorter. Then covid 19 happened um we were the largest critical care in our region, but we are purely cardiothoracic center with the with the crisis that happened. We had to stop operating apart apart from emergency cases. And we changed initially to take out of hospital cardiac arrest patients. But then the decision was made that actually wasn't appropriate use of resources during that critical care pandemic time. And so we turned into a full covid critical care for a for a reasonable period of time. And if I'm honest, we haven't really looked at this since then. And so then now we've looked at what our data is like now following restarting of the cardiac arrest program. And we found that we're not looking at it that things have drifted back. So the normal hermia phase again is going to need more work on it, especially following the latest guidance. We did some extra analysis of the do no harm bit of the protocol. And We've seen that in 2019, 2021, 22, we're still having times when we're warming patients Below that we're starting the machine below 35°. And so we need, we need to we need to work on that. We've done constant education about it and I feel that we all know that if we want things to work well, we need to make them easy. It's a key process in patient safety. So despite all that education, constant education, the CTM is still getting started. I think we need to think back to that tired team in the middle of the night that put the pads on. Think they're doing everything right. And it's it is not the same workforce during the night as it is during the day. And I think the industry has to respond And produce the mode. That means that we can just put the pads on or we can start the device or whatever whichever device happens to be and just press start and then has to just watch the patient passively until the patient gets to 36° and then kicks in ideally in the future which our product we're using needs to give us continual feedback in the form of compliance data and that that we can then be reviewing that in our divisional boards and make sure that we are, that we're always giving top quality care to our patients and as we as we know with all the end of all these patients on all these cases as a patient and I don't think it's that lot far away that if a patient is not having a great neurological outcome we're gonna get asked questions about the T. T. M. What was the T. T. M. Like? Was it good quality? Can you show me? And so it's no longer good enough to provide good T. T. M. You need to need to prove that they can do it. Thank you. Created by
