Transcript Video Starting a Therapeutic Hypothermia Program in the NICU El Noh, DOH, MPH, speaks on starting a therapeutic hypothermia program in the NICU. Hello. Uh, my name is Elle No. I'm a neonatologist at Penn Medicine at Chester County Hospital and Children's Hospital Philadelphia. I am happy to share with you something dear to my heart, which is therapeutic hypothermia and also starting the program. This presentation is geared towards developing a program within the neonatal intensive care unit. Uh, I want to share our experiences with you, uh, the successes as well as the struggles we face, going from a unit that was passively cooling neonates, um, with HIE while waiting anxiously for a transport team to, uh, arrive to complete the, um, therapeutic hypothermia. Also, while this presentation is about starting therapeutic hypothermia program in the NICU, the perspective, contents, and guidelines of the presentation may be applicable for units outside of the NICU as well. This is a common exchange at our unit. Um, I would get these bright ideas about something and like many eager, maybe a little delusional guy would approach my team about my grand schemes, uh, to which my smarter and wiser partners would bring me back to earth and tell me to slow things down a little bit. Um, but, Like those who are like Buzz and I, if you have ever a smoldering thought about potentially starting a therapeutic hypothermia program at your unit, uh, you are most welcome, um, to join our cold Space Ranger team, um, and venture with me into the inter-hospital, intergalactic universe, uh, about starting this marvelous program. I wanted to begin this presentation by introducing the hospital to which I work at, and the NICU where I have the privilege of serving. I wanted to give you an idea of the background and the resources we had when we were starting our program. Um, I hope that it does give you some optimism. and courage to develop and maintain a successful program at your institution. If our humble hospital and NICI can can do it, so can yours. So Chester County Hospital is a community hospital within the Penn medicine system, and it's located in Westchester, PA. Chester County Hospital opened in 1892 and is now a 330 bed facility that serves the Philadelphia's western suburbs. Uh, we have about 3400 deliveries a year. Our NICU is a level 3 NICU, um, a 15 bed and with wonderful working relationships between the staff within the NICU as well as other hospital staff. Uh, and like other level 3 NICUs, we take care of micro preemies, have high frequency ventilators, nitric oxide, um, tele consultation services as we are part of the CHOP neonatal network. Um, and dedicated ancillary support system such as physical therapy, occupational therapy, speech therapy. Um, and etc. and prior to starting our program, if we had any infants, uh, with moderate to severe HIE, we would passively cool the neonate and wait for transport from CHOP to arrive. Uh, once the neonate completed therapeutic hypothermia and was discharged, he or she would then follow up with one of our providers who runs our neo uh NICU neurodevelopmental follow-up clinic. What we did not have um were cooling device, continuous video EEG, and around the clock um echocardiogram or head ultrasound services. Uh, we also did not have any technical imaging guidelines for brain MRIs being performed on neonates with concerns for HIE. We didn't have ample blood bank supplies and many more services prior to starting our program. After developing the policy and obtaining the necessary equipment, we approached our program in a couple of phases. In phase one, between the years of 2019 and 2022, we began active cooling, um, while waiting for the CHOP transport team to arrive. This phase was designed to help our team learn the program, at least the beginning portion of the cooling phase of therapeutic hypothermia. As you are aware, the start of uh therapeutic hypothermia is quite involved and labor intensive. Um, So we needed to get accustomed to the ins and outs of the program. We continue to develop the program, especially in regards to services provided outside of the NICU, uh, such as collaborative work with the OB, um, and neuroimaging departments, appropriately banking blood products, streamlining delivery processes, and stocking of potential stat medications, um, in the NICU from the pharmacy. Uh, we also needed to do credentialing for a, uh, neurologist, um, to be able to perform teleconferences with our NICU staff and parents. Understanding that continuous video EEG is the gold standard for seizure monitoring, our biggest limiting factor in dividing up our program into phases was because of EEG technician availability. Getting the continuous video EEG was one task, but we had, we only had one technician in the hospital who could perform pediatric EEGs or put the leads on, on a pediatric patient. As such, um, we would treat clinical seizures, use amplitude EEG if we needed to, um, or during working hours, we would ask the technicians to place the EEG leads. During phase two, from 2022 to the present, Um, we implemented, um, continuous video EEG. Um, the last piece that we were missing was the ability, uh, to put the continuous video EEG on, uh, which we were able to achieve by utilizing EEG caps that, uh, could perform full EEGs, um, and be fully accessible to be remotely monitored by CHOP. The best part was that it could be placed by nurses, um, and providers without the help of an EEG technician. We still had guidelines for transport to higher level of care. Uh, we initially had stricter guidelines, especially in the realm of seizure control, uh, but as we gained a little bit more experience using the EEG cap, um, and our communication with CHOP remote EEG monitoring improved, we felt a little bit more comfortable taking care of infants who require various anti-epileptics. At this time, we transfer infants really only if uh they are nearing criteria for ECMO. Um, so we generally keep all of our therapeutic hypothermia patients other than that. Again, before we go into the main content of the presentation, I hope my summary of what we have done in our hospital and our NICU illustrates that you could do it at your institution as well. Some background for therapeutic hypothermia, um, as you know, therapeutic hypothermia has emerged as a, a standard intervention for neonates with moderate to severe HIE, um, as extensive research demonstrates its neuroprotective benefits in reducing brain injury and, uh, improving survival with fewer neurological complications. However, as beneficial as therapeutic hypothermia has proven itself to be, um, it is a demanding management that not only takes intensive resources within the NICU but a coordinated effort by multiple departments and ancillary resources. It requires clinicians and nurses to have a comprehensive understanding of the indications, preparations, administration, and complications of therapeutic hypothermia and neonates. Um, it requires optimization, um, of collaboration with obstetric team, perinatal preparation. Um, NICU team needs to refine timely resuscitation, uh, admission processes, and communication with families. Uh, you must ensure precise monitoring and prompt interventions, um, and effective collaborations with neurology, neuroimaging, potentially cardiology, all the ancillary services like, uh, uh, physical therapy, occupational therapy, respiratory therapy, uh, with blood bank and etc. And lastly, in an ever evolving practice, teams need to be proactive in reviewing the latest evidence and advanced practices. Not only that, you need to have the staffing or the manpower to support critically ill neonates. So why start a program? Um, the obvious and foremost reasons are medical and social indications. Um, as a birthing hospital, you have the opportunity to start a treatment intervention that emphatically is reliant on timing. Um, there are many factors that may delay prompt start of therapeutic hypothermia, such as significant time spent on resuscitation, Degree of illness requiring multiple procedures like intubations, chest tubes, central lines, um, delay in transport, etc. Um, you may try passive hypothermia, uh, but that still delays active treatment. And as a birthing hospital, you avoid complications of transferring a critically ill neonate who potentially requires uh many interventions, um, and has increasing seizure burden. Lastly, you avoid separating the neonates from his or her parents. Um, it's devastating enough for parents to have their newborn in a critical state, but to be separated from that child creates not only immediate emotional, physical burden, but also potentially long-lasting trauma for them, especially if there's an unfortunate outcome. Many or most referring NICUs already perform therapeutic hyperthermia. Um, if you're thinking about starting a therapeutic hyperthermia program, um, you have the opportunity to increase your practice and display and manifest your talents, um, and widen your referral base. It's not really only the NICU but the hospital system also uh benefits uh by promoting continuity of patient care from OB to NICU to consultations to follow-up care, um, improving interdepartmental collaboration processes and relationships. And of course, there is a financial benefit from taking care of an infant who requires prolonged critical care. While there are many benefits of starting a therapeutic hypothermia program, there are also difficulties as well. You may have limited experience in taking care of infants with HIE. There is also lack of equipment and MRI availability. Uh, you may have limited staffing within the NICU and also EEG technicians to put the leads on, and you may not have Services outside of the NICU, ancillary services outside of the NICU that are integral and very important in uh helping these infants, such as neurology, neuroimaging, again, potentially cardiology, respiratory therapy, and so on and so forth. And, but even with these challenges that may feel insurmountable, um, I wanted to share with you how to overcome these barriers and actually become a stronger unit and hospital as a whole. I wanted to um approach uh the rest of the content um of the presentation, dividing up on how we tackle these um different barriers by departments. Um, as you know, it takes a village and coordinated effort by many departments of the hospital to optimize the therapeutic hypothermia program. It's imperative that you design the program, um, and bring these teams together to work cohesively. Uh, we approached each department to emphasize the importance of their unique role in taking care of infants with HIE and in doing so, we laid down the foundation for systematic and efficient interdepartmental collaboration. Uh, I'll be going through each department to speak on their roles and their involvement. I wanted to start the conversation with LND. Everything starts with education. And so we got involved with labor and delivery by providing general education to the staff on HIE and therapeutic hypothermia. Improving communication between the NICU and labor and delivery became very important to us. Um, and so, we, um, developed morning and evening OB huddles, uh, to receive, um, up to-date, um, changes within the, the mothers in the LMD. Uh, we also Uh, wanted to improve communication with the parents. And so, as we were performing education for the LND staff, we also stressed the importance of their role in keeping the parents up to date, uh, while we were performing, um, Uh, different procedures within the NICU. Um, and of course, after everything was done, we would come back, uh, to LND and we would update the parents. While they are usually not going to be the ones to be updating and, and um educating the parents about HIE and therapeutic hypothermia, um, it is imperative that they have a working understanding of the complexities of HIE and therapeutic hypothermia management. Um, they were, are the ones at the mother's bedside when the NICU staff are busy taking care of the neonates. Streamlining core blood sampling and testing is crucial and timely treatment of HIE. And some questions you may ask, uh, to make this process easier are, how do you decide which patients get core blood gasses? Um, who collects the samples? How do you run the samples, and where do the uh results appear? Um, so, for us, um, we, uh, have the LND staff collect, uh, the cord blood samples. Um, what they would normally do is the obstetricians will clamp off, um, a segment of the cord. For any level 2, level 1 C-sections, or mothers who had uh laconium aspiration, significant uh laconium, uh, stain fluid, or have any other perinatal event that may warrant, um, core blood sampling, and so they would just automatically clamp off a segment and then the L&D nurses, uh, will draw the blood sample. Um, we run, usually try to run the samples using our point of care, uh, blood gas machine. Um, we, again, if you have, we try to improve the communication between the L&D team and the NICU team, so that when we are expecting an infant who may require resuscitation, uh, significant resuscitation, uh, then we bring over our point of care, um, blood gas device. Um, and in doing so, uh, the results of the blood gas actually appears on the baby's chart. Taking the time to do formal debriefs opens up conversations between all personnel involved in the case. Um, it allows each individual to give their accounts and go through the details of difficult events in a safe environment. Uh, these debriefs, uh, will help to encourage collaboration and improve processes while addressing areas of inadequacies. Next is the NICU. Um, some of the tasks within the NICU, um, started off by doing a value analysis. Um, and so, uh, we put together presentations for the hospital administrators regarding the therapeutic hypothermia program, as well as all the equipment that, uh, we needed to purchase for the program. And so we presented a value analysis to the administrators, um, To get their uh approval and support uh to move forward with the program. Uh, we then developed the protocol and guidelines of the therapeutic hypothermia. Uh, we also, uh, made some, uh, policy changes, uh, regarding our neuroprotection bundle, uh, and then also made, uh, sedation and seizure management policy. We, uh, then had, uh, some, uh, volunteers for super users, uh, from the provider staff, it was myself, uh, and then from the nurses, we had, um, uh, 4 super users, 2 for the morning team and 2 for the night team. Um, and then we of course had um the ancillary services who participated um in being super users for uh the therapeutic hypothermia program. We did just like with the L&D staff, we did a general education to the NICU staff about the protocol. Um, and to also, uh, To make sure that they have a working understanding, um, and again, the importance of therapeutic hyperthermia for HIE patients. Uh, we also develop competencies for our nurses. We thankfully did not have a lot of issues with staffing, but we did have to do some staffing arrangements, uh, mainly, um, especially for the beginning part of the therapeutic hypothermia as it is labor intensive, um, and it's all hands on deck, as you know, uh, we had to make sure that we had enough staffing, um, to be able to perform therapeutic hypothermia. We also developed the transport um criteria, as I mentioned, it was a little bit more strict initially, uh, and as we developed more experience, we were able to um expand our practices. I wanted to review some tactics or practices you may want to consider to optimize each phase of therapeutic hypothermia. Um, as you know, the core of optimizing therapeutic hypothermia, um, is education and competencies by all staff, including ancillary staff members. Um, the goal of therapeutic hypothermia is early recognition of HIE and prompt response. Uh, we have, uh, created guidelines that outline each specific task for each staff under, again, the different phases of, um, therapeutic hypothermia. So with initiation, um, early recognition of HIE, uh, and preparing for therapeutic hypothermia is, um, crucial. And so, as I mentioned before about the core blood sampling, um, and prompt communication with NICU, um, So that whoever is uh within the NICU can start getting all the preparations, um, such as gathering equipment and preparing the room. Uh, we do a timeout, uh, before we do anything. Um, and we have, um, specific, uh, therapeutic, uh, hypothermia procedure guidelines, um, to help us to, um, to perform and optimize the program, uh, the initiation of therapeutic hypothermia. Um, I've, I'm sharing with you a guideline for us, um, And it's divided into the nursing staff as well as the provider side, what each um staff members are doing, um, in a chronological order. Um. And um of course, during the initiation of therapeutic hypothermia, we are carefully monitoring for any signs of seizures. For the induction phase, uh, the goal is to get to goal temperature ranges. And so we turn off radiant warmer. Uh, place the infant on the cooling mattress and start the device. Um, as you know, once you start the device, it doesn't mean that that's when you start the cooling. Um, the, the machine needs to get the infant to goal temperatures at which, uh, the therapeutic hypothermia formally starts. And so, uh, we start the, uh, the device right away. Um, even before we put the central lines in. And so, um, we put the central lines in after we have started the machine. We have 2 to 1 nursing care, um, and we perform X-rays, uh, stat head ultrasounds, do the EEG placement, EEG cap placement, um, and then we continue to monitor for signs of seizures. For the maintenance phase, the goal is to maintain goal temperature, um, and try to get parental engagement. Uh, we do coordinator cares, um, with, uh, the nursing staff, the, the providers doing examinations and potentially insulatory staffs who are, um, helping out. Uh, we have a nursing time sheet that I'm sharing here that gives the nurses, um, clear idea of when, what needs to be done. And so, there is the actual time of, of the day, and then also time. At the therapeutic of the therapeutic hypothermia. We do perform sedation during the cooling phase. We are, thankfully our cooling device allows for parents to hold the infant. And so we encourage our parents to hold To be able to hold the infant during the maintenance phase. And of course, as usual, we do monitor for signs of seizures during the maintenance phase. For the rewarming phase, the goal is to return to normal thermia in a careful manner, in a time, um, you know, time-sensitive manner. And so again, we do coordinated cares not to disrupt the infant or the cooling or the rewarming process. Uh, we do monitoring for the seizures and then transition to normal thermia. There are occasions when uh neonates may take a little bit longer than the projected 6 hours to get to normal thermia. Um, and so, uh, after the 6 hours, we carefully monitor the infant's temperature, um, and start normal thermia protocol if as we need to. Neonatal brain injury is a complex and multifactorial process um that is affected by genetics, epigenetics, uh, metabolic, perinatal, uh, or and prenatal uh factors uh that interact to protect, cause, or exacerbate neonatal brain injury. This complexity makes developing a single or monotherapy challenging, um, since it is improbable that any one intervention will be applicable in all settings. Therefore, a multi um intervention bundle approach is used to alleviate neonatal brain injury. Neuroprotection bundles are divided into two categories, acute brain injury prevention and neuroplasticity bundles. Um, while I will not be going through the bundles in every detail, please feel free to stop the recording to review the different components of, um, of the methodology and, um, implement it into your practice. We developed a seizure pathway. Um, please note that this is an example of a seizure pathway and please refer to your institutional guidelines. This diagram is printed out and actually placed in our patient rooms uh when we have an infant being cooled and therefore the nurses know exactly what to do if there is seizures. If there are refractory seizures, midazolam, bolus, and infusion is um done. Um, and then we reconsider um etiology therapies uh for metabolic or genetic factors, um, and potentially transfer for inpatient neurology consultations. Next, for blood bank, uh, some of the tasks that we wanted to achieve or perform, uh, were to streamline processes of obtaining blood products. Um, we, our hospital did not, um, stock a lot of O negative blood. Um, and so we contacted the blood bank for, um, Of storing more O negative blood and then also um, Uh, developed a process in which they can deliver these blood potentially deliver these blood products to the LMD, um, so that we may be able to give transfusions as we needed to. Next for radiology, uh, the main task for radiology was to streamline processes of obtaining SAD radiographs, um, not just simply within the NICU, but also, um, we have a separate resuscitative room, resuscitation room, um, Uh, that connects to, um, obstetric ORs. Um, and so if we were performing resuscitation in that room, then, uh, we needed to teach our technicians, uh, where that room is. And so we needed to, um, Teach them the process of um obtaining the orders and also um coming to the right place. For neuroimaging and EEG, um, we started off this, um, with this department for the head ultrasounds, the fat head ultrasounds. Um, getting a head ultrasound prior to the start of therapeutic hypothermia is important. Um, it's not imperative, but it is very important. Um, you shouldn't delay therapeutic hypothermia to obtain a head ultrasound. Um, the purpose of the initial head ultrasound is to assess for any significant hemorrhages or possible brain abnormalities that may mimic the symptoms of HIE. Um, even if there was any of these findings, you may still opt to perform therapeutic hypothermia. Then we approached the brain MRIs. Um, brain MRIs, um, unlike head ultrasound, it is a necessary part of therapeutic hypothermia. We did, we do have, um, an MRI machine that is a pediatric, um, Uh, MRI as well. It can perform pediatric MRIs. Um, however, we didn't have specific guidelines for the technicians to follow, um, to image infants with HIE, um, and so, uh, we had to, um, develop a policy, uh, which involved reaching out to the neuroimaging department of CHOP and getting their guidelines, uh, so that we could use it. We had to make sure that we had very good communication between the neuroradiologists at CHOPP and our uh MRI's so that uh when we are actually performing the MRI's, uh, they are able to view uh the images in real time so that they can guide us as far as if we needed to continue performing the MRI's or if the imaging quality was good enough. For EEGs, the, our biggest hurdle was um Technical technician availability. Again, because we only had one technician who could perform um lead placement for pediatric patients, we had to find a different avenue. We did already have amplitude EEG, but again, that is not the gold standard, uh, conventional EEG is. Um, and so we had to find a different way to be able to perform conventional EEGs. We did it, um. A value analysis for um all the EEG devices and components that we needed. Um, and we had to also do um regulations and licensing for the new devices. Most states have a regulatory division governing outpatient, um, Uh, and acute care, uh, though we, the, the naming, um, conventions differ. Uh, through the Pennsylvania Department of Health, it is the division of acute and ambulatory care. Um, and just to give you some examples, um, in Virginia, it is a division of acute care services, in Maryland, it's Department of Health. Um, these Uh, licensure is handled by the Office of, um, Health Care Quality. And so, uh, the naming is a little bit different, but there are regulatory and licensing, um, departments for each state. I wanted to talk about the difference between amplitude EEG and conventional EEG and then briefly, uh, Uh, talk about the two different avenues that you can take, um, and why we chose conventional EEG. As you see, um, Amplitude EEG has 4 leads that you place onto the neonate's head. Um, before, uh, many, several years ago, they were actually these needle probes that you stick into the scalp, but they've now, um, developed these leads that you can place instead. These are the patterns of amplitude EEG that you may see, uh, just to give you a little background of amplitude EEG, unlike a conventional EEG that is actually looking at the electrical activity of the Brain, um, and mapping it out in real time. What amplitude EEG does is it takes short section, um, sections of the brain activity, brain electrical activity, and maps it out in a linear form. Uh, and you get in, in time, you get a mapping of Electrical activity um in in single lines. And so what you see here are single lines that um in over time, give you an idea of the brain activity. And so it's not a um continuous wave line of electrical activity, it's individual seconds of electric um activity at each point in time. I wanted to compare conventional EEG and amplitude EEG um and tell you why we decided to hold off on performing full therapeutic hypothermia until we were able to obtain conventional EEG. Amplitude EEG is similar to uh conventional EEG and predicting outcomes after HIE. Uh, when you compare it, amplitude EEG directly to conventional EEG, they are comparable for low voltage and flat records. They are comparable when looking at continuous birth suppression or inactive tracings. And also for seizures, amplitude EEG detects about 86% of seizures. Um, and they, it has a low Uh, false positive rates. So, while the two methods may have similar predicting outcomes after HIE, we decided to use a conventional EEG as it is a full array of electrodes to capture detailed brain activity across the entire brain, um, allowing it to detect short focal or low amplitude seizures that amplitude EEG often misses. As you saw before, it has 4 leads. Uh, and so, uh, you can see. Uh, potentially hemispheric changes, uh, you may be able to see the left side and right side of the brain, um, however, you don't get the full array of the entire brain. So, conventional EEG has that full complete coverage um using multiple electrodes uh across the whole scalp, while amplitude EEG typically only uses 4 channels. It has higher sensitivity that detects brief focal and subtle electrographic seizures, uh, that are compressed or filtered out by amplitude EEG. Detailed interpretation becomes very important, um. And it produces complex raw waveforms that trained neurophysiologists uh to analyze for Precise background patterns and localized abnormalities. For the neurology department, um, we have to obtain hospital privileges for the CHOP neurologist, um, mainly because they are doing remote monitoring and also because of the fact that they are performing, um, neurology consultations and teleconferencing for our families. We also needed them uh for discharge planning. If they indeed have significant HIE or any other concerns, uh, they would need to follow up with neurology and so we had to have their involvement to do these uh discharge planning. For some of the ancillary staff for respiratory therapy, physical and occupational therapy, and speech therapy, again, the education became paramount. Um, and, um, we decided to, um, automatically, uh, prophylactically do speech therapy consultations for our infants who are undergoing therapeutic hypothermia. When they usually start. POs, some babies do wonderfully, but many babies have trouble with oral feedings. And so we decided that we would get speech involved from the beginning so that when they are starting oral feedings, speech therapy can see them from the very beginning. For social work, case management, um, patient advocate, risk management departments, um, we wanted to again get them involved earlier, uh, so that they are following these parents and patients, uh, from the very beginning. We wanted to make sure that families are well educated, um, and that, uh, their involvement with the patient care, uh, that we encourage it, um, and that we empower them to be part of our team. One of the ways that Uh, the parents can be educated. It's through www.hopeFHIE.org. It's a wonderful website, um, designed for parents to, um, to review and to educate themselves about HIE. Uh, of course, uh, we do our own, um, education with the families. But it is a resource that is very helpful for them. Early patient advocate and risk management involvement, um, We do, uh, have them get again involved very early in, in the process, um, as, uh, the Parents, um, as you know, are, um. In, in need of emotional, physical support. Um, and so, um, earlier the better, uh, for these resources. For the pharmacy, we wanted to make sure that we streamline delivery um of uh important medications as well as stocking uh critical medications such as uh anti-epileptics and sedation medications within the NICU. And so we um have pharmacy check in on our supplies uh within the Omnicell and make sure that uh everything is um stocked properly and that we don't have any expired medications. Lastly, for the neurodevelopmental follow-up clinic, um, We thankfully again have a, uh, one of our physicians who uh run the NICU neurodevelopmental follow-up clinic. Um, and so, um, it's a little bit easier for us. Thankfully, we didn't have to work too hard, uh, for this, these follow-up appointments, um, as we were already doing so. But, um, if you do not have a follow-up clinic, uh, readily available, And, um, reaching out to, um, a colleague to, to be able to perform these appointments would be important. Also for early intervention, um, getting a referral for these patients will be important. I spoke about, uh, various departments, um, but I also wanted to talk about some, uh, special considerations that may, uh, that you may need to, um, think about, uh, when starting your program. We developed a, a binder, um, as you see in the picture there, uh, that outlines the protocol. Uh, it has the policy within it, the criteria, um, and I don't know if you can see clearly, but those tabs that you see on the right, it goes in chronological order of The, uh, therapeutic hypothermia program. Um, and so they can flip through the binder, um, to see, um, what they need to do next, and also, uh, making sure that they do everything according to our guidelines. We have a separate uh binder specifically for providers as well, um, as they also need to um have some guidelines or guidances um as far as what we need to do at each different phase of the therapeutic hypothermia. We also made uh bags of laboratory vials and bullets, um, and so that when we have an infant who needs therapeutic hypothermia, um, the NICU staff can quickly grab this bag, um, so that we, we have all the vials necessary, um, in hand to, to be able to get the blood sampling. Supply and inventory um becomes very important, um, as the special order materials, um, have, um, potentially different ordering procedures. Um, we used to have, um, our NICU secretary order some of these special materials such as EEG leads, uh, the mattress for the cooling device, um, and different adapters and components within the therapeutic hypothermia. Um, what Unfortunately happened is that sometimes if we were not able to uh readily review the expiration dates of these different components, um, then we would miss it. And so now we actually have the hospital supply chain, um, going through it and making sure that everything is up to date. And so, we actually now go through the hospital, um, just so that we don't miss anything. Having a close contact with local representative of the different devices that you may be using becomes very important, um, as you may be running into, um, different situations where you need, uh, their expertise. And so having a close contact, um, is paramount to making sure that the program runs smoothly. Documentation is one of the most important things. Um, and having a standard or center is why that you document decision making processes for starting or not starting therapeutic hypothermia is very important, um, as also documenting timing of therapeutic hypothermia is, um, crucial. Starting time of the device, uh, actual starting time of the hypothermia, um, uh, and also the, the cooling phase, the rewarming phase, normalthermia phase. Documenting all those things become very important. Unfortunately, we do live in a very litiginous, um, Uh, environment, um, especially nowadays a little bit more than before, um, and so that, especially with these infants who are in a critical state, With many different different departments as well, documentation becomes crucial to protect the unit, protect yourself, protect everybody involved. And so having a standardized ways that you do documentation becomes very, very important. Also in that light, having protected uh debriefing and case review, um, was very important to us. Um, and so that especially in the very beginning when uh we were just starting our therapeutic hypothermia program, we needed to learn. Uh, we needed to make sure that we have very good communication between all the parties involved. And so we had uh protected case reviews, um, With all the departments. Uh, to review our cases. Um, again, mainly for educational purposes and improving ourselves, but also to consider any potential, um, litigations that may happen, uh, and to, uh, have the protection, uh, from the, uh, patient advocate, um, and the, the legal team of the hospital. Here are some final thoughts for uh the therapeutic hypothermia and starting a program. Um, you need support from all parties. Um, thankfully, our NICU, our, um, wonderful nurses were one of the biggest supports of starting the program. We didn't have anything. We were transporting out all of our neonates. And maybe because of that, and maybe even more so because of the fact that we were needing to transport all of our, uh, neonates. The nurses were the biggest support system in starting the program. They were at the forefront, speaking with the families. They were the ones doing all the most of the hands-on care. Um, and so, they really wanted this program to, to happen. Um, and thankfully, we had their support, uh, but really, you need the support from all parties. And without the support from all of them, um, It, it, it wouldn't have gone, um, so, so nicely. Please be patient. These things take time and as you heard before, we started in 2019, um, and it was only in 2022 that we were able to be able to fully um start our therapeutic hypothermia program. And so it really takes time um to get everything um in line so that you can perform uh therapeutic hypothermia. Please be mindful about timing of management and procedures and processes. Um Um, everything about therapeutic hypothermia is about timing, starting within that six-hour window, um, making sure that, um, all the procedures are done in a prompt manner, um, making sure that the infant reaches, reaches the goal temperature, um, In, in, uh, in appropriate time. Um, and so timing becomes very, very important. And so having a very systematic way that you approach, uh, these neonates, uh, and the procedure becomes very important. It's, it's hard work, um, especially in the initial phase, um, but the reward is immense, um. Um, and there are other opportunities to continue to improve as well. Um, and so, not just simply within the NICU, um, and the workings within the NICU, the interdepartmental collaboration, uh, may improve, relationship with families will certainly improve, and just overall hospital processes, um, outside again outside of the NICU will improve as well. Please note that the contents of this presentation are just guidelines, um, and please cater the implementation to your specific needs, um, your specific wants, um, and, um, please follow your own, um, guidelines. For a comprehensive education on HIE and therapeutic hypothermia management, please watch the uh use of targeted temperature management in hypoxic ischemic encephalopathy recording. Finally, I wanted to um acknowledge um all the staff members who put endless hours on getting our program running. Um, the hospital staff members were amazing in making sure that their own individual departments had all the education, getting all the resources, and actually, um, performing. Um, it was An incredible thing to watch, um, how all the different departments of the hospital came together for our little NICU. It is, it is a lot, a lot is involved within this, um, this program, but, um, you can absolutely make it work. Here are the references. If you have any further questions or concerns, uh, you may scan the QR code here to get to the website, um, and you can reach out to us at any time. Thank you very much. Created by Related Presenters El Noh, DO, MPH Neonatologist View full profile
