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Current practice of target temperature management post-cardiac arrest in the Netherlands, a post-TTM trial survey
Resuscitation 97 (2015) e1–e2
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Current practice of target temperature management post-cardiac arrest in the Netherlands, a post-TTM trial survey
Table 1 TTM practice in Dutch ICUs and reasons to support current practice.
◦
Sir, Mild therapeutic hypothermia (MTH) aiming at a temperature of 33 ◦ C early in the post-resuscitation phase improves outcome of cardiac arrest. Implementation of MTH however has been slow worldwide following two landmark trials in 2002 and subsequent guideline advices.1–3 The recently published Target Temperature Management (TTM) 33 ◦ C versus 36 ◦ C after Out-of-Hospital Cardiac Arrest trial challenged the optimal target temperature of 33 ◦ C.4 Death and favourable neurological outcome were comparable for patients treated with a TTM target temperature of 36 ◦ C as compared to 33 ◦ C. Whether the results of TTM trial will translate into changes in TTM practice, prior to revision of guidelines is as yet unclear. Therefore, we performed a nationwide survey to determine the effect of the TTM trial on the current practice of TTM in post-cardiac arrest patients in Dutch intensive care units (ICUs). In July 2014 (8 months after the online publication of the TTM trial), an anonymous web-based-question survey on TTM practice was sent to all ICUs in the Netherlands (Supplement 1). Reasons not to adapt TTM practice were classified using the framework described by Cabana et al.5 The survey’s response rate was 77%. 74 out of 75 responding ICUs used TTM in post-cardiac arrest patients. 19 out of 75 (25%) Dutch ICUs adapted their TTM protocol to a target temperature of 36 ◦ C, while 55 out of 75 (73%) kept their target temperature at 33 ◦ C (Table 1). The change in TTM practice was not related to the type of hospital (academic vs. others), the presence of on-site PCI facilities or the number of ICU beds (Figure S1). The reasons reported not to change practice were: a lack of agreement (64%), wanting to await adapted guidelines (25%), insufficient time to consider implementation (18%), lack of self-efficacy (2%) and lack of motivation (2%). The main reasons reported to change TTM practice were: evidence of TTM trial deemed sufficient to change practice (95%), anticipating less side effects (21%) and adhering to regional decision on TTM (16%). Methodology used for TTM by Dutch ICUs largely followed current ILCOR guidelines (data not shown). In our survey performed shortly after publication of the TTM trial, we observed a surprisingly rapid adoption of TTM practice as compared to introduction of MTH in the early 2000s. Possible explanations for this rapid adoption by 25% of Dutch ICUs may include the anticipated decrease in adverse effect or complexity of TTM with a less deeper cooling strategy (21% of changing respondents), the high proportion of TTM practice already in place (99%), the presence of Dutch TTM trial researchers (‘local champions’) and easily available up-to-date medical information. A larger proportion of Dutch ICUs will probably adapt their TTM protocol in the near future as insufficient time to adopt and awaiting (soon to be http://dx.doi.org/10.1016/j.resuscitation.2015.06.031 0300-9572/© 2015 Elsevier Ireland Ltd. All rights reserved.
n
%
Adapt target to 36 C
19
25
Reasons New evidence sufficient Less side effects Regional network decision
18 4 3
95 21 16
Remain target at 33 ◦ C
55
73
Reasons Awaiting adapted guidelines Unclear
14 3
25 5
1 0
2 0
Attitude Lack of agreement Lack of outcome expectancy Lack of self-efficacy Lack of motivation/Inertia
35 0 1 1
64 0 2 2
Behaviour/external barriers Insufficient time for implementation
10
18
Knowledge Lack of awareness Lack of familiarity
published) adapted guidelines were important barriers for adoption. As Dutch ICUs appear to be rapid adopters of new evidence, a more widespread adoption of TTM protocols may be anticipated in the near future. Conflict of interest statement All authors declare no financial and personal relationships with other people or organisations that could inappropriately influence (bias) this work. Acknowledgements The authors would like to thank all respondents of the survey for participation. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.resuscitation. 2015.06.031. References 1. Nolan JP, Soar J, Zideman DA, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 2010;81:1219–76.
e2
Letter to the Editor / Resuscitation 97 (2015) e1–e2
2. Gasparetto N, Scarpa D, Rossi S, et al. Therapeutic hypothermia in Italian Intensive Care Units after 2010 resuscitation guidelines: still a lot to do. Resuscitation 2014;85:376–80. 3. Storm C, Meyer T, Schroeder T, Wutzler A, Jorres A, Leithner C. Use of target temperature management after cardiac arrest in Germany – a nationwide survey including 951 intensive care units. Resuscitation 2014;85:1012–7. 4. Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest. N Engl J Med 2013;369:2197–206. 5. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282:1458–65.
Evert-Jan Wils ∗ Department of Intensive Care, Ikazia ziekenhuis, Montessoriweg 1, 3083 AN Rotterdam, The Netherlands
Tineke van den Berg Department of Intensive Care, Langeland ziekenhuis, Toneellaan 1, 2725 NA Zoetermeer, The Netherlands Jasper van Bommel Department of Intensive Care, Erasmus MC University Hospital Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands ∗ Corresponding author. E-mail address: [email protected] (E.-J. Wils)
20 June 2015
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Current practice of target temperature management post-cardiac arrest in the Netherlands, a post-TTM trial survey
Table 1 TTM practice in Dutch ICUs and reasons to support current practice.
◦
Sir, Mild therapeutic hypothermia (MTH) aiming at a temperature of 33 ◦ C early in the post-resuscitation phase improves outcome of cardiac arrest. Implementation of MTH however has been slow worldwide following two landmark trials in 2002 and subsequent guideline advices.1–3 The recently published Target Temperature Management (TTM) 33 ◦ C versus 36 ◦ C after Out-of-Hospital Cardiac Arrest trial challenged the optimal target temperature of 33 ◦ C.4 Death and favourable neurological outcome were comparable for patients treated with a TTM target temperature of 36 ◦ C as compared to 33 ◦ C. Whether the results of TTM trial will translate into changes in TTM practice, prior to revision of guidelines is as yet unclear. Therefore, we performed a nationwide survey to determine the effect of the TTM trial on the current practice of TTM in post-cardiac arrest patients in Dutch intensive care units (ICUs). In July 2014 (8 months after the online publication of the TTM trial), an anonymous web-based-question survey on TTM practice was sent to all ICUs in the Netherlands (Supplement 1). Reasons not to adapt TTM practice were classified using the framework described by Cabana et al.5 The survey’s response rate was 77%. 74 out of 75 responding ICUs used TTM in post-cardiac arrest patients. 19 out of 75 (25%) Dutch ICUs adapted their TTM protocol to a target temperature of 36 ◦ C, while 55 out of 75 (73%) kept their target temperature at 33 ◦ C (Table 1). The change in TTM practice was not related to the type of hospital (academic vs. others), the presence of on-site PCI facilities or the number of ICU beds (Figure S1). The reasons reported not to change practice were: a lack of agreement (64%), wanting to await adapted guidelines (25%), insufficient time to consider implementation (18%), lack of self-efficacy (2%) and lack of motivation (2%). The main reasons reported to change TTM practice were: evidence of TTM trial deemed sufficient to change practice (95%), anticipating less side effects (21%) and adhering to regional decision on TTM (16%). Methodology used for TTM by Dutch ICUs largely followed current ILCOR guidelines (data not shown). In our survey performed shortly after publication of the TTM trial, we observed a surprisingly rapid adoption of TTM practice as compared to introduction of MTH in the early 2000s. Possible explanations for this rapid adoption by 25% of Dutch ICUs may include the anticipated decrease in adverse effect or complexity of TTM with a less deeper cooling strategy (21% of changing respondents), the high proportion of TTM practice already in place (99%), the presence of Dutch TTM trial researchers (‘local champions’) and easily available up-to-date medical information. A larger proportion of Dutch ICUs will probably adapt their TTM protocol in the near future as insufficient time to adopt and awaiting (soon to be http://dx.doi.org/10.1016/j.resuscitation.2015.06.031 0300-9572/© 2015 Elsevier Ireland Ltd. All rights reserved.
n
%
Adapt target to 36 C
19
25
Reasons New evidence sufficient Less side effects Regional network decision
18 4 3
95 21 16
Remain target at 33 ◦ C
55
73
Reasons Awaiting adapted guidelines Unclear
14 3
25 5
1 0
2 0
Attitude Lack of agreement Lack of outcome expectancy Lack of self-efficacy Lack of motivation/Inertia
35 0 1 1
64 0 2 2
Behaviour/external barriers Insufficient time for implementation
10
18
Knowledge Lack of awareness Lack of familiarity
published) adapted guidelines were important barriers for adoption. As Dutch ICUs appear to be rapid adopters of new evidence, a more widespread adoption of TTM protocols may be anticipated in the near future. Conflict of interest statement All authors declare no financial and personal relationships with other people or organisations that could inappropriately influence (bias) this work. Acknowledgements The authors would like to thank all respondents of the survey for participation. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.resuscitation. 2015.06.031. References 1. Nolan JP, Soar J, Zideman DA, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 2010;81:1219–76.
e2
Letter to the Editor / Resuscitation 97 (2015) e1–e2
2. Gasparetto N, Scarpa D, Rossi S, et al. Therapeutic hypothermia in Italian Intensive Care Units after 2010 resuscitation guidelines: still a lot to do. Resuscitation 2014;85:376–80. 3. Storm C, Meyer T, Schroeder T, Wutzler A, Jorres A, Leithner C. Use of target temperature management after cardiac arrest in Germany – a nationwide survey including 951 intensive care units. Resuscitation 2014;85:1012–7. 4. Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest. N Engl J Med 2013;369:2197–206. 5. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282:1458–65.
Evert-Jan Wils ∗ Department of Intensive Care, Ikazia ziekenhuis, Montessoriweg 1, 3083 AN Rotterdam, The Netherlands
Tineke van den Berg Department of Intensive Care, Langeland ziekenhuis, Toneellaan 1, 2725 NA Zoetermeer, The Netherlands Jasper van Bommel Department of Intensive Care, Erasmus MC University Hospital Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands ∗ Corresponding author. E-mail address: [email protected] (E.-J. Wils)
20 June 2015