title: A 4-year implementation strategy of aggressive post-resuscitation care and temperature management after cardiac arrest.
abstract: BACKGROUND
  target temperature management (TTM) not only improves neurological outcome and survival but has given momentum to a more aggressive and comprehensive treatment after resuscitation. Yet, implementation issues represent the main obstacle to systematic treatment with TTM and aggressive post-resuscitation care. We devised a strategy to introduce, monitor and improve the quality of aggressive treatment after resuscitation, including TTM.
  
  
  METHODS
  standard operative procedures on aggressive post-resuscitation care, written jointly by physicians and nurses, were introduced in November 2004. Data of all resuscitated patients admitted to the ICU were prospectively acquired for 4 years. Periodic audits (every 16 months) were programmed, leading to three equally long periods. Several critical issues were identified after each audit and addressed subsequently, leading to a growing complexity of care. Moreover, after 2 years we introduced an educational programme with medical credits for all staff attending critically ill patients. Neurological outcome and survival at hospital discharged were compared to historical controls of the preceding 22 months.
  
  
  RESULTS
  129 consecutively resuscitated patients were admitted to the ICU in the 4-year study period. Of these, 96 (74%) were treated with TTM and aggressive post-resuscitation care. Favourable neurological recovery among patients discharged alive significantly improved in the 4-year intervention period (81% vs. 50% in historical controls, p<0.01). A composite endpoint of mortality and poor neurological outcome also improved (64% vs. 82% respectively, p<0.05). Overall survival increased throughout the 4 years, leading to a significant improvement in the 3rd period compared to historical controls (60% vs. 35%; p<0.05).
  
  
  CONCLUSIONS
  we propose a strategy to successfully introduce and implement TTM and aggressive post-resuscitation care via standard operative procedures, periodic audits and feedback. Continuous education among other factors contributed to a significant improvement in neurological outcome and a progressive increase in survival.
authors.affiliation: Anaesthesia, Intensive Care and Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy. Electronic address: thomas.pellis@gmail.com.
authors.forename: T
authors.initials: T
authors.lastname: Pellis
authors.affiliation: Anaesthesia, Intensive Care and Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy; Cardiothoracic Intensive Care Unit, Intensive Care Directorate, St. George's Hospital, SW17 0QT, United Kingdom.
authors.forename: F
authors.initials: F
authors.lastname: Sanfilippo
authors.affiliation: Anaesthesia, Intensive Care and Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy.
authors.forename: A
authors.initials: A
authors.lastname: Roncarati
authors.affiliation: Anaesthesia, Intensive Care and Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy.
authors.forename: F
authors.initials: F
authors.lastname: Dibenedetto
authors.affiliation: Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy.
authors.forename: E
authors.initials: E
authors.lastname: Franceschino
authors.affiliation: Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy.
authors.forename: D
authors.initials: D
authors.lastname: Lovisa
authors.affiliation: Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy.
authors.forename: L
authors.initials: L
authors.lastname: Magagnin
authors.affiliation: Anaesthesia, Intensive Care and Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy.
authors.forename: W P
authors.initials: WP
authors.lastname: Mercante
authors.affiliation: Anaesthesia, Intensive Care and Emergency Medical Service, Santa Maria degli Angeli Hospital, Pordenone, Italy.
authors.forename: V
authors.initials: V
authors.lastname: Mione
mesh_terms: D000368:Aged; D016887:Cardiopulmonary Resuscitation; D005260:Female; D005334:Fever / Q000209:etiology / Q000517:prevention & control; D006323:Heart Arrest / Q000628:therapy*; D006801:Humans; D006979:Hyperthermia, Induced / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013997:Time Factors
keywords: Audit; Cerebral performance category; Continuous professional development; Hyperthermic rebound; Standard operative procedures; Target temperature management