title: Improving use of targeted temperature management after out-of-hospital cardiac arrest: a stepped wedge cluster randomized controlled trial.
abstract: BACKGROUND
  International guidelines recommend use of targeted temperature management following resuscitation from out-of-hospital cardiac arrest. This treatment, however, is often neglected or delayed.
  
  
  OBJECTIVE
  To determine whether multifaceted quality improvement interventions would increase the proportion of eligible patients receiving successful targeted temperature management.
  
  
  METHODS
  A network of 6 regional emergency medical services systems and 32 academic and community hospitals serving a population of 8.8 million people providing post arrest care to out-of-hospital cardiac arrest.
  
  
  METHODS
  Comparing interventions improve the implementation of targeted temperature management post out-of-hospital cardiac arrest through passive (education, generic protocol, order set, local champions) versus additional active quality improvement interventions (nurse specialist providing site-specific interventions, monthly audit-feedback, network educational events, internet blog) versus no intervention (baseline standard of care).
  
  
  RESULTS
  The primary process outcome was proportion of eligible patients receiving successful targeted temperature management, defined as a target temperature of 32-34ºC within 6 hours of emergency department arrival. Secondary clinical outcomes included survival and neurological outcome at hospital discharge. Four thousand three hundred seventeen out-of-hospital cardiac arrests were transported to hospital; 1,737 (40%) achieved spontaneous circulation, and 934 (22%) were eligible for targeted temperature management. After accounting for secular trends, patients admitted during the passive quality improvement phase were more likely to achieve successful targeted temperature management compared with those admitted during the baseline period (25.7% passive vs 9.0% baseline; odds ratio, 2.76; 95% CI, 1.76-4.32; p < 0.001). Active quality improvement interventions conferred no additional improvements in rates of successful targeted temperature management (26.9% active vs 25.7% passive; odds ratio, 0.96; 95% CI, 0.63-1.45; p = 0.84). Despite a significant increase in rates of successful targeted temperature management, survival to hospital discharge was unchanged.
  
  
  CONCLUSIONS
  Simple quality improvement interventions significantly increased the rates of achieving successful targeted temperature management following out-of-hospital cardiac arrest in a large network of hospitals but did not improve clinical outcomes.
authors: 1Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada. 2Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada. 3Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. 4Department of Emergency Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada. 5Division of Cardiology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. 6Division of Pulmonary and Critical Care Medicine and Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD. 7Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada. 8Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada. 9Department of Physiology, University of Toronto, Toronto, ON, Canada. 10Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. 11Department of Emergency Medicine and Critical Care, Lakeridge Health, Oshawa, ON, Canada. 12Institute of Clinical and Evaluative Sciences, Toronto, ON, Canada. 13Department of Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada. 14Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, ON, Canada. 15Applied Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada. 16Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
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mesh_terms: D000368:Aged; D001831:Body Temperature; D002985:Clinical Protocols; D004632:Emergency Medical Services / Q000458:organization & administration*; D004636:Emergency Service, Hospital / Q000458:organization & administration; D005260:Female; D006801:Humans; D007318:Inservice Training; D008297:Male; D008875:Middle Aged; D058687:Out-of-Hospital Cardiac Arrest / Q000628:therapy*; D058996:Quality Improvement / Q000458:organization & administration*