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ARTICLE IN PRESS
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Resuscitation xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Clinical paper
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Use of target temperature management after cardiac arrest in Germany – A nationwide survey including 951 intensive care units夽
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C. Storm a,∗ , T. Meyer a , T. Schroeder a , A. Wutzler b , A. Jörres a , C. Leithner c a Department of Intensive Care Medicine and Nephrology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany b Department of Cardiology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany c Department of Neurology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
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Article history: Received 5 February 2014 Received in revised form 23 March 2014 Accepted 17 April 2014
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Keywords: Cardiac arrest Hypothermia Target temperature management Nationwide survey Implementation Resuscitation
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1. Introduction
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Introduction: Target temperature management (TTM) after cardiac arrest is recommended by international guidelines, which have been last updated in 2010. Here we investigate the status of implementation in a nationwide survey in Germany which took place in 2012. Methods: We conducted a nationwide telephone survey including a total of 951 German intensive care units (ICUs). ICUs were identified by using the online registry for hospitals in Germany. A questionnaire was used for the interview about basic data of the intensive care unit and about details concerning use and implementation of TTM after cardiac arrest. Results: The overall response rate was 91% (865/951). 86% (742/865) of ICUs used TTM after cardiac arrest and implementation peaked in 2010. 95% (702/736) of the ICUs using TTM perform treatment independently of the initial rhythm and 48% (355/738) apply TTM with the use of a feedback device for cooling and controlled re-warming. However, 22% (166/742) still use conventional methods like ice and cold infusion and only 61% (453/742) of the participants provided a written standard operating procedure (SOP). Conclusion: With a delay of several years, TTM after cardiac arrest is now implemented in the majority of German ICUs. The moderate proportion of ICUs using SOPs for TTM and feedback-controlled cooling devices indicates the need of further improvement in post cardiac arrest care. © 2014 Published by Elsevier Ireland Ltd.
In post-resuscitation care after cardiac arrest targeted temperature management (TTM) as a key treatment has been recommended since 2003 by international guidelines.1 Initially only suggested in patients after out-of-hospital (OHCA) shockable cardiac arrest the indication has been broadened over the years with currently recommending a temperature management to almost all survivors after cardiac arrest that remain comatose after resuscitation within the last update of the guidelines in 2010 although the level of evidence is lower in non-shockable cardiac arrest patients.2 Before the
last guideline update several studies have investigated the adherence of German intensive care units to the guidelines and the rate of application has increased in Germany from 23% (2005) to 69% (2008/2009).3,4 This is the first nationwide survey after the last update of the recommendation concerning targeted temperature management after cardiac arrest in 2010. The aim was to investigate whether there is a still increasing rate of application of TTM, especially after the guideline update in 2010 has markedly broadened the indication of TTM after cardiac arrest.
2. Material and methods
Abbreviations: TTM, targeted temperature management; SOP, standard operating procedure; ICU, intensive care unit; CA, cardiac arrest; EMS, emergency medical service. 夽 A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.04.023. ∗ Corresponding author: Tel.: +49 30 450 553232. E-mail address: [email protected] (C. Storm).
The novel German online registry for hospital was used for identification of intensive care units (Deutsches Krankenhausverzeichnis; DKV: http://www.deutsches-krankenhaus-verzeichnis.de/). Hospitals have been legally obligated to register since 2005 and the register is based on the hospitals’ annual structured quality report. In addition to the official report hospitals are allowed to provide further data about specific treatments. The online search was
http://dx.doi.org/10.1016/j.resuscitation.2014.04.023 0300-9572/© 2014 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Storm C, et al. Use of target temperature management after cardiac arrest in Germany – A nationwide survey including 951 intensive care units. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.023
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performed in August 2012 in three steps to identify a high number of intensive care units that care for cardiac arrest survivors. Within the first search a combination of “intensive care” and “devices for invasive cardiology” (428 hospitals) or “left cardiac catheter” (316 hospitals) was used. The second search for “hypothermia” revealed 507 hospitals and the third search was only for “intensive care” identifying 637 hospitals. After adjustment of the results and deletion of intensive care units for children a final number of 951 intensive care units was identified with the possibility of more than one intensive care unit within one hospital. Due to the design of the trial as blinded telephone survey among ICU staff and no inclusion of any patient data an ethical approval or consent was not required. For the telephone survey a questionnaire was developed with a first part covering general questions on the structure of the hospital (university, teaching hospital, other), number of beds, specialty of the ICU (anesthesiology, internal medicine, surgery, others or interdisciplinary), availability of cardiac catheter for 12 or 24 h standby. The second part covered questions on use of TTM, duration, method, target temperature, speed of re-warming, availability of a standard operating procedure (SOP) and approximate number of cardiac arrest patients per year. All 951 identified intensive care units were contacted by telephone and the questionnaire was conducted with the doctor on duty or leading nurse of the ICU. We attempted to get a response at least five times per ICU.
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3. Results
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The overall response rate was 91% (865/951), of the initially 951 ICUs, 3% (25/951) could not be contacted via telephone despite at least five attempts and of the remaining 926 ICUs, a total of 7% (61/926) refused to participate in the survey (Fig. 1). Thus the results from 865 interviewed ICUs are presented in the style of the questionnaire used. 3.1. Proportion of ICUs performing targeted temperature management
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Overall, at the time of our survey, TTM after cardiac arrest was performed by 86% of the ICUs (742/865). The proportion of university and teaching hospitals performing TTM was 70% (522/742) compared to other hospitals 30% (220/742). Of 78 university ICUs, 87% (68/78) used TTM and 13% did not use TTM (4 neurology/neurosurgery; 5 surgery; 1 anesthesiology). 90% (454/506) ICUs of teaching hospitals and 78% (220/281) ICUs of other hospitals did not use TTM. A small number of patients treated after cardiac arrest and the high costs of the therapy were the main reasons given for not using any TTM. In the following, we present results for all ICUs that used TTM after cardiac arrest (n = 742).
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3.2. Specialty of participating ICUs and year of implementation
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Of all ICUs participating in the survey and which use TTM (n = 742), 24% (180/742) were medical ICUs, 24% (180/742) were anesthesiological ICUs, 3% (22/742) were surgical and 49%
Fig. 1. Number of German hospitals found in the German-online-hospital-registry (http://www.deutsches-krankenhaus-verzeichnis.de/) during the search. Search terms were specialty intensive care, devices for invasive cardiology, left-heart coronary angiography, hypothermia and general intensive care. GHR, German hospital registry; TTM, targeted temperature management.
(364/742) were interdisciplinary ICUs. The highest percentage of ICUs that used TTM was found among the interdisciplinary ICUs (Table 1). We detected a continuous increase of implementation starting in 2003 with a peak in 2010 (Fig. 2B). 3.3. TTM based on location of arrest and initial rhythm This question was answered by 98% (728/742) of ICUs. 89% (660/728) of those performed TTM independently of whether the cardiac arrest was in-hospital or out-of-hospital. Thirty-one ICUs stated that the use of TTM was limited to patients after in-hospital cardiac arrest but this may particularly be the case for institutions that only rarely are involved in the primary treatment of patients after out-of-hospital resuscitation and therefore those ICUs mainly treat patients after cardiac arrest in the operating room or in other areas of the institution. In 736 ICUs data concerning TTM and initial rhythm (shockable vs. non-shockable) were available. 95% (702/736) of those reported using TTM after cardiac arrest regardless of the initial rhythm. 3.4. Methods of targeted temperature management Of all 742 ICUs using TTM four were not able to describe the method of cooling even after repeated contact. Of the remaining 738 ICUs, 48% (355/738) used a computer-controlled feedback cooling device that automatically adjusts the patients’ temperature to the target temperature. Strictly conventional methods (ice, cold infusion) were used by 22% (162/738) of the ICUs, whereas the
Table 1 Distribution of baseline data according to the type of hospital, specialty of ICU, and number of beds compared to the use of TTM are given. Numbers are given in percent and absolute numbers. ICU, intensive care unit; TTM, targeted temperature management. Baseline data
All type of hospitals
University hospital
Teaching hospital
Non-teaching hospital
Standard protocol Coronary angiography Passive re-warming Specialty ICU
61% (453/742) 53% (393/742) 18% (132/742) Medical 24% (180/742)
57% (39/68) 63% 43/68) 6% (4/68) Anesthesiology 24% (180/220) 20 98% (78/80)
Number of bedsand use of TTM
Please cite this article in press as: Storm C, et al. Use of target temperature management after cardiac arrest in Germany – A nationwide survey including 951 intensive care units. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.023
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Fig. 2. (A) Number of interviewed ICUs in the different surveys 2005 (Wolfrum et al.), 2008 and 2012 (black bar) compared to the number of users of TTM after cardiac arrest (white bar).(B) Rate of implementation over the last years. (C) Type of targeted temperature management. (D) Number of ICUs receiving pre-cooled OHCA survivors by the emergency medical service.
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remaining 30% (221/738) of ICUs used cooling devices without a computer feedback. Conventional methods were mainly used by non-university institutions 11% (82/738) and teaching hospitals 11% (84/738). None of the university hospitals used conventional methods to achieve TTM. 50% (368/742) of all institutions additionally applied conventional methods together with a feedback-based cooling device to speed up the cooling process during induction (Fig. 2C).
3.5. Duration and target temperature level The duration of TTM was 24 h in 86% (638/742) of all hospitals. Five ICUs claimed a duration >48 h. From all university hospital ICUs, 93% responded that the duration of TTM was 24 h (72/78) and in 7% of the ICUs (6/78) cooling duration was 24–48 h. Two hospitals (non-university) performed TTM with a duration of 12 h. A target temperature was given by 734 ICUs. 93% (683/734) stated that the target range was 32–34 ◦ C. 45% (330/734) used a target of exactly 33 ◦ C, 7.6% (56/734) stated that the target was >34 ◦ C and 0.4% (3/734) used a target 0.5◦ /h was used by 1.1% (4/355). Passive re-warming was mainly allowed at teaching hospitals 20% (91/454) and other hospitals 17% (37/220). Four of 68 university ICUs allowed passive re-warming (6%).
3.6. Standard Operating Procedure A written Standard Operating Procedure (SOP) was available at 61% of the ICUs (453/742). An SOP was available at 57% (39/68) of the university hospitals, 63% (286/454) of the teaching hospitals and at 61% (134/220) of the non-teaching hospitals (Table 1). 3.7. Location of temperature measurement 80% (594/742) of ICUs measured the temperature via a urinary foley catheter (bladder). 5% (37/742) used oesophageal temperature measurement, 10% (74/742) a rectal probe, 1% (7/742) in-ear measurement and 4% (30/742) used intravascular catheters with thermistor. 3.8. Exclusion from TTM No participant of the survey responded to have exclusion criteria from TTM in general. The exclusion of patients from TTM is an individual decision but some ICUs stated that they would possibly exclude pregnant patients and patients with severe brain injury, but still would decide this depending on the individual case. 3.9. Induction of TTM by the emergency medical service (EMS) 20% of the ICUs (148/742) stated that TTM was started routinely in the pre-clinical setting by EMS, in 37% (275/742) on an irregular basis. TTM is continued at the ICU in all of those cases. In 5% (37/742)
Please cite this article in press as: Storm C, et al. Use of target temperature management after cardiac arrest in Germany – A nationwide survey including 951 intensive care units. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.023
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the participants did not know whether the EMS started induction of cooling or not (Fig. 2D).
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Of all hospitals with a 24-h standby emergency coronary angiography (460/836), 96% (441/460) performed TTM, while 90% (28/31) of the institutions with only daytime coronary angiography performed TTM. On the other hand 79% (273/345) of the ICUs without availability of any emergency coronary angiography performed TTM.
study by Merchant et al., also 2006, asked 13,272 physicians via an internet-based questionnaire whether they were using TTM or not. 17% answered and it could be demonstrated that the implementation of TTM varied depending on the geographic location (26% USA vs. 36% Finland and UK).6 In 2007 a study by Wolfrum et al. examined the implementation of TTM in 395 German hospitals using a standardized questionnaire. 23.5% of the hospitals used TTM at that time3 . The same group published data from 2008–2009 demonstrating among 450 out of 772 hospitals a further increased implementation rate to 69% (311/450) (Fig. 1A).4 At the time of our survey the vast majority (86%) of ICUs routinely used TTM after cardiac arrest. A recently published large randomized trial by Nielsen et al. indicates equal neurological outcome for post cardiac arrest treatment at 33 ◦ C as compared to 36 ◦ C.7 These results question the general benefit of TTM at 33 ◦ C for cardiac arrest patients. There was a very high rate of bystander CPR (72%), started within a minute after cardiac arrest in both groups of this trial. Many countries have much lower bystander rates in cardiac arrest patients and thus longer no-flow times. Strict control at the targeted temperature was performed in both groups and was followed by a device-controlled temperature management maintained for 72 h. Therefore, targeted temperature management should remain an essential part of modern post-cardiac arrest care. Future studies are needed to address whether subsets of patients may require different targeted temperatures or different durations of temperature management and it is non-controversial that fever has to be avoided at any time. General implementation of targeted temperature management and development of standard operating procedures for post-cardiac arrest care will very likely continue to contribute to improvements in neurological outcome in patients after cardiac arrest.
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3.10. Admission procedure
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3.13. Size of ICU and use of TTM
4.1. Reasons for not using TTM
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ICUs were classified as small (20 beds). Of all participating ICUs (865) 19 could not give data toward number of beds. Of the remaining 846 ICUs 374 were small, 392 medium and 80 ICUs were large. Of those the use of TTM varied considerably. 81% (302/374) of the small, 92% (360/392) of medium and 98% (78/80) of the large ICUs did use TTM after cardiac arrest (Table 1). Two ICUs that use TTM did not give any details toward their size.
The main reason for not using TTM given by the participants of our survey were the costs. Expenses may vary depending on the treatment method. Cold saline is cheap and efficient for the initial phase but leads to problems in temperature management especially during the recommended controlled slow re-warming phase. Automated feedback devices are therefore recommended.2 ICUs that did not use TTM (mainly surgical specialties) treated few patients after successful resuscitation who are probably frequently transferred to another ICU.
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3.14. Approximate number of TTM patients per year
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Depending on the individual organization structure of the hospital, in 12% (89/742) the first contact of the ICU staff with the patient was in the catheter laboratory, in 26% (193/742) in the emergency room and on the ICU in 61% (453/742). In 1% (7/742) of the cases, the setting of the first contact changed depending on the patient. In the university hospitals patients were more likely to be transferred by EMS directly to the catheter laboratory (28%; 19/68), while the patients are often transferred first to the ICU in teaching hospitals (58%; 263/454) and non-university hospitals (74%; 178/220).
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3.11. Coronary angiography routinely after resuscitation
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53% of ICUs (393/742) stated that immediate coronary angiography was performed in patients with suspected primary cardiac etiology of arrest. Coronary angiography was routinely performed in 63% of the university hospitals (43/68), 61% of the teaching hospitals (277/454) and 39% of the non-university hospitals (86/220) (Table 1).
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3.12. 24-h availability of coronary angiography
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4.2. TTM and initial rhythm
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52% of all ICUs (386/742) treated a mean number of 10–50 patients post-resuscitation. Overall 5% (37/742) of the ICUs (of those 22% university hospitals) stated that >100 patients are treated after resuscitation annually. 69% of non-university hospitals treats a mean of 10–25 patients per year (465/674).
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4. Discussion
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Results concerning cooling of non-shockable rhythms are partly conflicting and therefore a final recommendation cannot be given based on the given evidence.8–10 However the current guidelines recommend TTM for all patients after cardiac arrest that remain comatose with the clear advice to the limitation of evidence. 4.3. Location of temperature measurement and duration of TTM
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This is the first nationwide survey in Germany on the use of targeted temperature management after cardiac arrest following the update of the ERC recommendations on post-arrest treatment in 2010. Our survey indicates a further increase of implementation along with an increase of ICUs providing internal standard operating procedures for TTM. The majority of ICU used TTM independently of initial rhythm and only a minority reported routine preclinical hypothermia induction. In 2006 Sander et al. ascertained via a telephone interview that only 38.5% of all 39 German university hospitals used TTM (71.8% answered the questions). A standard operating procedure could had been implemented by 31% of these ICUs.5 The international
The temperature measurements are mainly conducted via a bladder catheter with an integrated thermometer. The esophagus temperature correlates well with the blood temperature.11–13 Also an easy and safe way is the bladder temperature via a catheter but during renal failure and low urine output the bladder temperature might reflect changes in the body temperature with a delay. 4.4. Induction by EMS The optimal time for the initiation of TTM is still under investigation. The Pre-hospital Intranasal Cooling after Cardiac Arrest study
Please cite this article in press as: Storm C, et al. Use of target temperature management after cardiac arrest in Germany – A nationwide survey including 951 intensive care units. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.023
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(PRINCE) showed at least in a subgroup (time to ROSC
ARTICLE IN PRESS
RESUS 5983 1–6
Resuscitation xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Clinical paper
1
Use of target temperature management after cardiac arrest in Germany – A nationwide survey including 951 intensive care units夽
2
3
4 5 6 7 8
Q1
C. Storm a,∗ , T. Meyer a , T. Schroeder a , A. Wutzler b , A. Jörres a , C. Leithner c a Department of Intensive Care Medicine and Nephrology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany b Department of Cardiology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany c Department of Neurology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
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a r t i c l e
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a b s t r a c t
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Article history: Received 5 February 2014 Received in revised form 23 March 2014 Accepted 17 April 2014
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Keywords: Cardiac arrest Hypothermia Target temperature management Nationwide survey Implementation Resuscitation
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1. Introduction
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Introduction: Target temperature management (TTM) after cardiac arrest is recommended by international guidelines, which have been last updated in 2010. Here we investigate the status of implementation in a nationwide survey in Germany which took place in 2012. Methods: We conducted a nationwide telephone survey including a total of 951 German intensive care units (ICUs). ICUs were identified by using the online registry for hospitals in Germany. A questionnaire was used for the interview about basic data of the intensive care unit and about details concerning use and implementation of TTM after cardiac arrest. Results: The overall response rate was 91% (865/951). 86% (742/865) of ICUs used TTM after cardiac arrest and implementation peaked in 2010. 95% (702/736) of the ICUs using TTM perform treatment independently of the initial rhythm and 48% (355/738) apply TTM with the use of a feedback device for cooling and controlled re-warming. However, 22% (166/742) still use conventional methods like ice and cold infusion and only 61% (453/742) of the participants provided a written standard operating procedure (SOP). Conclusion: With a delay of several years, TTM after cardiac arrest is now implemented in the majority of German ICUs. The moderate proportion of ICUs using SOPs for TTM and feedback-controlled cooling devices indicates the need of further improvement in post cardiac arrest care. © 2014 Published by Elsevier Ireland Ltd.
In post-resuscitation care after cardiac arrest targeted temperature management (TTM) as a key treatment has been recommended since 2003 by international guidelines.1 Initially only suggested in patients after out-of-hospital (OHCA) shockable cardiac arrest the indication has been broadened over the years with currently recommending a temperature management to almost all survivors after cardiac arrest that remain comatose after resuscitation within the last update of the guidelines in 2010 although the level of evidence is lower in non-shockable cardiac arrest patients.2 Before the
last guideline update several studies have investigated the adherence of German intensive care units to the guidelines and the rate of application has increased in Germany from 23% (2005) to 69% (2008/2009).3,4 This is the first nationwide survey after the last update of the recommendation concerning targeted temperature management after cardiac arrest in 2010. The aim was to investigate whether there is a still increasing rate of application of TTM, especially after the guideline update in 2010 has markedly broadened the indication of TTM after cardiac arrest.
2. Material and methods
Abbreviations: TTM, targeted temperature management; SOP, standard operating procedure; ICU, intensive care unit; CA, cardiac arrest; EMS, emergency medical service. 夽 A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2014.04.023. ∗ Corresponding author: Tel.: +49 30 450 553232. E-mail address: [email protected] (C. Storm).
The novel German online registry for hospital was used for identification of intensive care units (Deutsches Krankenhausverzeichnis; DKV: http://www.deutsches-krankenhaus-verzeichnis.de/). Hospitals have been legally obligated to register since 2005 and the register is based on the hospitals’ annual structured quality report. In addition to the official report hospitals are allowed to provide further data about specific treatments. The online search was
http://dx.doi.org/10.1016/j.resuscitation.2014.04.023 0300-9572/© 2014 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Storm C, et al. Use of target temperature management after cardiac arrest in Germany – A nationwide survey including 951 intensive care units. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.023
35 36 37 38 39 40 41 42 43
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45 46 47 48 49 50 51
G Model RESUS 5983 1–6
ARTICLE IN PRESS C. Storm et al. / Resuscitation xxx (2014) xxx–xxx
2
75
performed in August 2012 in three steps to identify a high number of intensive care units that care for cardiac arrest survivors. Within the first search a combination of “intensive care” and “devices for invasive cardiology” (428 hospitals) or “left cardiac catheter” (316 hospitals) was used. The second search for “hypothermia” revealed 507 hospitals and the third search was only for “intensive care” identifying 637 hospitals. After adjustment of the results and deletion of intensive care units for children a final number of 951 intensive care units was identified with the possibility of more than one intensive care unit within one hospital. Due to the design of the trial as blinded telephone survey among ICU staff and no inclusion of any patient data an ethical approval or consent was not required. For the telephone survey a questionnaire was developed with a first part covering general questions on the structure of the hospital (university, teaching hospital, other), number of beds, specialty of the ICU (anesthesiology, internal medicine, surgery, others or interdisciplinary), availability of cardiac catheter for 12 or 24 h standby. The second part covered questions on use of TTM, duration, method, target temperature, speed of re-warming, availability of a standard operating procedure (SOP) and approximate number of cardiac arrest patients per year. All 951 identified intensive care units were contacted by telephone and the questionnaire was conducted with the doctor on duty or leading nurse of the ICU. We attempted to get a response at least five times per ICU.
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3. Results
52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74
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The overall response rate was 91% (865/951), of the initially 951 ICUs, 3% (25/951) could not be contacted via telephone despite at least five attempts and of the remaining 926 ICUs, a total of 7% (61/926) refused to participate in the survey (Fig. 1). Thus the results from 865 interviewed ICUs are presented in the style of the questionnaire used. 3.1. Proportion of ICUs performing targeted temperature management
95
Overall, at the time of our survey, TTM after cardiac arrest was performed by 86% of the ICUs (742/865). The proportion of university and teaching hospitals performing TTM was 70% (522/742) compared to other hospitals 30% (220/742). Of 78 university ICUs, 87% (68/78) used TTM and 13% did not use TTM (4 neurology/neurosurgery; 5 surgery; 1 anesthesiology). 90% (454/506) ICUs of teaching hospitals and 78% (220/281) ICUs of other hospitals did not use TTM. A small number of patients treated after cardiac arrest and the high costs of the therapy were the main reasons given for not using any TTM. In the following, we present results for all ICUs that used TTM after cardiac arrest (n = 742).
96
3.2. Specialty of participating ICUs and year of implementation
85 86 87 88 89 90 91 92 93 94
97 98 99
Of all ICUs participating in the survey and which use TTM (n = 742), 24% (180/742) were medical ICUs, 24% (180/742) were anesthesiological ICUs, 3% (22/742) were surgical and 49%
Fig. 1. Number of German hospitals found in the German-online-hospital-registry (http://www.deutsches-krankenhaus-verzeichnis.de/) during the search. Search terms were specialty intensive care, devices for invasive cardiology, left-heart coronary angiography, hypothermia and general intensive care. GHR, German hospital registry; TTM, targeted temperature management.
(364/742) were interdisciplinary ICUs. The highest percentage of ICUs that used TTM was found among the interdisciplinary ICUs (Table 1). We detected a continuous increase of implementation starting in 2003 with a peak in 2010 (Fig. 2B). 3.3. TTM based on location of arrest and initial rhythm This question was answered by 98% (728/742) of ICUs. 89% (660/728) of those performed TTM independently of whether the cardiac arrest was in-hospital or out-of-hospital. Thirty-one ICUs stated that the use of TTM was limited to patients after in-hospital cardiac arrest but this may particularly be the case for institutions that only rarely are involved in the primary treatment of patients after out-of-hospital resuscitation and therefore those ICUs mainly treat patients after cardiac arrest in the operating room or in other areas of the institution. In 736 ICUs data concerning TTM and initial rhythm (shockable vs. non-shockable) were available. 95% (702/736) of those reported using TTM after cardiac arrest regardless of the initial rhythm. 3.4. Methods of targeted temperature management Of all 742 ICUs using TTM four were not able to describe the method of cooling even after repeated contact. Of the remaining 738 ICUs, 48% (355/738) used a computer-controlled feedback cooling device that automatically adjusts the patients’ temperature to the target temperature. Strictly conventional methods (ice, cold infusion) were used by 22% (162/738) of the ICUs, whereas the
Table 1 Distribution of baseline data according to the type of hospital, specialty of ICU, and number of beds compared to the use of TTM are given. Numbers are given in percent and absolute numbers. ICU, intensive care unit; TTM, targeted temperature management. Baseline data
All type of hospitals
University hospital
Teaching hospital
Non-teaching hospital
Standard protocol Coronary angiography Passive re-warming Specialty ICU
61% (453/742) 53% (393/742) 18% (132/742) Medical 24% (180/742)
57% (39/68) 63% 43/68) 6% (4/68) Anesthesiology 24% (180/220) 20 98% (78/80)
Number of bedsand use of TTM
Please cite this article in press as: Storm C, et al. Use of target temperature management after cardiac arrest in Germany – A nationwide survey including 951 intensive care units. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.023
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Fig. 2. (A) Number of interviewed ICUs in the different surveys 2005 (Wolfrum et al.), 2008 and 2012 (black bar) compared to the number of users of TTM after cardiac arrest (white bar).(B) Rate of implementation over the last years. (C) Type of targeted temperature management. (D) Number of ICUs receiving pre-cooled OHCA survivors by the emergency medical service.
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remaining 30% (221/738) of ICUs used cooling devices without a computer feedback. Conventional methods were mainly used by non-university institutions 11% (82/738) and teaching hospitals 11% (84/738). None of the university hospitals used conventional methods to achieve TTM. 50% (368/742) of all institutions additionally applied conventional methods together with a feedback-based cooling device to speed up the cooling process during induction (Fig. 2C).
3.5. Duration and target temperature level The duration of TTM was 24 h in 86% (638/742) of all hospitals. Five ICUs claimed a duration >48 h. From all university hospital ICUs, 93% responded that the duration of TTM was 24 h (72/78) and in 7% of the ICUs (6/78) cooling duration was 24–48 h. Two hospitals (non-university) performed TTM with a duration of 12 h. A target temperature was given by 734 ICUs. 93% (683/734) stated that the target range was 32–34 ◦ C. 45% (330/734) used a target of exactly 33 ◦ C, 7.6% (56/734) stated that the target was >34 ◦ C and 0.4% (3/734) used a target 0.5◦ /h was used by 1.1% (4/355). Passive re-warming was mainly allowed at teaching hospitals 20% (91/454) and other hospitals 17% (37/220). Four of 68 university ICUs allowed passive re-warming (6%).
3.6. Standard Operating Procedure A written Standard Operating Procedure (SOP) was available at 61% of the ICUs (453/742). An SOP was available at 57% (39/68) of the university hospitals, 63% (286/454) of the teaching hospitals and at 61% (134/220) of the non-teaching hospitals (Table 1). 3.7. Location of temperature measurement 80% (594/742) of ICUs measured the temperature via a urinary foley catheter (bladder). 5% (37/742) used oesophageal temperature measurement, 10% (74/742) a rectal probe, 1% (7/742) in-ear measurement and 4% (30/742) used intravascular catheters with thermistor. 3.8. Exclusion from TTM No participant of the survey responded to have exclusion criteria from TTM in general. The exclusion of patients from TTM is an individual decision but some ICUs stated that they would possibly exclude pregnant patients and patients with severe brain injury, but still would decide this depending on the individual case. 3.9. Induction of TTM by the emergency medical service (EMS) 20% of the ICUs (148/742) stated that TTM was started routinely in the pre-clinical setting by EMS, in 37% (275/742) on an irregular basis. TTM is continued at the ICU in all of those cases. In 5% (37/742)
Please cite this article in press as: Storm C, et al. Use of target temperature management after cardiac arrest in Germany – A nationwide survey including 951 intensive care units. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.023
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the participants did not know whether the EMS started induction of cooling or not (Fig. 2D).
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Of all hospitals with a 24-h standby emergency coronary angiography (460/836), 96% (441/460) performed TTM, while 90% (28/31) of the institutions with only daytime coronary angiography performed TTM. On the other hand 79% (273/345) of the ICUs without availability of any emergency coronary angiography performed TTM.
study by Merchant et al., also 2006, asked 13,272 physicians via an internet-based questionnaire whether they were using TTM or not. 17% answered and it could be demonstrated that the implementation of TTM varied depending on the geographic location (26% USA vs. 36% Finland and UK).6 In 2007 a study by Wolfrum et al. examined the implementation of TTM in 395 German hospitals using a standardized questionnaire. 23.5% of the hospitals used TTM at that time3 . The same group published data from 2008–2009 demonstrating among 450 out of 772 hospitals a further increased implementation rate to 69% (311/450) (Fig. 1A).4 At the time of our survey the vast majority (86%) of ICUs routinely used TTM after cardiac arrest. A recently published large randomized trial by Nielsen et al. indicates equal neurological outcome for post cardiac arrest treatment at 33 ◦ C as compared to 36 ◦ C.7 These results question the general benefit of TTM at 33 ◦ C for cardiac arrest patients. There was a very high rate of bystander CPR (72%), started within a minute after cardiac arrest in both groups of this trial. Many countries have much lower bystander rates in cardiac arrest patients and thus longer no-flow times. Strict control at the targeted temperature was performed in both groups and was followed by a device-controlled temperature management maintained for 72 h. Therefore, targeted temperature management should remain an essential part of modern post-cardiac arrest care. Future studies are needed to address whether subsets of patients may require different targeted temperatures or different durations of temperature management and it is non-controversial that fever has to be avoided at any time. General implementation of targeted temperature management and development of standard operating procedures for post-cardiac arrest care will very likely continue to contribute to improvements in neurological outcome in patients after cardiac arrest.
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3.10. Admission procedure
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3.13. Size of ICU and use of TTM
4.1. Reasons for not using TTM
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ICUs were classified as small (20 beds). Of all participating ICUs (865) 19 could not give data toward number of beds. Of the remaining 846 ICUs 374 were small, 392 medium and 80 ICUs were large. Of those the use of TTM varied considerably. 81% (302/374) of the small, 92% (360/392) of medium and 98% (78/80) of the large ICUs did use TTM after cardiac arrest (Table 1). Two ICUs that use TTM did not give any details toward their size.
The main reason for not using TTM given by the participants of our survey were the costs. Expenses may vary depending on the treatment method. Cold saline is cheap and efficient for the initial phase but leads to problems in temperature management especially during the recommended controlled slow re-warming phase. Automated feedback devices are therefore recommended.2 ICUs that did not use TTM (mainly surgical specialties) treated few patients after successful resuscitation who are probably frequently transferred to another ICU.
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3.14. Approximate number of TTM patients per year
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Depending on the individual organization structure of the hospital, in 12% (89/742) the first contact of the ICU staff with the patient was in the catheter laboratory, in 26% (193/742) in the emergency room and on the ICU in 61% (453/742). In 1% (7/742) of the cases, the setting of the first contact changed depending on the patient. In the university hospitals patients were more likely to be transferred by EMS directly to the catheter laboratory (28%; 19/68), while the patients are often transferred first to the ICU in teaching hospitals (58%; 263/454) and non-university hospitals (74%; 178/220).
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3.11. Coronary angiography routinely after resuscitation
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53% of ICUs (393/742) stated that immediate coronary angiography was performed in patients with suspected primary cardiac etiology of arrest. Coronary angiography was routinely performed in 63% of the university hospitals (43/68), 61% of the teaching hospitals (277/454) and 39% of the non-university hospitals (86/220) (Table 1).
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3.12. 24-h availability of coronary angiography
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4.2. TTM and initial rhythm
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52% of all ICUs (386/742) treated a mean number of 10–50 patients post-resuscitation. Overall 5% (37/742) of the ICUs (of those 22% university hospitals) stated that >100 patients are treated after resuscitation annually. 69% of non-university hospitals treats a mean of 10–25 patients per year (465/674).
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4. Discussion
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Results concerning cooling of non-shockable rhythms are partly conflicting and therefore a final recommendation cannot be given based on the given evidence.8–10 However the current guidelines recommend TTM for all patients after cardiac arrest that remain comatose with the clear advice to the limitation of evidence. 4.3. Location of temperature measurement and duration of TTM
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This is the first nationwide survey in Germany on the use of targeted temperature management after cardiac arrest following the update of the ERC recommendations on post-arrest treatment in 2010. Our survey indicates a further increase of implementation along with an increase of ICUs providing internal standard operating procedures for TTM. The majority of ICU used TTM independently of initial rhythm and only a minority reported routine preclinical hypothermia induction. In 2006 Sander et al. ascertained via a telephone interview that only 38.5% of all 39 German university hospitals used TTM (71.8% answered the questions). A standard operating procedure could had been implemented by 31% of these ICUs.5 The international
The temperature measurements are mainly conducted via a bladder catheter with an integrated thermometer. The esophagus temperature correlates well with the blood temperature.11–13 Also an easy and safe way is the bladder temperature via a catheter but during renal failure and low urine output the bladder temperature might reflect changes in the body temperature with a delay. 4.4. Induction by EMS The optimal time for the initiation of TTM is still under investigation. The Pre-hospital Intranasal Cooling after Cardiac Arrest study
Please cite this article in press as: Storm C, et al. Use of target temperature management after cardiac arrest in Germany – A nationwide survey including 951 intensive care units. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.023
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(PRINCE) showed at least in a subgroup (time to ROSC
