Mind the Gap: Knowledge Translation in Remote Care

Knowledge translation in medicine is a sluggish process.  Research can take many years to become ‘practice changing’ and be applied at the clinical coalface.  Conversely it can take a generation shift to debunk long and strongly held medical dogma despite a lack of evidence or even evidence of harm being available.  Country hospitals in Australia are traditionally ‘behind the times’.   One might say that this is an accepted norm – that we rural clinicians are expected to be behind the curve of modern practice.  In recent years with the advent of Free Open-Access Medical Education this is changing.

There are so many wonderful examples of how the FOAM community has facilitated and accelerated knowledge translation into practice.  So I thought I would share with you a story.  It is a story about my little hospital and how we can break the traditional stereotypes of rural hospitals struggling to deliver adequate care.  In fact, I believe that we have the potential to do great things – to be at the cutting edge and provide the sort of care that we all went into this gig to deliver.

I will start by telling you about Misty – she is one of the great nurses I work alongside.  Misty is a Resus machine!  She is an ALS trainer and can run a team like anyone.  I love doing Resus with Misty  – I know that there will be continuous CPR, rapid rhythm checks and the protocol will be followed without any fuss.  This gives me time and the headspace to fart around with the other bits – looking for reversible causes, getting some context – and of course intra-arrest Ultrasound to find soluble problems.

Misty is very up to date.  So we have been discussing therapeutic hypothermia over the past few years – trying to work out a way that it could be done in our corner of Australia.  We see our share of cardiac arrests – but we area  small shop, so actually getting ROSC post-arrest happens only a few times a year.  Therapeutic hypothermia – as practiced prior to Nov 2013 – is tricky for the occasional operator.  We do not have access to fancy cooling devices – just a fridge and a fan!  And once we cooled a patient we are then faced with the logistical nightmare of transferring them at < 34 degrees for 2000 km.  This involves several planes, a few long waits in hangars and a constant ambient temperature of about 38 degrees!  However – it is on the Resus protocol and drilled in the curriculum for nurses and trainee doctors.

For the last few years I have been feeling a little frustrated about this.  I wrote one of the first Broome Docs posts on it 3 years ago.  I have been wanting to provide great care for our remote patients – but therapeutic hypothermia was just too logistically hard. Yet it seemed like an important intervention with a potent NNT of ~6.  Then last November the TTM trial came out.

Now a lot has been written by folk who do a heck of a lot of post-arrest care about how to apply this paper in practice.  However for me – there is no agonising.  Our current standard of care was essentially trying to do good ICU housekeeping and avoid fever.  I wished I could get them down to 34 degrees, but there was no way to do this consistently.  So imagine my delight at reading this paper!  Bottom line: no difference between targeting 36 and 34 degrees in post-arrest patients.  That is some knowledge I can translate.

So as luck would have it, a few weeks after the TTM papers hit the street – we resuscitated a patient in my ED.  It was a great team effort – 20 minutes of CPR, 4 DC shocks and no break in compressions with a team of 3!  That is cool.  Once we got ROSC and the dust settled the conversation turned to post-arrest care – and the bugbear of hypothermia.  But this time I was not conflicted.

The FOAM discussions I had seen and taken part in were all fresh in my mind.  Instead of being worried about doing “as good as possible” care.  I was confident that we could do excellent, up-to-date care.  This was a very empowering experience for me.  No more doubts, or lingering concerns about what we were doing – this was a moment where we could push on and do “aggressive” intensive care.  We could give our patient the best chance to recover.

So here is a list of the stuff I have learned over the past few years that I could translate into practice and do the best care in our little ED:

  • Continuous CPR is key.  Minimising breaks for rhythm checks to a few seconds.
  • Watch this space for the automated devices. {LUCAS} has great potential in small EDs with a skeleton staff who struggle to maintain CPR for long periods.
  • NO intubation prior to ROSC – this is a hard habit to break for those of us with Anaesthesia background – but it makes a lot of sense in Resus care
  • Using ET CO2 to guide resus, quantify CPRs effectiveness and detect ROSC – this patient maintained a pretty good ETCO2 – and it gave our team great motivation to continue despite a longish downtime
  • Post ROSC assessment: taking time to do a basic neuro exam after ROSC in order to assess function.  In the past I would have been to hasty to get the patient paralysed and sedated and lost the window to assess disability.  Another benefit of using the LMA during the Resus – no need to rush in with ETT securing agents.
  • Positioning for ventilation – supine is not cool – all our patients should be head up where possible.
  • Lung-protective vent strategies – dialling up 6 – 7 ml/kg IBW on the vent is easy,
  • Maintaining a sensible set of parameters – not aiming for EUBOXIA, but just enough to keep the physiology in a happy place.
  • Temperature control:  my interpretation  of the TTM paper and discussion is that we (i.e. rural resus teams) should aim for 36 degrees.  We should avoid fever as that seems to be the true culprit.  In my experience this can be done with a few wet towels and a bedside fan.
  • Good housekeeping – e.g FAST HUGS IN  BED
  • Family in the Resus Room.  Lets be honest – this is a bad scenario.  Despite our high-riving at achieving ROSC – this is a disaster for the family.  Fewer than 10% are going to make a full recovery and many will die in the coming days.  So the post-arrest period is also the only window many family will have to say “Goodbye” before their loved-one is shipped across the country.  We need to respect this and give as much access as is possible, answer questions and explain the process ahead for the relatives.

Now – back to Misty.  We did a debrief the next day – and the TTM trial was news to all in the room.

Misty is now in the absurd position of having to teach “therapeutic hypothermia” in a hospital which cannot in reality provide it!  This was just absurd prior to the TTM trail – now it becomes just silly really.  The protocols which our Health Service employ have taken many years to get hypothermia onto the algorithms – and now I think we should try and undo this in a blink.  The reality is that we have not been able to achieve the old standard – so we should embrace the new data and focus our attention on excellent TTM and careful ICU care.  However, I suspect it could be another few years before the official local protocols are amended – so what to do?

I believe that at the end of the day we as individual clinicians working in our teams have to keep up to date and try to close the knowledge translation gap.  Relying on protocols which are often well out of date or not really applicable to our immediate patient is problematic.  So this is where FOAM becomes so important to me – rapid translation of knowledge to the bedside.

My final thoughts come from my Manchester mate – Prof. Simon Carley [@EMManchester].  He gave a smashing talk at SMACC GOLD about changing our practice based on new data – summarised nicely below.   The trick is to make sure the data is applicable to your context and that it is of appropriate quality.  We have a responsibility to narrow the knowledge translation gap – but also to ensure we are moving to higher ground when we bridge the gap!

Evidence

2 Comments

Add a Comment

Your email address will not be published.