Targeted Temperature Management Protocol in a Pediatric Intensive Care Unit: A Quality Improvement Project

BACKGROUND In patients with acute neurological injury, abrupt temperature change exacerbates increased intracranial pressures and negatively affects perfusion pressure and cerebral blood flow. Critical care nurses must provide coordinated and effective interventions to maintain normothermia without precipitating shivering immediately after acute neurological injury in pediatric patients. OBJECTIVE To improve hyperthermia management in a 40-bed pediatric intensive care unit, an inter-disciplinary pediatric critical care team developed, implemented, and evaluated a targeted temperature management protocol. METHODS The project was guided by the organization's plan-do-study-act quality improvement process. Quality improvement was assessed retrospectively using electronic medical records of patients meeting eligibility criteria. Samples of pediatric patients who received temperature interventions were compared before and after protocol implementation. The protocol included environmental, pharmacological, and body surface cooling device interventions, as well as use of a bedside shivering assessment scale and step-wise interventions to prevent and control shivering. RESULTS Before implementation of the targeted temperature management protocol, 64% of patients had documented temperatures higher than 37.5 degrees C, and body surface cooling devices were used in 10% of patients. After protocol implementation, more than 80% of patients had documented temperatures higher than 37.5 degrees C, and body surface cooling devices were used in 62% of patients. Four patients (6%) before and 5 patients (31%) after protocol implementation were treated with body surface cooling without requiring use of neuromuscular blockade. CONCLUSIONS Creation and implementation of a targeted temperature management protocol increased nurses' documented use of body surface cooling to manage hyperthermia in pediatric intensive care unit patients with acute neurological injury.