ORIGINAL ARTICLE Critical Pathways in Cardiology •  Volume 11, Number 3, September 2012 www.critpathcardio.com | 91 Abstract: Out-of-hospital cardiac arrest is common and is associated with high mortality. The majority of in-hospital deaths from resuscitated victims of cardiac arrest are due to neurologic injury. Therapeutic hypothermia (TH) is now recommended for the management of comatose survivors of cardiac arrest. The rapid triage and standardized treatment of cardiac arrest patients can be challenging, and implementation of a TH program requires a multidisciplinary team approach. In 2010, we revised our institution’s TH protocol, creating a “CODE ICE” pathway to improve the timely and coordinated care of cardiac arrest patients. As part of CODE ICE, we implemented comprehensive care pathways including measures such as a burst paging system and computerized physician support tools. “STEMI on ICE” integrates TH with our regional ST-elevation myocardial infarction network. Retrospective data were collected on 150 consecutive comatose cardiac arrest victims treated with TH (n = 82 pre-CODE ICE and n = 68 post-CODE ICE) from 2007 to 2011. After implementation of CODE ICE, the mean time to initiation of TH decreased from 306 ± 165 minutes to 196 ± 144 minutes (P < 0.001), and the time to target temperature decreased from 532 ± 214 minutes to 392 ± 215 minutes (P < 0.001). There was no significant change in survival or neurologic outcome at hospital discharge. Through the implementation of CODE ICE, we were able to reduce the time to initiation of TH and time to reach target temperature. Additional studies are needed to determine the effect of CODE ICE and similar pathways on clinical outcomes after cardiac arrest. Key Words: therapeutic hypothermia, cardiac arrest, critical pathways (Crit Pathways in Cardiol 2012;11: 91–98) T he annual incidence of sudden cardiac death and out-of-hospital cardiac arrest (OHCA) in the United States is estimated to be as high as 450,000. 1 In the minority of OHCA patients who are suc- cessfully resuscitated with return of spontaneous circulation (ROSC) and survive to hospital admission, only 30% to 50% of patients sur- vive to hospital discharge with a meaningful recovery of neurologic function. 2,3 In the “postcardiac arrest syndrome,” patients may suf- fer multiorgan ischemic-reperfusion injury particularly in the brain and myocardium, significant myocardial dysfunction, a systemic inflammatory response, and sequelae from the underlying pathology responsible for the OHCA. 4,5 Sustained and progressive neurologic From the Vanderbilt University Medical Center, Nashville, TN. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.critpathcardio.com). Reprints: John A. McPherson, MD, Vanderbilt University Medical Center, 1215 21st Avenue South, MCE 5th floor, Suite 5209, Nashville, TN 37232. E-mail: john.mcpherson@vanderbilt.edu. Copyright © 2012 by Lippincott Williams & Wilkins ISSN: 1535–282X/12/1103–0091 DOI: 10.1097/HPC.0b013e31825b7bc3 Implementation of a Standardized Pathway for the Treatment of Cardiac Arrest Patients Using Therapeutic Hypothermia: “CODE ICE” Ryan D. Hollenbeck, MD, Quinn Wells, MD, Jeremy Pollock, MD, Michael B. Kelley, MD, Chad E. Wagner, MD, Michael E. Cash, MD, Carol Scott, RN, Kathy Burns, RN, Ian Jones, MD, Joseph L. Fredi, MD, and John A. McPherson, MD injury is a prominent feature of the postcardiac arrest syndrome and is reported as the cause of death in up to 68% of hospitalized OHCA patients. 6 Several studies have now shown that treating comatose OHCA victims with mild therapeutic hypothermia (TH) improves neurologic outcome and survival to hospital discharge. 2,7–9 TH has been endorsed in practice guidelines published by the International Liaison Committee for Resuscitation 10 and the American Heart Association. 11 TH is now recommended for the treatment of coma- tose survivors of cardiac arrest after ventricular arrhythmia (class I recommendation), 11 and should be considered for cardiac arrest due to nonshockable rhythms (class IIb recommendation). The administration of TH results in many cardiovascular and metabolic changes, including bradycardia, increased systemic vascular resis- tance, hypokalemia, metabolic acidosis, decreased insulin secretion, and a leftward shift of the oxyhemoglobin dissociation curve. 12 As a result, the management of cardiac arrest victims treated with TH is often beyond the scope of a practicing cardiologist and may require a multidisciplinary critical care approach to address the various car- diovascular and metabolic derangements seen in TH patients. With appropriate management, the risks of TH are relatively low 9 ; how- ever, the implementation of a comprehensive approach to TH proto- col can be challenging. In victims of cardiac arrest, obstructive coronary artery lesions are found in 40% to 86% of patients, depending on the age and sex of the population. 15 Acute coronary syndromes are believed to account for a significant proportion of cases of OHCA in adults, 13 and successful immediate percutaneous coronary intervention is associated with improved survival in OHCA victims due to acute coronary syndromes with or without STnelevation. 14 Based on these considerations, Vanderbilt University Medical Center modified its TH program in 2010 and implemented a comprehensive “CODE ICE” TH pathway. “STEMI on ICE,” a separate pathway built into CODE ICE, was specifically designed to address the unique requirements of the subset of cardiac arrest victims with evidence of ST-elevation myocardial infarction (STEMI). This article highlights key aspects of the CODE ICE and STEMI on ICE pathways and evaluates the effect of the pathways on quality metrics such as time to initiation of TH and clinical outcomes of cardiac arrest victims treated with TH at our facility. METHODS The study was approved by the Institutional Review Board with a waiver of consent due to the observational nature of the study. The study was conducted at Vanderbilt University Medical Center, a large academic tertiary referral center with 24-hour percutaneous coronary intervention (PCI) capability. The Vanderbilt cardiovascular intensive care unit (CVICU) has 27 beds and is a combined cardiol- ogy/cardiac surgical unit with full-time cardiovascular and intensive care specialists. The aim of the CODE ICE protocol is to improve the care of cardiac arrest victims in Middle Tennessee and surrounding