BRR

Purpose

To identify ALL patients who are treated with therapeutic hypothermia following a Cardiac Arrest Witnessed 100-2 or Cardiac Arrest Unwitnessed 100-1. By identifying all patients that receive this therapy a further audit can be done to identify if therapy was appropriate or not.

• NOTE: this field does not include other populations which cooling can be used for. Only cardiac arrests.

Guidelines

For any ICU patient with a witnessed or unwitnessed cardiac arrest, code the ICU Var 2 - BRR variable as follows:

• BRR - cooling protocol was applied (BRR stands for "Brrrr" as in shivering or cold)
  • Note: Do not code BRR when a cooling protocol is used to normalize temperature for any type of NON CARDIAC ARREST patients!
    • OR
• XBR - means no cooling protocol applied for cardiac arrest patient
  • by coding XBR rather than leaving the variable empty we can automatically cross check that this was not just missed

• "We want to capture all patients who are cooled post cardiac arrest whether they meet criteria or not. A significant portion of patients following cardiac arrest do not meet ALL the criteria however, based on the available evidence it is reasonable to consider cooling them.

• The rationale for the code XBR is to identify those patients who had a cardiac arrest but were not cooled regardless if they met criteria for cooling or not. XBR was implemented after an audit of cardiac arrest was done and it was found that there were several cardiac arrests coded that were missing code BRR. By leaving Variable 2 blank for a cardiac arrest, it is not clear to Kendiss or Julie whether a data collector missed tagging it or if indeed cooling was not applied. Coding XBR indicates to both Kendiss and Julie that a collector verfied that the cooling protocol was not applied. See Purpose at the top of this article.Trish Ostryzniuk 17:43, 2012 June 18 (CDT)

Context: Cardiac Arrest Cooling Protocol

• Target temp: 32°C to 34°C for 12 to 24 hours.

Taken from the Hypothermia Protocol:

• Cooling is indicated if all of the following are checked:
  • Cardiac Arrest
  • Initial rhythm ventricular fibrillation/tachycardia(Dx code: 131-4, or 131-1)
  • Time to ACLS <15 minutes
  • Total ACLS time <60 minutes
  • Persistent Glasgow Coma Scale < or = 9
  • Systolic BP currently over 90 mmHg (pressors allowed)
  • < 8 hours elapsed since Return of Spontaneous Circulation (ROSC)

Discussion

• After reviewing these instructions I do not think I am doing this right. I have been only coding BRR or XBR whether cooling protocol was used or not after a cardiac arrest. The criteria above and Kendiss' note indicate that XBR should only be used if the all the criteria listed above are met and still not cooled. Please clarify if this is indeed the way this should be done. If this is correct then there may be some cardiac arrest patients where neither BRR or XBR would be used.

--LKolesar 07:26, 2012 April 27 (CDT)

• See above. You were correct in the first place, only coding BRR or XBR whether cooling protocol was used or not after a cardiac arrest .Trish Ostryzniuk 17:44, 2012 June 18 (CDT)

• Even though Dr. Garland's opinion in past email was that would be niced to be tag cooling protocol applied for all reasons, this is a request for addition to data collection which must be brought forth to Steering Committee for approval. Currently BRR is only being used for a very specific project related to cardiac arrests. Keep in mind that it is very easy to keep adding things to list of collected items. Unless there is someone requesting to do a specific project related cooling for other reasons and they will acutally be doing something with the data, then we won't just add it because it is a good idea. As you can see it is a challenge to keep criteria straight for even this one project here. The question needs to be asked of the Critical Care Quality Improvment team, Kendiss Olafson & Dave Easton (chairman) if BRR and XBR really needs to be collected indefinitely or if it can be done as an intermittent audit. I will pose the question to Dave and Kendiss and/or raise it at next Steering Committee meeting. Trish Ostryzniuk 18:08, 2012 June 18 (CDT)

Data Integrity Rules

If Cardiac Arrest Witnessed 100-2 or Cardiac Arrest Unwitnessed 100-1 in admit or complications diagnosis field then both the following must also be marked:

• ICU Var 2 - BRR – “BRR” or “XBR”
• TISS item T6-hypothermia/hyperthermia blanket
• changes made.--TOstryzniuk 17:58, 26 August 2009 (CDT)

Start Dates and other historical information

• collection was started August 2004
• XBR and CCMDB.mdb cross checks were added to detect occasions where entry was just forgotten/missed March 19.09
• reviewed with Kendiss Olafson and Dean Bell.--TOstryzniuk 17:58, 26 August 2009 (CDT)
• cross-checks changed to include Unwitnessed Cardiac Arrest August 27.09