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Crit Care Med. 2010 Feb;38(2):504-9. doi: 10.1097/CCM.0b013e3181cb0a02.

Perceived barriers to therapeutic hypothermia for patients resuscitated from cardiac arrest: a qualitative study of emergency department and critical care workers.

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Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.



To identify the barriers to implementation of mild therapeutic hypothermia for adult survivors of cardiac arrest. Despite scientific evidence to support therapeutic hypothermia for resuscitated cardiac arrest patients, it is inconsistently and at times inadequately used.


Qualitative study, using semistructured interviews.


A stratified random sample of 14 sites from an established network of 43 hospitals, including both community and tertiary care centers in Southern Ontario, Canada.


Twenty-one intensive care unit and emergency department physicians and nurses.




Purposive sampling was used to interview individuals who were most likely to be involved in the implementation and evaluation of the hypothermia protocol. All interviews were conducted by telephone by a clinician and a qualitative researcher. Interviews were recorded electronically and transcribed unless the participant declined to have the interview recorded. Untranscribed interviews were recorded as field notes and as direct quotations. New interviews were conducted until thematic saturation occurred. The analysis was completed through three phases of coding. Respondents identified lack of familiarity and availability of concrete therapeutic hypothermia protocols and process issues as the most frequent barriers. Process concerns included availability of equipment, equipment costs, and high workload demands for emergency nurses. Other barriers identified were variable nursing awareness, variable staff uptake, lack of agreement with supporting evidence, lack of interdisciplinary collaboration between the intensive care unit and emergency department, lack of interprofessional education between nurses and physicians, and challenges inherent in applying an intervention infrequently.


This study demonstrated that the systematic adoption of a new intervention, therapeutic hypothermia, is met with interdependent generic, local, and individual barriers. A working awareness of the types of barriers that exist at multiple sites will assist in targeting specific knowledge translation strategies to improve adherence to evidence-based practice.

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