ArticleCJEM2026
Development and implementation of a severe accidental hypothermia resuscitation pathway in an urban Canadian emergency department: a quality improvement initiative.
Article in CJEM, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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7 authors.
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Abstract
objectivesSevere accidental hypothermia (core temperature < 28 °C) is an infrequent but resource‑intensive emergency department (ED) presentation that requires altered Advanced Cardiac Life Support (ACLS) management, aggressive rewarming, and timely consideration of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Prior to this project, our inner‑city academic ED lacked a standardized approach, contributing to variability in care. We designed, implemented, and achieved ≥ 95% real‑time utilization of a bedside pathway for patients with severe accidental hypothermia.
methodsIn response to issues identified in the review of a case of severe hypothermia, a multidisciplinary team developed and revised a severe hypothermia pathway through eight Plan‑Do‑Study‑Act cycles. Implementation strategies included an in situ simulation, targeted nursing skills sessions, and interdepartmental case debriefings. From January 2025 to April 2025, cases of severe hypothermia were reviewed. Our primary outcome was pathway utilization; secondary outcomes were staff perceptions, including timely access to VA-ECMO.
resultsOur severe hypothermia pathway includes a flowchart alongside a set of cue cards. The flowchart prompts management in three key realms: modified ACLS, rewarming techniques, and prognostication/VA-ECMO. The cue cards guide step-by-step management, including how to access mechanical CPR and VA-ECMO. Key themes included: development of a streamlined pathway, clinical provider education, and improved interdepartmental communication. 100% (6/6) of cases utilized the pathway. Interdisciplinary feedback suggests providers find the pathway to be useful and that it facilitates timely access to consideration for VA-ECMO.
conclusionA pragmatic hypothermia resuscitation pathway was successfully implemented in our ED, supporting access to VA-ECMO. Our work acknowledges these resuscitations are resource intensive and may disrupt care to other patients. Therefore, cases for VA-ECMO should be carefully selected. Future work includes exploring an ED Code ECMO at our site and a city-wide prehospital VA-ECMO referral pathway.
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