BILL ANALYSIS
AB 1882
Page 1
Date of Hearing: April 20, 2010
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 1882 (Portantino) - As Amended: March 10, 2010
SUBJECT : Health facilities: chilling or therapeutic
hypothermia.
SUMMARY : Requires acute care hospitals with an emergency
department (ED) to implement a policy or protocol to assess if
an ED patient who is or becomes comatose following cardiac
arrest is an eligible candidate for chilling or hypothermia
therapy. Specifically, this bill :
1)Requires acute care hospitals with an ED to adopt a policy or
protocol for assessing a patient in the ED who is or becomes
comatose following cardiac arrest, weighing the benefits
against the risks to determine if the patient is an eligible
candidate for chilling or hypothermia therapy.
2)Requires acute care hospitals to adopt procedures for
communication between the ED and other hospital units where
the patient is transferred during chilling or hypothermia
therapy. Requires the information communicated to include all
of the following:
a) The length of time the patient has been in chilling or
hypothermia therapy;
b) The ED assessment that determined the need for chilling
or hypothermia therapy; and,
c) Instructions or recommendations on how long the patient
should remain in chilling or hypothermia therapy.
3)Requires acute care hospitals, when transferring a comatose,
cardiac arrest patient to the ED or intensive care unit of any
other general acute care hospital, to inform that destination
hospital that the patient is being treated by chilling or
hypothermia therapy or has been assessed to be a candidate for
chilling or hypothermia therapy.
4)Requires acute care hospitals that treat a patient using
chilling or hypothermia therapy to note this in the patient's
record.
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5)Makes legislative findings and declarations on the usefulness
of chilling or hypothermia therapy patients that have suffered
heart attack, cardiac arrest, or stroke; and, guidelines
issued by the American Heart Association (AHA) and the
International Liaison Committee on Resuscitation (ILCOR).
EXISTING LAW :
1)Requires the licensure of health facilities, including general
acute care hospitals, by the Department of Public Health.
2)Requires licensed hospitals which maintain and operate an ED,
to provide emergency care and services to any person
requesting the emergency services or care, or for whom
emergency services or care is requested, for any
life-threatening or serious injury or illness.
3)Defines "emergency care and services" to mean medical
screening, examination, and evaluation by a physician or other
appropriate personnel under the supervision of a physician, as
permitted by law, to determine if an emergency medical
condition exists and, if it does, the care, treatment, and
surgery by a physician necessary to relieve or eliminate the
emergency medical condition, within the capability of the
facility.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill is
needed because not all hospitals use therapeutic hypothermia
for cardiac arrest patients, and of those hospitals that do
have procedures in place, there is no uniformity. The author
argues that once hypothermia is used, there need to be
procedures to ensure communication between the ED and any
other units in that hospital or any other hospital where the
patient is subsequently transferred.
2)THERAPEUTIC HYPOTHERMIA . According to AHA, therapeutic
hypothermia is a medical treatment that lowers a patient's
body temperature in order to help reduce the risk of the
ischemic injury to tissue following a period of insufficient
blood flow. Periods of insufficient blood flow may be due to
cardiac arrest or the occlusion of an artery by an embolism,
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as occurs in the case of strokes. With therapeutic
hypothermia, a patient's body temperature is cooled and the
patient is monitored so that their internal body temperature
remains between 32 and 34 degrees centigrade (89.6 to 93.2
degrees Fahrenheit) for at least 12 to 24 hours. External
cooling methods are simple to use but slow in reducing core
temperature. These techniques include the use of cooling
blankets; application of ice packs to the groin, axillae, and
neck; use of wet towels and fanning; and use of a cooling
helmet.
3)AHA AND ILCOR . While AHA has published articles recommending
the use of therapeutic hypothermia, studies published in
Circulation: Journal of the American Heat Association
(Circulation) seem to be somewhat contradictory. An article
published in 2007 in Circulation titled, "Abstract 60:
Prehospital induced hypothermia after out-of-hospital cardiac
arrest: Emergency Medical Services State of the Practice in
the US in 2007" stated that resuscitation care of comatose
survivors of cardiac arrest using induced hypothermia is
recommended by AHA and ILCOR. However, AHA guidelines
published on December 2, 2008 recommend that a
well-thought-out multidisciplinary approach for comprehensive
care be established and executed consistently; however, the
reliability of early prognoses remain limited, and the impact
of emerging therapies (e.g., hypothermia) has yet to be
substantiated. AHA's 2005 guidelines state the use of
therapeutic hypothermia "may be beneficial" and only "in a
select subset of patients was beneficial." An AHA press
release dated August 4, 2009 about how cooling therapy for
cardiac arrest survivors is a cost-effective treatment states
that one of the limitations on the use of therapeutic
hypothermia is the lack of long-term outcomes data.
The latest guidelines in an ILCOR publication were published in
2003 in Resuscitation titled, "Therapeutic hypothermia after
cardiac arrest" stated that there seems to be good evidence to
recommend the use of induced mild hypothermia in comatose
survivors of out-of-hospital cardiac arrest. Selection
criteria for treatment were narrowly defined in the best
evidence used and thus should be considered carefully when
deciding to treat. Despite these potential advantages,
hypothermia can also produce adverse effects. The 2005
guidelines adopted by both AHA and ILCOR were based on two
studies done outside the U.S. Both trials were published in
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2002, the first was completed in nine centers in five European
countries and the second was completed in four hospitals in
Melbourne, Australia. In total, less than 100 patients
studied were treated with therapeutic hypothermia.
Additionally, these trials excluded children and these
guidelines state there is insufficient evidence to recommend
this therapy on children. According to ILCOR children treated
with hypothermia were at an increased risk for death,
neutropenia (abnormally low number of the white blood cells
that fight infections and bacteria), and sepsis compared with
children treated without hypothermia.
4)OPPOSITION . The California Hospital Association (CHA),
Emergency Nurses Association (ENA), the California Chapter of
the American College of Cardiology (ACOC), the American Nurses
Association of California (ANA\C), and the California
Children's Hospital Association (CCHA) all oppose this bill
because it creates a mandate on clinical procedures in
hospital EDs. CHA, ENA, and CCHA state that clinical care
provided by hospitals, determined by physicians and other
clinical staff, is complex and uses evidence-based practices
and that since research is constantly evolving as new and more
effective procedures are introduced, certain treatments can
become obsolete. ANA\C and ACOC write that since treatments
can change as technology changes they do not believe that such
a specific treatment should be put into statute.
5)POLICY CONCERNS . This bill creates a specific mandate on
hospital EDs to establish procedures to determine whether a
patient who has suffered cardiac arrest and is comatose should
undergo therapeutic hypothermia. The author points out that
AHA and ILCOR have guidelines recommending that these patients
be treated by inducing hypothermia. The current studies, at
best, all point out that there is not much clinical trial
information and no clinical trial information on patients in
the U.S. Before any mandates are passed, should the author
wait until there is more data? With the constant changes in
available technology and medical practice guidelines, should
there be a specific mandate for all EDs to develop these
guidelines for all cardiac arrest, comatose patients? There
are many tests and treatments for patients suffering from
stroke and heart attack and each patient and situation is
different. Would it be best left to the treating physician
and ED staff to determine which treatment should be used and
when?
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REGISTERED SUPPORT / OPPOSITION :
Support
None on file.
Opposition
American Nurses Association of California
California Chapter of the American College of Cardiology
California Children's Hospital Association
California Emergency Nurses Association
California Hospital Association
Analysis Prepared by : Patty Rodgers / HEALTH / (916) 319-2097