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www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Each year more than 350,000 patients have an out-of-hospital cardiac arrest (OHCA) with less than 10% survival. Anoxic encephalopathy is the main cause of morbidity and mortality. Target temperature management (TTM) improves neurologic outcomes in comatose patients with return of spontaneous circulation (ROSC). Goals for time of TTM initiation are not defined; however, similar to other disease states, earlier may improve outcomes. Assessing TTM at a tertiary referral center found patients with TTM initiated ≤4 hours compared to > 4 hours were twice as likely to be discharged home (30% vs. 14%). This resulted in TTM protocol changes focusing on earlier initiation, minimizing interruptions, and cooling faster. The Emergency Department (ED) was educated on TTM and began initiating upon presentation. Cardiologists agreed to maintain TTM during catheterizations to avoid interruptions. Shivering protocol was improved to facilitate faster time to target temperature, including analgesia infusions, countersurface warming, and an algorithm for anti-shivering medications. Methods: This retrospective study evaluated adult patients receiving TTM following an OHCA before and after implementing changes to the TTM protocol. Outcomes included time to TTM, time to target temperature, proportion of patients receiving analgesia infusion, and number of shivering medications administered. Results: Forty-nine patients were evaluated: 25 pre-TTM changes, 24 post-TTM changes. Shockable rhythms were found in 72% of pre group and 25% of post group. Time to ROSC (20 minutes) and GCS (3) were similar. TTM was initiated in the ED in 33% of post group patients. There was a decrease in time to TTM initiation (4.6 hrs pre to 3.2 hrs post; p = 0.012). However, there was not a difference in time to target temperature. The post group had a 25% increase in proportion of patients who received analgesia infusions and a decrease in median number of antishivering medications (5 vs. 3 doses). Conclusions: TTM protocol changes resulted in decreased time to TTM initiation, increased analgesia infusions, and decreased anti-shivering medication doses. Further education to enhance time to initiation as well as decrease time to target temperature by better shivering control will further enhance outcomes in OHCA patients.