The Surgical Care Improvement Project, a national collaboration of healthcare organizations that aims to engineer a reduction in surgical complications, has identified the maintaining of patient normothermia — a core temperature of greater than or equal to 96.8 ?F (36 ?C) — within the first 15 minutes after the patient exits the OR as a key infection prevention measure. SCIP has been monitoring this measure only among colorectal surgery patient populations, but has announced that hypothermia prevention is such a high priority to patient safety that it plans to expand the measure to surgical patients receiving general or neuraxial anesthesia lasting 60 minutes or more by next year. Here are 5 common missteps than can sink your efforts to warm patients effectively. Are you guilty of making any of them?

1. Underestimating hypothermia. Unplanned perioperative hypothermia can result in clinical consequences ranging from adverse physiological outcomes for patients to increased expenses for surgical facilities. If your staff lacks an awareness of the detrimental effects of hypothermia or if they neglect patient warming outright, they might fail to notice, or even contribute to, the following problems:

• Impaired coagulation from changes in the viscosity of the blood, leading to altered tissue perfusion. The body's response to hypothermia may also result in increased red blood cell, plasma and platelet usage and, in turn, an increased need for transfusions.
• Delayed wound healing and increased risk of surgical site infection, as a result of impaired neutrophil and macrophage function and decreased oxygen levels.
• Poor drug utilization, since shivering — the body's mechanism for preserving and generating heat — can lead to increased oxygen consumption and metabolic demands.
• Post-operative myocardial ischemia caused by changes in blood flow and oxygen consumption.
• Hypertension and cardiac irritability stemming from an increase in norepinephrine.
• Increased facility costs and lower efficiency, since re-warming and slowed recovery lengthen a patient's stay in PACU.
• Lower patient satisfaction, brought on by the psychological effects of feeling cold and shivering, coupled with pre-existing surgical anxiety.

2. Keeping ORs too cold. Let's face it: The operating room environment can be a cold, cold place for patients. According to AORN's recommendations for providing a safe environment of care, an OR's temperature should be between 68 ?F and 73 ?F. But not every OR complies with these recommendations, and some have been observed to be as cold as 55 ?F or 60 ?F.

A too-cold OR, or any perioperative environment, can cause patients to lose heat and risk suffering hypothermia in 2 ways: through conduction and through convection. Lying on a cold surgical table or mattress, a patient loses heat through conduction when his body heat transfers to the colder surface. Heat loss through convection occurs when cold air currents pass over a patient's skin. This can lead patients who have large areas exposed for antiseptic skin preps before surgery to lose heat by way of evaporation.

As a member of the surgical team, you're gowned, gloved and masked, moving around and holding positions under OR lights. Your body temperature can become quite uncomfortable, especially during lengthy procedures. That's why surgeons frequently ask for the room's temperature to be lowered, for the comfort of the team.

But for patients, whose shivering and other involuntary responses for handling cold temperatures may be impeded by anesthesia, this chilly OR is anything but comfortable. In addition, specific patient populations such as pediatric, geriatric and trauma patients are at a particular disadvantage from the start since their bodies have a reduced ability to generate heat (and are more prone to infections, which may result from hypothermia). They may even require higher room temperature settings than those that AORN recommends.

With quick turnover times, it can be difficult to keep a "cool it down, warm it up" cycle going in an OR, especially since many thermostats and HVAC systems cannot respond and fully act that quickly.

Knowing this, however, our surgical staff now strives to maintain consistent OR temperatures in the 68 ?F to 73 ?F range in the name of patient safety. They also assess patient ages and populations to ensure that they are implementing the necessary measures for OR climate control, both before the patient enters the room and during the case.

3. Ignoring the evidence. Several professional organizations have compiled guidelines on preventing and minimizing perioperative hypothermia, including AORN, the American Society of PeriAnesthesia Nurses, the American Society of Anesthesiologists and the American Association of Nurse Anesthetists. Our performance improvement project team examined these standards and also searched for evidence-based studies on hypothermia prevention in the medical literature (see "Recent Studies On Patient Warming" on page 6).

Our review revealed that some of the practice guidelines, such as ASPAN's and AORN's, prescribed specific interventions, while others (such as ASA's) seemed vague on the details. Additionally, we found conflicting research published on the effects of patient warming. But these collected strategies and evidence can hardly be ignored, and it is advisable for you to understand them, pattern your patient warming protocols on them and use them as a springboard to improvement.

As the clinical nurse specialist, I took this review as an opportunity to hold a book-club-style meeting, during which we discussed a journal article we'd found that examined the question of why some surgical facilities neglect hypothermia prevention protocols (Weirich TL. Hypothermia/warming Protocols: Why Are They Not Widely Used in the OR? AORN J. 2008 Feb;87(2):333-44).

Our project team's review of evidence-based practices found consistent support for intraoperative patient warming, but it also revealed some interesting research on pre-op warming practices. For instance: Patients who undergo surgery with general anesthesia lose body heat after induction when their warm core blood mixes with cooler blood from their periphery, causing their body temperature to drop.

After reading about this, our pre-op nurses established a practice in which, if a patient's temperature registers lower than 96.8 ?F, the patient is warmed with a forced-air blanket and their temperature checked every 30 minutes until they are transported to the OR. The nursing staff also noticed that 3 types of thermometers were routinely used in our pre-op and PACU areas: oral, tympanic and temporal artery. Taking and comparing temperature measurements with each type, they found the temporal artery to be the most consistent, so they changed their monitoring practice to incorporate this finding.

4. Passing the buck. As with any perioperative process, roles and responsibilities for patient warming must be explained and assigned. Otherwise, you might find differences of opinion leading to turf wars between your RN circulators and CRNAs over who's responsible for warming patients. The short answer: It's everyone's job.

Using the professional organizations' guidelines and evidence-based studies, our project team created a hypothermia prevention protocol for perioperative services across the board. It identifies actions to be taken by each discipline, including active and passive warming methods to apply throughout the continuum of care. Turf wars can be eliminated if each discipline understands the part they play in preventing hypothermia and takes ownership of their role in patient safety.

5. "Free hosing." No discussion of hypothermia prevention and patient safety would be complete without mentioning the serious hazard presented by "free hosing."

Free hosing occurs when the hose from a forced-air warming unit is not connected to the warming blanket component as directed, but is instead placed directly under the cloth blankets on a patient's bed. As a result, instead of circulating through the warming blanket for even distribution, the air blows freely onto the patient.

This incorrect use of a forced-air warming unit is driven by thrift. Healthcare providers may think that they are saving the patient or the surgical facility money by not connecting the single-use warming blanket to the hose. But make no mistake, this misguided practice puts patients in danger of suffering first-, second- or even third-degree burns. The facility is also allowing negligent practices to occur. Keep in mind that lawsuits have been filed over patient injuries resulting from free hosing.

Even the most budget-conscious facility administrator would agree that spending $7 to $25 on a warming blanket is preferable to facing the cost of settling a legal claim. And it is virtually unthinkable that any other piece of equipment in the surgical setting would be modified from its manufacturer's directions for convenience or cost savings. Since patient safety takes clear precedence over cost savings, we have strictly prohibited free hosing at our facility.