WARM RECEPTION Cotton blankets alone won't prevent the onset of hypothermia, but there's no denying that they reduce anxiety and provide comfort.

Patients often arrive at your facility in the cool before dawn, enter air-conditioned pre-op rooms, strip down to nothing, put on paper-thin gowns and slide between chilly sheets and lie on cold, hard operating tables. Is it any wonder their core body temperature might quickly slip below 36°C and have you playing patient-warming catch-up?

Maintaining normothermia demands applying active warming measures as soon as possible, but research suggests that up to 70% of surgical patients become hypothermic during their care. That's a concerning rate, because hypothermia increases risks of myocardial ischemia, post-op infections, delayed wound healing and prolonged anesthesia emergence. Hypothermic patients are also less likely to be ready for timely discharge, which increases the overall cost of care and bogs down efficient case flow. Now for the good news: Active warming measures are easy to implement and proven to protect patients from the chilling effects of hypothermia.

It starts with measuring each patient's near-core body temperature soon after they enter the pre-op area, whether that's done orally, rectally, or at the temporal artery, tympanic membrane, or armpit. Whichever method you choose, use it consistently and correctly so that you gather accurate patient temperature data.

Make sure the ambient room temperature in the pre-op area is set high enough to support your warming efforts, and check and recheck the thermostats throughout the day. The hospital where I used to work had private pre-op rooms, and we kept the thermostat in each one at 70°F. We discovered, however, that members of the overnight housekeeping staff turned down the temperature in the bays as they cleaned. The rooms were chillier than we wanted when the day's first patients arrived in the morning, and remained that way until (or unless) one of our nurses checked the thermostats. We voiced our concerns to the housekeeping crew, who agreed to keep the room temperatures set as they were.

ROAD TO RECOVERY Forced-air warming is one of several active measures available to maintain normothermia from pre-op to the PACU.

Start active warming practices in pre-op for patients who have recorded temperatures less than 36°C and for those who might be at increased risk of hypothermia: women, the very old and the very young, and individuals with systolic blood pressure less than 140 mmHg. But why not apply active warming measures to all patients — aside, perhaps, from those who undergo minor procedures lasting less than 30 minutes or those who receive local anesthesia — to be sure they remain normothermic until discharge?

Active warming, which involves forced-air warming or conductive fiber warming devices, can be applied in pre-op to lessen the chill of hypothermia. Warmed cotton blankets are a definite patient perk and appreciated comfort measure, but their use alone has not been proven to reduce the risk of hypothermia. Still, applying blankets is a good way to augment active heating measures and boost your patient satisfaction scores.

FASHION FORWARD Cooling vests let surgeons and staff work comfortably in warmer ORs.

Warming IV fluids is another effective way to maintain normothermia, especially during cases that require the infusion of a large amount of fluid in a short amount of time. Follow the manufacturer's directives for how long you can store the bags in fluid warming cabinets and the maximum allowed temperature to which you can warm them. AORN suggests you warm IV and irrigation solutions in separate warming cabinets or in warming units with separate areas with independent temperature controls.

Active warming methods, warm cotton blankets and warmed IV fluids are most effective when used in combination than when they're applied alone. Regardless of the warming methods you use, the goal is the same: to make sure patients are normothermic when they enter the OR.

CASE STUDY
Conduct a Patient Warming Improvement Project

REAL DATA Track patients' core body temperatures to measure your hypothermia rate.

Don't assume every member of your surgical team knows about the dangers of hypo-thermia. During a patient warming project initiated at my former hospital, I was surprised by how many of my colleagues were unaware of the adverse events associated with hypothermia.

To drive the point home and garner support for improved warming protocols, track core body temperatures in pre-op, the OR and PACU over the course of several months to determine how many patients are hypothermic. Present that hard data to your surgeons and staff, and share case studies and clinical outcomes of patients who became hypothermic under their care. Using real-life examples involving patients your staff cared for — and likely remember — will make the issue real for them, and will increase the likelihood that they'll back your process improvement plans.

I used real data when implementing the patient warming improvement project, and the staff quickly realized they weren't doing enough to protect their patients from avoidable adverse outcomes. At the launch of the project, 92% of our patients were normothermic when they reached the PACU. That might seem acceptable, but if 8% of patients are hypothermic at a high-volume facility, too many of them are being unnecessarily exposed to adverse events and bad outcomes.

Soon after managing hypothermia became a team mission, 100% of our patients were adequately warmed when they reached recovery. Accept no less at your facility. Invest the time and effort to analyze the effectiveness of your warming protocols, because one cold patient is one too many.

— Kim York, BSN, MS, RN, CNOR, CSSM

Maintaining the momentum
The impact of your pre-warming efforts will quickly fade if you lose focus on keeping patients normothermic during surgery. A cold body naturally shivers to warm up, but unconscious patients in the OR cannot perform that most basic self-regulating action. General and regional anesthesia also shift the body's thermal energy from the core to the periphery, which results in vasodilation and a drop in blood pressure.

To maintain normothermic temperatures during surgery, make sure the ambient temperature in the OR is set within the AORN-recommended range of 68°F to 75°F, especially during the initial half hour of the case, when patients are at greatest risk of losing body heat. Upper- and lower-body forced-air warming gowns and underbody radiant heat mattresses help keep patients warm, while giving surgeons the access they need.

It's understandable that surgeons and surgical team members might prefer to keep rooms cool for their personal comfort, but that self-interest can be a significant barrier to maintaining normothermia in exposed patients. To keep the surgical team satisfied and your patients safe, consider investing in cooling vests, which surgeons and team members can wear to remain comfortable while they work in adequately warm ORs. CMS's Surgical Care Improvement Project for Body Temperature Management (SCIP Inf-10) states that patients who undergo procedures expected to last longer than 60 minutes should either be actively warmed or have a body temperature greater than or equal to 36°C within 30 minutes before or 15 minutes after anesthesia end time. That's why it's important to actively warm patients both in the OR and in the PACU, and to continually measure their temperature readings until you can document normothermia has been achieved. At that time, warming techniques can be applied simply to keep patients comfortable until discharge. OSM