Patient Warming Pays Off Big

Inadvertent perioperative hypothermia is a preventable complication that can have disastrous consequences. A patient whose temperature dips below 36 C will react to the cold. Their arteries and veins constrict, leading to possible angina attacks, ventricular tachycardia and dysrhythmias. Thrombocytes lose their function as a coagulation mediator, causing more blood loss. The patient experiences a prolonged medication effect, more pain and a higher risk for surgical site infection.

There's plenty of research that shows the clinical risks associated with not adequately warming patients. We wanted to know if prewarming patients helps keep them normothermic during and after surgery. That's what we set out to measure with our small, in-house study that was conducted over a four-week period.

The first thing we did was prewarm patients for 30 minutes in cotton blankets warmed to 130 ?F. To be clear, we would have loved to use active warming measures in pre-op, but our budget couldn't handle the investment. We instead opted for the warmed blankets because our hospital already owned two refrigerator-sized warming units, and they were at our disposal.

During the intra-op phase, we used forced-air warming, warmed IV fluids and warmed irrigation fluid (at the time of surgical site irrigation). Warmed blankets were draped on patients during transport to the PACU.

We took and documented patients' temperatures in pre-op, when they entered the OR and PACU, and 30 minutes after arrival in recovery. Of the 63 patients included in the study, 20% were hypothermic in pre-op, 32% in the OR, 41% in PACU and 7% after 30 minutes in recovery. These percentages were all well below 70%, the national average of inadvertent perioperative hypothermia in 2018.

In the end, we saw $2.35 million in potential savings from the study. We analyzed the previous year's patient data (2017) and compared it to the time period we measured for our study. In 2017, documentation showed a staggering 70% (15,434) of the 22,049 procedures for which we had data included a hypothermic incident. These incidents cost an average of $7,000 per case, according to literature review. We applied the $7,000 figure to the 15,434 cases with hypothermic incidents and added it to the savings realized by shorter lengths of stay in our hospital — reducing hypothermic incidents would save 2.6 days of overnight stays at $875 per day) — and came up with $2.35 million in savings just by standardizing our patient warming protocols.

I'd love to tell you what we've saved since implementing this system full-time to keep patients warm from pre-op to post-op, but the coronavirus limited the number of surgeries we could perform. Currently, we have closed three-quarters of our hospital's ORs and are performing only emergent or critical surgeries. However, our study proved warming patients throughout the entire surgical process ultimately pays off big.

There's also a secondary benefit to maintaining normothermia. If a patient is anxious, that extra contact with the nurse who is covering them with a warmed blanket helps tremendously to reduce stress levels. You want patients to be comfortable while they're in your facility. This small comfort measure also helps to build trust with patients in a short amount of time.

Considering our study's relatively low cost, you'd expect the hospital's stakeholders would have been all in on enhancing our patient warming protocols. They weren't. Changing mindsets is hard. Most OR staff members are Type-A personalities. We have our way of doing things, and change becomes personal.

Altering frontline practices wasn't easy but we knew that going in. Ours was an evidence-based project, so we understood getting the results we needed would involve changing mindsets, because it involved changing routines. We also knew that permanently altering our warming routines would take constant, consistent reinforcement. We wanted to warm patients before surgery, but we needed buy-in to do it. Our approach wouldn't be large scale. It would be personal. One on one. If I talked to a nurse, the message was: This warming protocol is directly improving patient care. It is a level higher than what we are doing now.

I also reminded everyone that adding this extra layer of warmth was already approved by the American College of Surgeons, the Joint Commission and AORN. We put information in our OR newsletter, showing why pre-warming was important for patients. I assembled two PowerPoint presentations. One was for surgical staff and another was for non-surgical personnel who would learn about our warming protocols in an academic setting.

If you're considering a prewarming program that will require multi-level buy-in, tailor your approach to each stakeholder's role. Your surgeons need to be approached differently than OR staff. Consider focusing on a quick elevator speech for surgeons as they tend to focus on how the participation can make their busy lives easier. If we spoke to physicians, the message was fact-filled: The patient can go home earlier, there will be a lower chance of surgical site infections and you will be reducing recovery times, which could ultimately allow you to do more cases.

Your OR staff wants to know how patient warming will improve the patient experience and clinical outcomes. If you want to alter their day-to-day work pattern, it better be justified through a patient benefit. You need to explain how "as patient advocates" the benefits to those in their care is worth the extra work. Make it personal for them.

Administration needs to see some clear return on investment and, ideally, how the move can save your facility money. If you customize an approach to each stakeholder's needs, the buy-in comes quicker and easier. But remember, conversations constantly need to be reinforced with all stakeholders, as they have many moving parts in their day and require constant reminding. OSM