Eight Best Practices in Patient Warming

A standardized protocol can significantly reduce the risks of complications for your patients.

An inadvertent hypothermic event during surgery can turn a routine procedure into a case with multiple complications.

The effects of a drop in core body temperature to below 96.8°F can range from shivering and slower recovery in the PACU to increased bleeding and surgical site infection (SSI). A core temperature of just three degrees below normothermia is classified as severe hypothermia, according to the latest guideline on patient temperature management from the Association of periOperative Registered Nurses (AORN).

High-risk areas

A patient who is feeling cold can rapidly develop preoperative anxiety, which in turn can negatively impact their satisfaction levels across all phases of their care. While these risks are well known among perioperative providers, they aren’t always addressed proactively, according to J.D. Buchert, MSN, MEd, MS, RN, CPHQ, CNOR, workforce safety manager in quality and safety operations at Parkland Health in Dallas. “Most hospitals and ambulatory surgical centers are missing this key component to reduce SSI rates while also increasing patient satisfaction scores,” he says.

Why warming matters

Inadvertent perioperative hypothermia is a common surgical complication, and it doesn’t just occur in the OR. A study of perioperative hypothermia incidences reviewed body temperature drops measured at various phases of care. While the bulk (73.5%) of hypothermic events among the group of 742 patients occurred intraoperatively, primarily after anesthesia induction, 11.9% involved a temperature drop while the patient was in the PACU, while 0.4% occurred in pre-op.

As with many patient safety measures, there is an additional benefit to patient warming, as standardizing the practice also can provide financial rewards. “This one protocol in particular can increase potential income for a facility because the cost of SSIs, extended recovery times and low patient satisfaction scores can have a significant impact on the bottom line of the perioperative earning potential,” says Mr. Buchert. For these reasons, he has championed patient warming as standard practice for every surgical patient in his facility.

He’s not alone. Seeing the need for a standardized patient warming protocol inspired Jennifer Rose, MSML, BSN, RN, CNOR, CV-BC, at Houston Methodist The Woodlands Hospital in Conroe, Texas, to take action and bring the idea to management. She advises that providing evidence that warming is a key ingredient of safe and effective care is the best way to get leadership and staff on board with the practice.

BEST PRACTICES

Keys to Developing a Temperature Management Plan

Strategies for building a warming plan are outlined in AORN’s new Patient Temperature Management Guideline. Here are some recommendations from the guideline to include in your plan:

• Look at interventions across all phases of care for all patients.
• Make sure policy and procedure development and review are part of the process.
• Take a formal approach to evaluation and selection of warming and temperature monitoring devices.
• Incorporate preoperative warming protocols that include established timeframes according to patient temperature status in coordination with anesthesia induction.
• Standardize how — and how often — patient temperatures are monitored throughout all phases of surgical care.
• Standardize the process for selecting the warming methods that will be used.
• Evaluate patient warming compliance and knowledge with tools such as gap analysis.
• Provide teamwide education on all elements of the patient temperature management plan and verify competency.
• Establish a clear process for monitoring your facility’s warming practices.
• Track data in a systematic way to monitor patient outcomes specific to patient temperature management and share these data in ongoing performance improvement.

— Carina Stanton

What’s your warming protocol?

SNUG AND SAFE Warming is a proven way to alleviate preoperative anxiety and bolster satisfaction levels throughout all phases of patient care.  |  Boston Children’s

Ms. Rose and Mr. Buchert always incorporate new research to improve their respective warming protocols. Here are their best practices.

• Share data and collaborate. Data sharing should go beyond the nursing team, anesthesia providers and others on the front lines. “Sharing the data in specialty committees, especially when the facility is seeking specialty accreditation, will increase the focus from a surgeon perspective,” says Mr. Buchert. Once a protocol is in place, OR team members should work together to track the patient’s temperature and take appropriate measures if the temperature is too high or too low.

• Use warm fluids. Hanging a “hot plate” on the IV pole, placing IV bags and bottles in warming cabinets, as well as using warmer basins and in-line warmers for IV infusions, all ensure that cold fluids don’t enter a patient’s body, says Ms. Rose. Warmed fluids are most beneficial when used as an adjunct with other warming methods, adds Mr. Buchert. One systematic review concluded that administration of warmed IV fluids kept patients warmer than room-temperature fluids did.

• Apply active warming. This is a common practice at Houston Methodist. The updated AORN guideline recommends the use of forced-air — also known as active — warming devices for any procedure that will last longer than 30 minutes or for high-risk patients.

• Warm throughout the episode of care. Shielding the patient from temperature inversions, even in different areas of the building, makes a difference. “We deliberately focus on monitoring and maintaining the patient’s temperature in every perioperative space through their surgical experience,” says Ms. Rose. Mr. Buchert recommends warming patients for at least 30 minutes preoperatively.

• Test and assess. Look for evidence and test new practices to optimize patient warming on an ongoing basis. However, don’t feel as though you must incorporate everything you try. For example, after adding thermoreflective foil leggings intraoperatively to patients in the lithotomy position over a six-month period, Houston Methodist found no significant difference in rates of intraoperative patient normothermia.

• Use multiple tactics. Mr. Buchert’s facility employs several methods to keep patients warm. “This can include pre-surgical warming, the use of underbody or regionalized warming during procedures, warmed intravenous fluids and maintaining a temperature in the operating room between 68°F and 75°F,” he says.

• Get everyone on board. An interdisciplinary team should decide which warming methods to use for which patients and procedures, as well as who should be responsible for monitoring how they’re all working, says Mr. Buchert. The circulator and anesthesia team won’t carry the weight of the program’s success when the protocol is developed by the entire surgical team. “Let them develop the protocol,” says Mr. Buchert. “That way, they own it.”

• Consider circulating-water blankets. Heated water in these devices provides consistent and effective heat transference to the patient. Several studies suggest these products are effective.

“We’ve made a deliberate focus on monitoring and maintaining the patient’s temperature in every perioperative space through their surgical experience.”
Jennifer Rose, MSML, BSN, RN, CNOR, CV-BC

Manufacturers’ instructions for use with active warming devices should be well understood by all team members to prevent thermal injury and infection. Some circulating liquid devices, for example, have been associated with nontuberculous mycobacteria infections, primarily in cardiothoracic surgical patients, according to an FDA investigation.

Make warming stick

Regular communication has helped Ms. Rose improve compliance across her department. She categorizes warming protocol compliance data by service line, which inspires staff to bring their “A” games. “It has helped foster a competitive spirit among the staff and has made the data more palatable and fun,” she says.

Mr. Buchert says staff shouldn’t shy away from discussing patient warming’s benefits for the facility’s bottom line as well as for the patient. He also urges surgical leaders to celebrate the positive outcomes. “When everyone is a part of the process, everyone should be celebrated, too,” he says. OSM