Eight Ways to Make Patient Warming a Reality

Best practices from providers who have seen incredible results.

JD Buchert, MSN, M.Ed., MS, RN, recalls a patient encounter that has stuck with him over the years, one of many cases that has helped shape his understanding of how important it is to establish trust and create a comfortable environment for patients in the limited time he has with them.

Mr. Buchert, workforce safety manager for Parkland Health in Dallas and a member of the AORN Board of Directors, was working in the OR when he was met with a difficult, overly anxious patient. “Staff was having trouble de-escalating, and we didn’t want to force him down and restrain him for the IV, so we were considering canceling the surgery,” he says.

The patient had dementia and the journey to get him to the facility had been difficult enough, so Mr. Buchert decided to speak with the family before the case was called off. He discovered the patient, like him, was a veteran and that the sound of the forced-air warming device system being used had triggered his anxiety.

Tool for trust

Mr. Buchert was able to connect to the patient on a peer-to-peer level and bring down his triggers. “The military history conversation brought him back to comfort, and we applied three layers of blankets,” he says. “By the time I applied the head and neck-wrap blanket, I could see him visibly relax, and he was no longer trying to get out of the bed.” Staff then got the IV started without issue, Mr. Buchert stayed with the patient through discharge, and an almost-canceled case was ultimately successful.

“Patient warming can be a tool for trust, and it can create a comfortable environment,” he says. His experience, and that of the patient and his OR colleagues, illustrates why facilities and their staff should make warming a priority through the entire perioperative process. Here are eight ways to do just that.

1. Use data to drive decisions. When Oluwatoyin Akinyemi, MSN, RN, CNOR, and her team at Inova Fairfax Medical Campus in Falls Church, Va., wanted to incorporate active warming measures into the preoperative phase for ambulatory surgical patients, they launched an evidence-based project to prove the ROI was there.

Previously, only passive warming with cotton blankets was employed at the facility, while active warming with a forced-air warming device was used intraoperatively to maintain normothermia. “Our project involved actively warming patients in the pre-op area to determine how that impacted their perioperative temperatures,” says Ms. Akinyemi.

The results: Patients who were actively prewarmed preoperatively were 53% more likely to remain normothermic during surgery than patients who weren’t. In fact, only 38% of the patients who weren’t actively prewarmed remained normothermic during surgery.

“We showed that it’s worth spending the extra 10 to 30 minutes prior to surgery to achieve and maintain normothermia throughout the perioperative care continuum,” says Ms. Akinyemi.

MULTIPLE BENEFITS Active warming methods effectively maintain core body temperatures in the normothermic range for small and large patients.  |  Phoenix Children’s

2. Show leadership the potential savings. Safety is the primary reason for patient warming policies, but the cost savings facilities can realize by maintaining normothermia certainly helps, too.

Whenever you can show leadership exactly how much they stand to save by warming patients throughout the entire perioperative process, you can better ensure the practice becomes a top priority.

Case in point: Mr. Buchert was among the staff who conducted a four-week in-house study at Parkland Health in 2017 to measure whether prewarming patients helps keep them normothermic during and after surgery.

Of the 63 patients included in the study, 20% were hypothermic in pre-op, 32% in the OR, 41% in the PACU and 7% after 30 minutes in recovery, notes Mr. Buchert. “These percentages were all well below 70%, the national average of inadvertent perioperative hypothermia in 2018,” he says.

Driven by the results of the study, Parkland Health identified millions of dollars in potential savings. “We analyzed the previous year’s patient data and compared it to the time period we measured for in our study,” says Mr. Buchert. “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 a literature review.

To determine potential savings, Mr. Buchert and his team applied that $7,000 figure to the 15,434 cases with hypothermic incidents and added it to the savings realized by shorter lengths of stay — warming would save 2.6 days of overnight stays at $875 per day — and came up with a total savings of $2.35 million.

3. Audit, educate and act. Direct observation of OR staff during rounds is one of the most effective ways to ensure your warming protocols are performed correctly, according to Jennifer A. Rose, BSN, MSML, RN, CNOR, RNIV in perioperative services at Houston Methodist The Woodlands (Texas) Hospital. “During rounds, I’m able to make sure new processes are being followed, provide help and support and make suggestions during challenging cases,” says Ms. Rose.

Patient warming can be a tool for trust, and it can create a comfortable environment.
JD Buchert, MSN, M.Ed., MS, RN

Even seemingly minor tasks such as restocking warming cabinets can be used as a teaching opportunity. For instance, whenever Ms. Rose restocks the warmers, she points out the temperature readings on the IV bag warming cabinets to staff and explains that the fluid bags start at only 70°F. “This turns into an educational moment, and staff realize the effect that continuously putting cold bags of saline into a 98.6°F body has on patients, something we don’t think enough about,” she says. “This is especially true on scope cases, such as cystoscopy, arthroscopy and laparoscopy procedures where large amounts of irrigation are utilized.”

4. Mix methods. While active warming is the most effective method, it’s not always practical for every case.

At Urology Surgical Center in Lincoln, Neb., all patients receive warm cotton blankets before surgery as well as warmed IV fluids. As an additional warming strategy, patients who undergo surgeries that last more than one hour also receive a forced-air warming blanket prior to anesthesia, according to Clinical Director Jill Hain, RN. “For surgeries less than 60 minutes, we found we can keep the patient snug by using warmed cotton blankets and warmed IV fluids,” she says. In the PACU, patients — most of whom do not undergo procedures longer than 60 minutes — are given warm blankets, and if they do not maintain normothermia, forced-air warming is applied.

5. Highlight personal examples. Facilities often point to positive comments about warming on patient satisfaction surveys to reenergize staff and show them the work they do every day makes a difference. But it can be even more impactful when those testimonials come from perioperative staff themselves.

Take the example of Melissa Kellam, CRNA, DNAP, a staff CRNA and clinical coordinator at the Mobile (Ala.) Infirmary. “I had to go to the hospital for a procedure, and I told the staff, ‘Look, I don’t have any veins, so get your best person on it,’” says Dr. Kellam, who possesses more than 30 years of experience in anesthesia. “A nurse came in and put a warming blanket on me, and suddenly I was warm. My veins perked up and she got [the vein] on the first try. It was incredible, it decreased my anxiety, and she only tried one time to get an IV on me. I haven’t stopped raving about the experience since!”

6. Regularly check room temperature. Kim York, BSN, MS, RN, CNOR, CSSM, director of surgery at Dosher Memorial Hospital in Southport, N.C., shares an experience that highlights the importance of checking and rechecking the thermostats in patient care areas 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,” says Ms. York. “We discovered, however, that members of the overnight housekeeping staff turned down the temperature in the bays as they cleaned. That made the rooms chillier than we wanted when the day’s first patients arrived in the morning, and it remained that way until one of our nurses checked the thermostats.”

Ultimately, Ms. York says staff voiced their concerns to the housekeeping crew, who agreed to keep the room temperatures set as they were.

7. Get creative. Warm blankets can do wonders for patient satisfaction, but why limit yourself to blankets? At Advanced CardioVascular Solutions in Oklahoma City, every patient who comes through its doors receives not only two toasty blankets, but also a warmed gown and a pair of heated socks to keep them comfortable.

Amanda Stanley, RN, BSN, CNOR, chief operating officer/chief nursing officer, codified the head-to-toe warming protocol when she first opened the facility.

“After patients reported feeling cold and uncomfortable in thin gowns, we felt it would be a way to add a level of comfort to the start of their surgical experience,” she says.

8. Spread the word. Ms. Rose and her team at Houston Methodist were able to make warming a priority and have consistently maintained momentum by first getting everyone involved in forming a multidisciplinary committee on the topic.

“We had representatives from pre-admit, pre-op, OR, recovery and anesthesia on our warming committee to address the issue and each of these stakeholders became champions for their respective units,” she says.

Those champions then brought forward their perspectives and their particular challenges surrounding the issue, and the committee devised collaborative solutions.“The committee members, in turn, took the solutions back to their respective huddles, so we were intervening at each phase of care,” says Ms. Rose.

Share your ideas!

There are no shortage of ways to embed warming into your facility’s culture. We’ve only scratched the surface. If you have strategies of your own, feel free to email me directly at [email protected] or our team at [email protected]. OSM