July 13, 2023

Three keys to implementing — and sticking to — protocols that keep hypothermia at bay.

CONFIRM AND RECORD Providers not only should consistently monitor patients’ temperatures, but also document those readings along the way.

Patient warming is a patient safety and patient satisfaction must for top-performing outpatient facilities. But this crucial area of practice also tends to require regular, consistent reminders from facility leaders to better ensure it remains top-of-mind among staff.

If you’ve found your warming efforts tend to cool over time, here are three ways to reignite interest and compliance among your teams.

Consistency is crucial. Meghan Quinn, RN, nurse administrator at Valley Surgery Center in Scottsdale, Ariz., believes effective warming protocols come down to consistent application, which requires buy-in from multiple stakeholders. “Standardization is a key factor in making sure a patient warming protocol is practiced the same way for every patient,” she says. To shape her facility’s protocol, Ms. Quinn worked with a team of nurses, physicians, surgical techs and anesthesia care professionals to draft a policy and procedure that includes each representative’s role in patient warming practices. She says anesthesia’s participation is especially important because that provider plays such a prominent role in patient warming and temperature monitoring.

Solid documentation is a must. This popular HR mantra also rings true with patient warming: If it wasn’t documented, it didn’t happen. Jill Hain, RN, clinical director at Urology Surgical Center in Lincoln, Neb., advises facilities to develop a clear plan for how a patient warming protocol will be completed and documented.

Case in point: At Ms. Hain’s facility, every patient warming encounter is documented in the patient’s chart to show all steps have been completed. She also runs a quarterly report for procedures lasting more than 60 minutes to evaluate those patients’ PACU temperatures at or below normothermia, and also uses a spreadsheet to track outcomes data according to the name of the anesthesia professional who was in the room for each surgery.

Talk it up. To keep enthusiasm for warming high and increase long-term sustainability, share practical, real-world examples of how it works in practice. “If the team realizes that this is not just something else to chart but something that ensures patients will have a better, happier stay, nurses will be on board,” says Ms. Hain.

A veteran anesthetist shares 10 important steps to consider to maintain an effective protocol.

Melissa Kellam
BUNDLING UP An effective protocol ensures that active warming is employed before anesthesia is inducted.

Looking to institute or refine your facility’s patient warming protocol? Melissa Kellam, CRNA, DNAP, a staff anesthetist and clinical coordinator at the Mobile (Ala.) Infirmary, offers these 10 steps around which you can build a patient warming protocol that better keeps your patients both comfortable and safe.

• Begin active warming prior to induction of anesthesia.
• Warm IV fluids and blood products to 37°C.
• In a thermostatically controlled cabinet, warm any irrigation fluids that will be used intraoperatively to 38°C to 40°C.
• Document temperature routinely, such as every five minutes.
• Measure the patient’s core temperatures whenever possible.
• Do not induce anesthesia unless the patient’s temperature is 36°C or above.
• Employ active warming intraoperatively if the patient will be anesthetized for more than 30 minutes, or if the patient is at high risk of inadvertent perioperative hypothermia and will be sedated for less than 30 minutes.
• Set active warming devices to maintain a patient temperature of at least 36.5°C.
• Measure and document the patient’s temperature upon admission to PACU and then every 15 minutes thereafter until a normothermic reading is achieved.
• Do not discharge the patient unless their temperature is 36°C or above. If the patient’s temperature is below 36°C, actively warm them until they reach normothermia.

While Dr. Kellam’s tips suggest that patient warming should begin before induction of anesthesia, in her practice there is no doubt as to how long before. “It should begin the minute patients change into their surgical gowns,” she says. Her reasoning has as much to do with the patient experience as it does for patient safety. “In too many facilities, the patient is already sedated by the time active warming starts,” she says. “They wake up warm, but all they remember is being cold before surgery.”

Maintaining normothermia throughout the surgical experience can help support positive outcomes.

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The comfort and safety of patients is of great importance during the surgical experience, no matter what the surgery or the duration of the procedure. Ambulatory surgery centers (ASCs) look to guidelines and safe practices to ensure the best possible outcomes for their patients. These practices include temperature monitoring and active prewarming during the preoperative phase, in addition to intraoperative warming, to help prevent unintended intraoperative hypothermia.

The therapeutic strategy differs depending on whether hypothermia is being prevented or treated, which means the purpose and warming strategy may differ between the three perioperative phases. Patient prewarming efforts are, in fact, made to help minimize the effect of post-induction redistribution temperature drop (RTD) and minimize cutaneous heat loss, which helps maintain intraoperative normothermia as the patient’s autonomic reflexes are unable to maintain normothermia. These prewarming efforts are made during the pre-op phase prior to patients being given anesthesia.

What exactly is active prewarming? There are two ways in which warming occurs in preop – active warming and passive insulation. Active warming adds heat to the body surface using a warming system such as those that use warm air to increase mean body temperature.¹ Passive insulation methods are used to help prevent heat loss, but do not transfer heat to the patient – for example, warmed cotton blankets and reflective drapes.¹ Prewarming can only be done by active warming, not by passive insulation.

Why is active prewarming so important? Its benefits are supported by research that states, “preoperative forced-air warming can limit the redistribution of body heat that occurs after the induction of anesthesia.”² Studies have shown that passive insulation, such as warmed blankets, is simply not effective in preventing unintended hypothermia during surgery and post-operative recovery.^3,4,5

Enhanced Recovery After Surgery (ERAS) Society recommends, “It is important to maintain normothermia by active methods throughout the perioperative period, including prewarming patients to avoid an initial drop in body temperature.”⁶

From a nursing perspective, the prewarming phase may be the most challenging because it requires anticipation of an unseen event (redistribution) and can produce thermal discomfort. It is not practically possible to prewarm patients solely by minimizing heat loss from the skin. Prewarming requires the transfer of heat into the body by an active warming device.

With close attention paid to all three perioperative phases when it comes to patient warming, teams can help support positive outcomes for both the comfort and safety of their patients. Patient satisfaction is important during the entire surgical journey starting at the very beginning. Attention to the prewarming stage, where both comfort and clinical warming may be needed, can help yield favorable results.

References:

1. Sessler, D. I. Consequences and treatment of perioperative hypothermia. Anesthesiology Clinics of North America, J. L. Benumof, Editor. 1994, W. B. Saunders Company: Philadelphia. p. 425-456

2. Adriana M., Moriber N. Preoperative Forced-Air Warming Combined with Intraoperative Warming Versus Intraoperative Warming Alone in the Prevention of Hypothermia During Gynecologic Surgery. AANA Journal. 2013;86(6):446-561.

3. Fossum S, Hays J, Henson MM. A Comparison Study on the Effects of Prewarming Patients in the Outpatient Surgery Setting. J Perianesth Nurs. 2002;16(3):187-194

4. Wagner D, et al. Effects of Comfort Warming on Preoperative Patients. AORN J 2006; 84:427-448

5. Benson E. E., McMillan D. E., and Ong B. The effects of active warming on patient temperature and pain after total knee arthroplasty. American Journal of Nursing. 2012;112(5): p. 26-33

6. Nelson G, Altman AD, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations - Part I. Gynecologic Oncology. 2016;140:313-322

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