June 22, 2023

Patient Safety Patient Experience Infection Prevention

By: Outpatient Surgery Editors

Published: 6/22/2023

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THIS WEEK'S ARTICLES

Always Aim for Active Warming

Patient Warming Effective for Infection Prevention and Wound Healing

Temperature Monitoring for Surgery Patients is an Important Step for Safe Surgery - Sponsored Content

Eliminating Variability in Temperature Monitoring

Building Enthusiasm About Patient Warming

 

Always Aim for Active Warming

Shorter procedure times shouldn’t automatically mean passive measures.

WarmJ.D. Buchert
COMFORT AND SAVINGS Warming patients for surgery not only improves the patient experience, but also can prevent emergent hypothermic events that are expensive for facilities to address.

Facilities that base active warming protocols on the length of the surgery may want to revisit that approach.

Warming every patient no matter the duration of the surgery is the best course of action for facilities, says J.D. Buchert, MSN, M.Ed., MS, RN, workforce safety manager for quality and safety operations at Parkland Health in Dallas, who adds that ASCs in particular could benefit from more consistent active warming of patient populations. “These patients tend to have shorter procedure times that may preclude them from receiving active warming due to a facility’s policy,” he notes.

It’s not uncommon for surgery centers to implement a 60 minute-or-longer threshold to determine the warming method the patient will receive. At many facilities, passive warming methods are used for procedures lasting less than 60 minutes. These surgical duration thresholds are not in place for clinical or patient experience reasons. It’s simply to control costs.

Mr. Buchert urges facility leaders to look beyond short-term savings by factoring in the wide range of costs associated with patients who experience unplanned hypothermia. Specifically, a 2021 study found that intraoperative hypothermia was associated with higher risks of bleeding, surgical site infection and shivering, at a cost of $363.80 per patient. The study further determined that the per-patient investment in active warming is $292.

Hypothermic events can also have costly ripple effects on the PACU. “A patient experiencing unplanned hypothermia in the PACU can take up valuable space needed for outgoing patients, and the negative impact unplanned hypothermia can have on patient satisfaction creates another major issue,” says Mr. Buchert.

Ultimately, a facility’s best defense against hypothermia is active warming across the entire perioperative continuum. “Too many times, I have walked into a preoperative holding room and been told by a patient they are cold,” says Mr. Buchert. “A patient typically has a decrease of 1° F in body temperature upon induction. If that patient is entering the operating room already cold, their temperature drop can have devastating effects because there is typically not enough time to bring that patient’s temperature back to normothermic range.”

Patient Warming Effective for Infection Prevention and Wound Healing

The practice goes far beyond comfort. It’s about patient safety as well.

InfectionAndersen Eye Surgery Center
SSI-FREE Warming protocols can keep patients safer for surgery, especially in terms of preventing surgical site infections and promoting better wound healing.

Warming patients before, during and after surgeries delivers two primary benefits. The most obvious is the comfort — soothing a shivering, nervous patient. The less readily apparent benefit is patient safety. Warming patients throughout their perioperative episode maintains normothermia, which in turn reduces the probability of surgical site infection and promotes better healing of surgical wounds.

Premier Outpatient Surgery Center in Colton, Calif., began actively warming patients in the mid-2010s, after previously using only warmed blankets. Mimi DesBiens, BSN, RN, administrator and director of nursing, says active warming is now firmly ensconced as a core tenet of patient safety at the facility, with SSI prevention the primary reason. “It’s an evidence-based practice for infection control,” says Ms. DesBiens. “If you keep the patient warm enough, you have good blood flow to the incision site, and it helps with healing.”

Another positive patient safety impact for Premier has been quicker recoveries with reduced postoperative usage of narcotics. “We don’t want that risk of hypothermia,” says Ms. DesBiens. “Before we started using warming devices, some patients came into the PACU shivering, and we had to use quite a bit of narcotic medications.”

Premier has criteria in place to trigger implementation of its active warming protocols. “For the most part, active warming is always used when the patient’s body is exposed and under general anesthesia using inhalational agents for procedures that last longer than 30 minutes,” says Ms. DesBiens. The intervention is regularly employed for longer cases involving MAC sedation as well — but not for shorter procedures. “If it’s a quick 30-minute carpal tunnel case under MAC sedation, we’ll give them warm blankets,” she says.

Patient age is an exception to those rules. If an 80-year-old patient who is cold to begin with comes into pre-op, there’s a very good chance active warming will take place, says Ms. DesBiens. “We do a lot of nursing assessment when it comes to warming, and if the anesthesia provider requests it, we do it,” she adds.

Ms. DesBiens nevertheless also appreciates the patient comfort component of warming. “Patients feel like royalty when we wrap them up,” she says. “It’s that extra added comfort measure that helps ease them through the surgical journey. I think it’s so cute when the patient giggles and says, ‘Wow! This is great! Can I take this home with me?’”

Temperature Monitoring for Surgery Patients is an Important Step for Safe Surgery
Sponsored Content

Even shorter surgeries would require the watchful eye of the OR team for positive outcomes.

Bair Hugger3M®
Temperature monitoring throughout the surgical journey helps keep patients safe.

Temperature monitoring of surgical patients is a very important part of the safe patient journey. As more complex surgeries migrate to ambulatory surgery centers (ASCs) today, the attention paid to thermoregulation during the pre-, intra- and post-operative phases to prevent unintended perioperative hypothermia is the responsibility of the entire team.

Working as a team, the ideal goal for each patient entering the facility for a surgical procedure is to follow standards for warming practices and temperature monitoring. Consistent temperature monitoring and active management are keys to success.

Perioperative hypothermia is defined as any core temperature less than 36.0°C (96.8°F)1,2,3 In fact, unintended perioperative hypothermia is considered a frequent, preventable complication of surgery. Unless preventative measures are taken, it can occur in as many as 90% of surgical patients.4

Normothermia is the body’s ideal thermal state. For a patient entering surgery, their ideal normal core temperature is approximately 37°C (98.6°F).1 Research shows that even mild hypothermia can result in significant negative outcomes. Some of the adverse effects of unintended perioperative hypothermia include wound infection, myocardial ischemia and cardiac disturbances, shivering and thermal discomfort as well as delayed emergence from anesthesia.5

What causes unintended hypothermia and how can it be minimized? The induction of anesthesia is the most significant contributor to unintended perioperative hypothermia in surgical patients.1 Anesthesia causes vasodilation, opening of arterial shunts, allowing the warm blood from the core to flow freely and mix with the colder periphery.1 An average core temperature drop of 1.6°C can occur in the first hour of general anesthesia.1

Monitoring a patient’s temperature as a key vital sign is critical to detect unintended temperature changes and maintain appropriate body temperature of the patient during anesthesia. Using the same temperature measurement modality for a patient's core body temperature throughout the perioperative phases offers an efficient way to monitor the patient’s temperature with consistent results through the pre-op stage, in the OR and then post-operatively.

Accuracy is another critical part of the temperature monitoring process. For patients under regional anesthesia or who are awake, noninvasive devices are typically used, however, these devices mostly estimate core body temperature. In fact, wide variations exist in methods and techniques for measuring patient temperature, which can lead to inaccuracies. Accurate temperature measurement is crucial for providers to be able to actively manage patient normothermia and help avoid the costly complications of unintended hypothermia.

Facilities should supply clinicians with the temperature management systems they need to effectively monitor and warm patients in any type of procedure, under any type of anesthesia, throughout the perioperative journey. Active warming and accurate temperature monitoring throughout the surgical process are important components to aid in a successful surgical outcome and overall patient satisfaction.

References:

1. Guideline for the Prevention of Hypothermia in Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2023

2. Sessler DI. Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737.

3. Sessler DI. Perioperative Heat Balance. Anesth. 2000;92:578-596.

4. Young V, Watson M. Prevention of Perioperative Hypothermia in Plastic Surgery. Aesthetic Surgery Journal. 2006;551-571

5. Sessler DI, Kurz A. Mild Perioperative Hypothermia. Anesthesiology News. October 2008: 17-28.

Note: For more information please go to bairhugger.com.

Eliminating Variability in Temperature Monitoring

Standardizing with a consistent method through the perioperative process reduces incidences of unintended patient hypothermia.

Clinically speaking, maintaining a patient’s perioperative normothermia is less about patient comfort and more about patient safety. When undetected, hypothermia in the perioperative setting can increase the possibility of surgical site infections, cardiac arrythmias, blood loss, altered medication metabolism, pain perception and longer recovery times.

After a number of patients at WellSpan-York (Pa.) Hospital suffered from post-op complications, Clinical Nurse Educator Sarah Bosserman Matulewicz, MSN, RN, CNOR, and Perianesthesia Clinical Nurse Educator Cristina Brooks, MSN, RN, CPAN, decided to closely examine the issue. They uncovered a crucial inconsistency in their warming protocol.

“We were able to identify inconsistent temperature measurement practices being used throughout each phase of surgical care,” says Ms. Brooks. “These various forms of temperature measurements included oral, rectal, temporal-artery, esophageal and pulmonary artery temperatures. Each of these techniques had varying reliability, which created variability and inconsistency in hypothermia identification and treatment.”

The nurses responded by implementing a non-invasive core temperature monitoring (NCTM) system after it was trialed and approved by hospital stakeholders. “In the past, the only options for this method were invasive, which limited its use and availability for less severe surgical procedures,” says Ms. Matulewicz. “Our goal was to implement a consistent and reliable and method of temperature measurement.”

After nursing and anesthesia staff members from all perioperative settings received proper training, the NCTM system was implemented in all phases of surgical patient care. The facility now enjoys more stability with temperature measurement and, most importantly, sees less unintended patient hypothermia. The nurses’ investigation led to further standardization of the facility’s patient warming protocols. Active warming is now employed preoperatively, with patients as well as providers able to control the temperature.

“The continuous evaluation of accurate temperature measurement and effective warming techniques allow us to provide a safe and comfortable place for our surgical patient population,” says Ms. Brooks.

Building Enthusiasm About Patient Warming

Nurses at this hospital are armed with the education and tools needed to lead normothermia compliance efforts in the OR and beyond.

Houston Methodist The Woodlands Hospital knew it had to improve the 56% intraoperative normothermia compliance rate at its 25-OR facility. To tackle the problem, it employed multiple interventions that boosted its rate to nearly 75% over the nine months that followed.

Jennifer A. Rose, BSN, MSML, RN, CNOR, an RNIV in perioperative services at the hospital, decided the surgical teams’ nurses would take the lead. “Warming, fundamentally, is a nurse intervention,” she says. “That’s exciting and empowering.”

The first step was to educate the OR team not only that the problem existed, but that a patient’s temperature should be considered one of their vital signs, and that the solution couldn’t be farmed out to pre- and post-op staff. Ms. Rose and other project leaders obtained buy-in by quoting literature that shows inadvertent perioperative hypothermia’s negative effects on surgical site infections, wound healing, myocardial ischemia events, hospital stays and patient comfort. They also explained that treating related complications of intraoperative normothermia costs about $5,000 on average.

Next, the facility got its data in order. Nurses began taking patients’ temperatures immediately before entering the OR, rather than relying on readings taken immediately when they entered the building fresh from the Texas heat, before they were subjected to multiple pre-op interventions that cooled them.

Inside every OR, Houston Methodist began to warm IV fluids, and acquired inexpensive hotplate-like devices that attach to IV bags. Fluid-warming cabinets were purchased for the core, and active patient warming tools are used. Ms. Rose says the key to these interventions is how easy to implement and staff-friendly they are.

“Direct observation during rounds by the project leader helps to ensure new processes are being followed, support new warming efforts and make suggestions during challenging cases,” adds Ms. Rose. “They can also help us educate in real time. For example, when warmers get restocked, we explain how room-temperature IV fluids would really shock a patient with a normal 98.6° F body temperature.”

Friendly competition also aided the cause. Houston Methodist rounded up numbers from its six sister hospitals with the goal of bettering their normothermia compliance rates. Even patients’ families were involved — the facility asked them to make sure their loved ones plugged their warming devices back in after trips to the bathroom.

“The takeaway for us has been that because this problem never ends, neither does the solution,” says Ms. Rose. “We partner with manufacturers to have their reps come to train staff. We constantly talk about the issue in huddles. We offer the nurses a buffet of options — a tool belt with lots of choices at their fingertips that allows them to customize the appropriate care for their patients.

As Ms. Rose notes, education, communication and collaboration are the timeless keys to success in maintaining patient normothermia throughout the entire perioperative process. OSM

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