Normothermia Is the New Normal

Warm blankets and warming devices are easy-to-apply interventions that prevent a patient's temperature from dipping below 36 ?C before, during and after surgery. So why is inadvertent perioperative hypothermia still an issue? Spectrum Healthcare Partners, a multispecialty physician-owned medical group based in Southport, Maine, had been documenting how many patients are normothermic when they come out of the OR at the group's former orthopedic surgery centers.

"We'd been measuring that rate for a long time within our anesthesia group," says Miriam Dowling-Schmitt, MS, RN, CPHQ, CPPS, director of quality at Spectrum. "Although a majority of our patients were emerging from surgery normothermic, we noticed some opportunities for improvement."

The ultimate push for change came at the start of 2018, when CMS began requiring the documentation of a normothermic temperature reading within 15 minutes of a patient's arrival in the PACU as a quality metric of the Ambulatory Surgery Center Quality Reporting (ASCQR) Program. Spectrum seized the opportunity to review their internal data to make sure the patient warming practices at the surgery centers met the ASCQR's national benchmark of 95% or more of patients being normothermic in recovery.

Ms. Dowling-Schmitt launched a quality improvement project based on methodology used in Lean Six Sigma: Define, Measure, Analyze, Improve, Control (DMAIC).

• Define and measure. They began by identifying the problem and assessing why it was happening. Ms. Dowling-Schmitt's team reviewed the records of patients who did not meet the normothermic metric and discovered 87.1% of patients who underwent procedures lasting 60 minutes or longer under general or neuraxial anesthesia were normothermic in the PACU — below the 95% threshold.
• Analyze. After the team determined the extent of the issue, they drilled down to its root causes. Ms. Dowling-Schmitt says they reviewed 674 patient records to determine how staff were recording patient temperatures and documenting the readings. Were patients colder than they should have been in the PACU because their core temperatures were truly low or because temperatures were documented incorrectly? "We had to understand the underlying causes of the issue to identify what improvements needed to be made," says Ms. Dowling-Schmitt.

 

She discovered the center's flow sheet had only a single space for staff to record a patient's temperature. Nurses could jot down a patient's initial temperature reading, but had no place to note remeasurements after warming interventions were applied.

"We also realized the forehead monitoring strips staff used measured temperatures in two-degree increments," says Ms. Dowling-Schmitt. "They were useful for recognizing large temperature swings, which could indicate the onset of malignant hyperthermia, but they didn't provide the accuracy needed for a quality reporting metric."

The quality improvement project revealed staff used both Fahrenheit and Celsius readings to record and document patients' temperatures. The lack of standardization created confusion among members of the care team, who didn't always know how to convert one temperature scale to the other and therefore weren't clear on when to apply active warming methods to hypothermic patients.

Additionally, the surgery center did not have a temperature monitoring and management protocol in place to identify and treat patients who arrived for surgery in a hypothermic state or for high-risk patients — such as frail, older individuals without significant body mass — who needed to be prewarmed before surgery.

Finally, says Ms. Dowling-Schmitt, staff members who felt hot while working in the OR didn't hesitate to turn down the temperature in the room without considering how the cooler ambient environment would impact efforts to keep patients normothermic.

• Improve. This is the step where real change happens. The surgery center invested in a large-capacity blanket and fluid warmer for the pre-op area. Having immediate access to the unit means pre-op nurses can cover patients with warmed blankets while they're waiting for surgery. Nurses can also apply active warming measures to patients who arrive with initial temperature readings below 36 ?C, are at high risk of becoming hypothermic and are scheduled to undergo procedures expected to last 60 minutes or longer.

Prewarming is an important way to ensure patients remain normothermic throughout their stay. "General anesthesia stops the body's normal thermoregulatory response that's needed to counteract low temperatures," says Irl Rosner, MD, an anesthesiologist and medical director of surgery centers at Spectrum. "It's important to maintain a patient's normothermic temperature when they enter the OR."

Shivering increases oxygen consumption by 400%, according to Dr. Rosner, who says that's a significant risk factor for patients with a history of cardiac issues.

The facility replaced its temperature monitoring strips with temporal scanning thermometers and clinical educators conducted in-services to train staff on the proper use of the devices. Nurses record and document temperatures when patients arrive in pre-op, at regular intervals during surgery and upon their arrival in PACU. All temperatures are taken and recorded in Celsius to avoid confusion. Temperatures are retaken after a warming intervention is applied if the initial measurement was outside the normal range — 36 ?C to 38 ?C — and the reading is documented on a new line added to the flow sheet.

The new policy ensures that the temperature taken within the first 15 minutes of a patient's arrival in the PACU was properly documented. It also helps to ensure staff actively warm patients who are hypothermic, check their temperatures again and document a normothermic reading. The goal is to prepare patients for surgery in a warm environment in order to prevent hypothermia.

To ensure members of the surgical team don't turn down the temperature in the ORs, one staff member now holds the key to a small plastic lockbox that covers the thermostat. The staffer is the only one who can adjust the temperature upon request, but ensures the room temperature always remains within the AORN-recommended 68 ?F to 73 ?F. "We had conducted a lot of staff education to make sure they understand the patient's needs come before their own," says Ms. Dowling-Schmitt.

• Control. The staff at the ASC remain vigilant in efforts to maintain normothermic readings in patients. They continue to monitor outcomes on a monthly basis, and respond immediately if they see a cooling trend in recorded temperatures.

Ms. Dowling-Schmitt says it's important to focus on the importance of consistent and accurate charting. "It provides data for quality metrics, and nurses need to document the wonderful clinical care they provide," says Ms. Dowling-Schmitt. "That documentation needs to reflect everything they do to improve outcomes. If patients came out of the OR hypothermic, and nurses took steps to ensure they were normothermic before discharge, those steps must be recorded.

"What really surprised me is 'if it wasn't documented, it wasn't done' still needs to be reinforced," she continues. "I think some nurses still don't fully understand that concept."