Warming is not just for the shivering patient. Many surgical facility managers now consider patient warming essential for maintaining normothermia from pre- to post-op, and they routinely use warmed blankets, patient warming devices, warmed IV fluids and the OR thermostat to achieve this goal. Their rationale goes beyond hypothermia prevention to one of patient satisfaction and economics.
"It's important to the overall well-being of the patient to keep body temperature within an acceptable range," says Wichita (Kansas) Clinic Day Surgery manager Janelle Oliver, RN, BSN, CNOR, CAN-BC. "It also aids in fast-tracking."
We're seeing a warming trend
Here are some key findings from Outpatient Surgery's survey of 150 managers of hospital ORs and ASCs:
- When you warm. Ninety-nine percent of survey responders (n=148) warm patients at least sometimes, and 55 percent (n=83) warm nearly every surgical patient routinely.
- How you warm. Eighty-eight percent use a forced-air warming system, 86 percent use pre-warmed blankets, and fewer use other warming methods - including warming mattresses or pads (16 percent), warming gowns (7 percent) and body wraps (3 percent).
Perhaps the most striking trend from our survey is that practitioners are integrating warming into the entire patient stay. That is, our panelists typically don't wait for the patient to express discomfort or show signs of hypothermia before taking warming measures. Instead, they monitor temperatures, pre-warm patients before surgery, and work to maintain patients' core temperatures intra- and post-operatively.
In our survey, 57 percent of facility managers typically warm patients pre-operatively, 97 percent warm them intra-operatively and 82 percent warm patients post-operatively.
Says one staff nurse from a northeastern hospital who recently conducted a chart review of patient temperatures: "Only 10 percent of patients met the universal guideline of maintaining a minimal temperature of 36'C (96.8'F) on entry to PACU, and 40 percent did not even reach this pre-operatively." Since championing the importance of normothermia and introducing warming devices pre-, intra- and post-operatively, 90 percent of patients there now maintain normothermia, she says.
For this staff nurse, as for many of our panelists, warming measures go beyond traditional warming devices to the use of warmed fluids and the OR thermostat. Overall, our survey shows that 12 percent of facility managers use warmed IV fluids, and many are also altering the ambient OR temperature.
"Our anesthesia providers were behind our change in OR ambient temperatures," notes Roxie Bailey, BSN, assistant administrator of surgical services for Smith Northview Hospital in Valdosta, Ga., where she recently increased OR temperatures from 68'F to 70'F because of research showing that warming can reduce certain complications.
Adds another nurse-manager: "Our room temperature starts out at 63'F. I warm it up to at least 68' F so patients won't feel a blast of cold air when first wheeled into the OR. This keeps them from shivering and losing body heat at the beginning. I will also turn the temperature back up at the end of the case, if we turn it down intra-operatively, for the same reason."
What's your OR thermostat set at?
The median ambient OR temperature of the facilities we surveyed (n=134) is 68'F (range: 60'F to 72'F). The American Institute of Architects Academy of Architecture recommends maintaining ambient OR temperatures between 68'F to 73'F. AORN and the Centers for Disease Control and Prevention (CDC) support this recommendation.
The clinical rationale for warming in the outpatient setting is prevention of hypothermia and its well-documented complications - including shivering, altered drug metabolism, coagulopathy, cardiac events, impaired wound healing and an increased susceptibility to surgical site infections. Of those 44 percent of facility managers who warm patients on a case-by-case basis, most rely on surgical duration, the procedure, patient age, ambient OR temperature and pre-existing medical conditions as determining factors - each can warrant patient warming independently.
Procedures that require lots of skin exposure (such as cosmetic and gynecological procedures) or significant fluid exchange (such as long laparoscopic and orthopedic procedures), for example, are among the most likely procedures to merit warming even when they are relatively short. "Some patients are cold even during short procedures when they are unclothed, like lipocontouring," says Richard Mattison, MD, with the Tuxedo Surgery Center in Atlanta. "Patients undergoing longer procedures who are covered are rarely cold."
The total rationale for warming, however, goes well beyond a clinical one. Our panelists' comments support research showing that warming can improve efficiency. In one study of 150 patients undergoing elective major abdominal surgery, patients who received warming to maintain normothermia had core temperatures approximately 2'C higher than patients who received warming for hypothermia only. Hypothermic patients required about 40 more minutes of recovery time to achieve fitness for discharge when normothermia was not a criterion and 90 minutes more recovery time when normothermia was a criterion. [Anesthesiology. 1997 Dec;87(6):1318.]
Facility managers consistently report PACU times shorten 30 minutes to one hour when patients stay normothermic.
"Occasionally, patient PACU time has increased due to the need to normalize core temperature that has dropped because we did not warm the patient," says Jo-Ann Pinel, RN, CPN(C), director of nursing with Palmetto Surgery Center in Columbia, S.C. "If the patient has been kept normothermic throughout the perioperative period, this does not happen." Adds Beverly Kirchner, BSN, president/CEO of Highland Village, Texas-based Genesee Associates, Inc., where practitioners warm patients undergoing 90-minute-plus abdominal procedures (including laparoscopic cholecystectomies and gynecologic laparoscopies) from start to finish using pre-warmed cotton blankets and forced-air warming: "Our PACU stay from these larger cases decreased by 30 minutes in most instances." One plastic surgeon reports the most significant PACU time savings of all: Since he began focusing on achieving normothermia throughout the patient stay, PACU times shortened by one hour for some patients undergoing long liposuction cases. Previously, he said, patients would commonly enter the PACU with temperatures of 95'F.
Above all, our panelists put patient comfort and satisfaction at the top of their lists of reasons for routine patient warming. Many facility managers say patients make a point to tell them how much they appreciate their soothing warm blankets, and several ophthalmic facilities say they offer warm blankets to every cataract patient for this reason alone. Writes one ophthalmic surgeon from a western eye clinic: "Patients are much happier when we give them warm blankets. They remain in street clothes for the procedures, and the blanket also allows for coverage of the clothes with a clean surface." Elizabeth Hanley, RN, nurse-manager with South Jersey Eye Physicians in Moorestown, N.J., adds that the warmed blankets also help dilate peripheral veins and facilitate IV insertion.
In all, the comments of Nanci Commaille, RN, with the Fairfield (Conn.) Surgery Center, mirror that of most panelists we surveyed, no matter what type of surgical facility or hospital-based OR they manage: "Patients mention the warming ' when they return patient surveys, and returning patients often say they are looking forward to the warm blanket they remember."
Preventive Pre-Warming Catches On
Research suggests warming patients before surgery can prevent intraop hypothermia, and with 57 percent of facility managers warming patients pre-operatively, our survey shows this practice is catching on. Here are some findings about pre-warming from research literature:
' Patients who receive one hour of pre-op skin-surface warming cool at half the rate of non-pre-warmed patients, slowing the development of intra-op hypothermia. When peripheral tissue temperatures remain near or equal to core temperature, hypothermia is less likely because there is no need for the body to redistribute heat away from the core to the periphery. This is the general finding of a study of 16 ASA status I and II adult patients who underwent laparoscopic cholecystectomy under general anesthesia. [J Clin Anesth. 1995 Aug;7(5):384-8.]
' Thirty minutes of pre-warming before clean surgery may reduce infections. In a study of 421 patients who underwent breast, varicose vein or hernia surgery, pre-warmed patients had a 5 percent wound infection rate after six weeks compared with 14 percent of non-warmed patients. [Lancet. 2001 Sep 15;358(9285):876-80.]
Worse than pain?
The personal experience of Kimberley Caltagirone, RN, nurse-manager with the Foster Center for Cosmetic Surgery in Toms River, N.J., illustrates the potential impact of warming on patient satisfaction. "When we perform tumescent liposuction, the patient is generally wet and partially exposed during the procedure. We always use a warming device during this procedure. One of the main reasons is that I was a patient who experienced tumescent liposuction in the past and I remember the only thing that caused me any discomfort during my procedure was how cold I was," she says. "Being cold is sometimes worse than being in pain. I was glad to be able to experience this so I can know what my patients are feeling and what I can do to make them more comfortable."
Clearly, managers are aware that routine warming can provide a number of benefits - from safety to efficiency to patient satisfaction. Says S. Lynn Brian, RN, risk manager with the Surgery Center in Middleburg Heights, Ohio: "As patient advocates, we are committed to providing the best possible care to our patients ' Small acts of kindness and caring are important. How many times has a patient asked 'Why is it so cold in the ORs?' If we provide warmth and a comfortable environment, it will only add to the patient's comfort and calmness."