Watching smiling, satisfied patients walk out of your facility after surgery is reason enough to implement a patient-warming program. But that shouldn't be the motivating factor for maintaining normothermia from pre-op to PACU. CMS's SCIP Infection 10 measure requires that you use forced-air warming as part of your warming protocols, and many clinical studies have linked hypothermia to increased surgical site infection rates. Let's review common patient-warming techniques and explore how they can augment your infection control efforts.

• Forced-air warming. This is the gold standard in hypothermia prevention, according to more than 100 research studies. Forced-air warming is typically thought of as being effective only in the operating room, but research demonstrates that warming patients preoperatively helps prevent intraoperative hypothermia associated with heat redistribution caused by general anesthesia.

Forced-air warming gowns are easy to apply and cost effective because 1 gown can be used throughout the perioperative continuum. The custom gowns used with forced-air warming units are available in various shapes and sizes — upper- and lower-body designs, for example — that allow easy access to the surgical site while still working to keep patients warm.

One word of caution: Forced-air warming should never be delivered with the hose unattached to the warming gown (yes, it still happens). Placing the warming unit's hose underneath the patient's covers is a dangerous practice that can easily cause first-degree burns.

• Fluid warmers. Clinical evidence has shown that warmed IV and irrigation fluids, circulating water garments, circulating water mattresses, radiant heat and gel pads used alone or in combination with forced-air warming may also help reduce intraoperative hypothermia.
• Warmed blankets. Patients usually exhale with pleasure as a warm blanket is applied. It's the "ahhh" factor. That boon to patient satisfaction is somewhat offset by the reality that warmed blankets lose their heat after about 10 minutes. Freshly warmed blankets must therefore be applied under cooled blankets, which can be a chilling experience for the patient.

You must also consider the costs associated with the use of cotton blankets. We're in the process of a cost-reduction project centered on limiting warmed blanket usage. Our materials services department estimates that each cotton blanket costs $1.98 based on the average purchase price, laundering and drying fees, replacement costs, and the increased labor time needed to gather warmed blankets and apply them to the patient. A patient typically needs 10 to 12 warmed cotton blankets during the perioperative stay, for a total cost between $12 and $14 — or about the average price of a forced-air warming gown. Since the warming unit is provided free of charge by the manufacturer — we're on the hook for the cost of the disposable gowns — you'll find that adding a forced-air warming unit to your patient warming arsenal will be at least budget neutral. In fact, our facility saved $14,000 in the months following the addition of our units.

Slow to warm up?
Several research studies have demonstrated a link between hypothermia and SSIs. These studies have also shown that forced-air warming is the most effective method for maintaining normothermia. Many of these studies were conducted in the mid-1990s, which shows the lag between evidence-based patient-warming research and its implementation in everyday practice. Some healthcare practitioners are reluctant to use forced-air warming because they think it blows bacteria onto the sterile field, but there is no empirical data to back this belief.

Organize a multidisciplinary team within your facility to develop a hypothermia prevention protocol based on evidence-based practices. Use professional organizations' standards — from the American Society of PeriAnesthesia Nurses or AORN, for example — when developing those evidence-based protocols.

More importantly, engage your staff in deciding how to best warm your patients. Educate them about the adverse effects of hypothermia and how forced-air warming is the most effective way to prevent the complication. It is imperative to educate staff about the importance of quality measures, particularly SCIP Infection 10 (see "Warming By the Book: What SCIP Infection 10 Tells Us"), and how their nursing care can have a positive effect on quality outcomes.

Are your patients normothermic in pre-op? If not, initiate forced-air warming there and make sure you monitor patients' temperatures every 30 minutes. Always keep forced-air warming blankets on patients, even when they go from the OR to PACU. Check with the anesthesia provider when patients are in recovery; don't remove a forced-air warming blanket that's keeping patients normothermic just to replace it with cotton blankets that can lose heat in as quickly as 10 minutes.

More than hot air
The effects of hypothermia are widespread. It can result in decreased patient satisfaction from feeling cold, which can be a lifelong memory. Hypothermic patients may also spend more time in PACU while their temperatures return to acceptable levels, grinding your surgical efficiencies to a halt.

Too often quality improvement data stall on the desks of surgical administrators. Facility leaders need to do a better job of filtering the reasons behind their directives to the staff who implement them on a daily basis. When it comes to patient warming, help staff to understand that the practice reduces SSIs, adds to patient comfort and, yes, will now be linked to pay-for-performance measures and therefore higher reimbursements. We hate to think of health care as a bottom-line business, but in reality, sometimes it is.