START TO FINISH Warming the patient for every leg of the perioperative journey, from the pre-op bay to the recovery room, helps to maintain normothermia.

It's not like ambulatory surgical centers needed another incentive to warm patients, but now they have one anyway in the form of a quality measure they must begin reporting in 2018: "ASC-13: Normothermia Outcome."

Starting next year, ASCs must measure the percentage of patients having surgery under general or neuraxial anesthesia for 60 minutes or longer who are normothermic — a temperature of 35.5 ? C (95.9 ? F) or higher — within 15 minutes of arrival in the post-anesthesia care unit.

Validating hypothermia prevention, or at least measuring your efforts to do so, has been a part of hospital federal quality reporting requirements for many years, but is new to the ASC program.

"ASC-13: Normothermia Outcome" is among the new measures Medicare has added to the ASC Quality Reporting Program (ASCQRP) for 2018. Data collection begins in 2018, but the measure won't impact reimbursement until 2020. A few points worth noting:

• The measure applies only to cases involving general or neuraxial anesthesia, which impair the body's ability to control thermoregulation. Patients who are under either monitored anesthesia care or treated with nerve blocks are exempt.
• The measure doesn't include cases lasting less than an hour, even those that use general or neuraxial anesthesia.
• You must submit data directly to CMS via a web-based tool.

"There's a lot of latitude in this measure," says anesthesiologist David Shapiro, MD, an ASC Quality Collaboration board member. "For example, you may not be reporting on a patient who is in for a 55-minute surgery, but you still need to make sure that patient is normothermic, for so many physiologic reasons. This measure is really about bringing more attention to the issue. Now is the time to make sure you have all the processes in place, and that you have strategized with your entire facility about how to collect the data needed to meet the specs of the measure."

Eventually, the metric will likely be tied to the overall patient experience scores, says Dr. Shapiro. For now, however, it's about awareness and making sure facilities are focused on patient safety.

"Like all the measures in the ASCQRP, you're being paid for reporting rather than for performance," he says. "It doesn't matter what grade you get as long as you take the test."

But he sees benefits as well. In addition to increasing awareness of the importance of keeping patients warm, the measure will institutionalize and popularize the assessments of patients when they come out of the OR.

ASCs will submit a simple equation — a numerator over a denominator — as part of their regular ASCQRP reporting. You divide the number of patients who arrive in PACU normothermic (numerator) by the total patient population as defined by the measure (denominator).

The right way to warm
Is there a "right" way to warm patients? The evidence is clear, says Victoria M. Steelman, PhD, RN, CNOR, FAAN, an associate professor with the University of Iowa in Iowa City: Active warming, such as forced-air warming and conductive blankets, heat the skin and peripheral tissue to prevent a drop in core body temperature, as opposed to passive-warming techniques, which are largely considered ineffective against hypothermia.

Passive warming, such as warmed cotton blankets, can also be a costlier option. Beverly Kirchner, RN, BSN, CNOR, CASC, chief nursing officer of Surgery Direct, an ASC development firm based in Dallas, Texas, says it's not uncommon for nurses and techs to "pile on 5 or 6 blankets" — each one bearing a reprocessing cost of about $5 — trying to keep the patient's core temperature from dropping. In comparison, some vendors of forced-air warming systems provide the warming units at no cost on the condition that the facility agrees to purchase a set number of the accompanying disposables from them.

For virtually every case, Ms. Kirchner advocates the use of an upper-body or lower-body forced-air warming blanket. "We don't have anything to lose, and in some instances patients have a lot to gain," she says. "You're keeping patients comfortable versus having them shiver and being exposed to a situation that could cause a post-op problem."

Besides the mode of warming, there's also the critical issue of timing, as in when you start the warming process. Some facilities do so only after surgeries run a certain length — longer than an hour, say — but waiting until anesthesia has been administered may be too late (see "Busting 4 Myths About Normothermia" above). Studies suggest pre-warming the patient 15 to 60 minutes before surgery, and continuing through to PACU, can effectively prevent redistribution hypothermia.

"To me, warming is not just for a surgery that's greater than an hour," adds Ms. Kirchner. "Whether a surgery lasts 5 minutes or 5 hours, we need to make sure every patient has every opportunity to not get an infection."

Besides, warming a patient for the duration of the perioperative journey makes more sense from a workflow perspective, says Dr. Steelman. A forced-air warming blanket or conductive blanket can be more easily implemented in pre-op, as long as close consideration is given to the process of care, including the anticipated surgical position.

As 2018 approaches, your facility should have all the tools and techniques in place to monitor a patient's core temperature and to document how and when you use active-warming measures.

"The focus should always be on high-quality patient care and how we can improve on that, not on meeting a certain threshold," says Dr. Steelman. OSM