A WELCOME PERK Warmed cotton blankets are a preferred means of keeping patients normothermic.

If you don't start actively warming patients until they enter the OR, you're "already behind the 8-ball," says Kim York, BSN, MS, RN, CNOR, CSSM, the director of surgery at Dosher Memorial Hospital in Southport, N.C. She learned this lesson the hard way while working at her last job, as a circulating nurse with a different medical center in North Carolina.

"We were doing a good job of warming patients post-operatively, but by then we were playing catch-up," she says. "We had a number of patients in PACU that were cold. After evaluating what was going on, we found out not enough people [on staff] knew about the dangers of perioperative hypothermia."

The hospital was using forced-air warming blankets intra-operatively as its primary mode of maintaining normothermia, but it wasn't quite enough. Ms. York says more than 90% of the facility's patients were "adequately warm" when they arrived in PACU, but the remaining patients were hypothermic. So she did something about it.

Her "project," as she calls it, was to revamp the hospital's culture. She began with a thorough evaluation of current perioperative processes, followed by educational outreach to all perioperative services personnel and follow-ups to ensure staff compliance. In other words, managing hypothermia earlier into the process became a team mission. The result: normothermia in 100% of patients.

Solving problems
How did they get there? The turnaround started in pre-admissions, where staffers were asked to educate patients about the risks associated with hypothermia and the need for active warming. But, as Ms. York remembers it, "the bulk of the problems" were in pre-op.

In the course of the process review, Ms. York learned that members of the housekeeping staff would turn down the temperatures in each room when they came in to clean at the end of each day, meaning a.m. patients arrived in a cold room — and it stayed cold throughout the day unless patients spoke up.

A new plan was put into action, including the adoption of warming IV fluids and other pre-operative warming methods, such as warmed cloth blankets in pre-op. The hospital also increased the ambient temperature for pre-op holding rooms to 70 degrees, and members of the housecleaning staff were instructed to keep it there.

They opted to inch up ambient OR temperatures as well, to no less than 68 degrees. To make sure surgeons could stay comfortable given the increase, the hospital purchased cooling vests for surgical staff — "They loved them," Ms. York insists — meaning patients and surgeons alike could remain comfortable in the OR.

Doing the math
Improving comfort is one thing, but studies have shown that pre-operative warming produces a number of measureable benefits, too. A study of 141 patients undergoing colorectal surgery shows that patients who were warmed pre-operatively had a decreased incidence of surgical site infections and spent less time in the hospital. The study, which was published in the journal Anesthesiology, also indicates that pre-operative warming is more effective than intra-operative warming in terms of achieving normothermia in PACU.

James H. Philip, ME(E), MD, CCE, might respectfully disagree pre-warming is necessary. Dr. Philip, the director of clinical bioengineering in the department of anesthesiology at Brigham and Women's Hospital in Boston, Mass., sees tremendous value in keeping patients normothermic, but he says intra-operative warming does the trick just fine.

"Patients almost always leave here normothermic," he says, even if the OR has a low ambient temperature. "If they're not, I usually ask that they check twice to make sure the reading is accurate."

He brings up a recent case — a robot-assisted laparoscopic myomectomy performed in an OR known for having a low ambient temperature — that took 5 hours, during which the patient was warmed intra-operatively. The patient's temperature upon arriving at PACU: 98.6 degrees.

Dr. Philip, who has a background in electrical engineering, became interested in active patient warming after taking a closer look at "the math." He can offer a complex equation to illustrate how forced hot air counteracts the effects of a surgical environment the human body should consider hostile, but the bottom line, he says, "is that external heating is very effective at patient warming and maintenance of temperature."

WARMING TRENDS
Shaking Up How Patients Warm Up

PRE-GAMING Pre-operative warming can result in increased patient comfort, quicker recovery times and a reduced risk of infection.

Whether you choose to warm patients pre-operatively, intra-operatively or in PACU — or all of the above — chances are the forced-air warming blanket is your preferred means of keeping patients normothermic. It's the method of choice at Logan (Utah) Regional Hospital, too, but the hospital is open to the idea of change. Kimberly Klinkowski, RN, MSN, CNOR, the hospital's director of surgical services, says they might consider alternatives in light of ongoing though unproven allegations that forced air can contribute to surgical site infections, particularly in orthopedic cases.

"Some of the orthopedic surgeons keep bringing it up," she says. "Our infection rate is below 1%, so we haven't had problems with infections. If we did, we'd definitely have a reason to jump off the curb. I haven't been pushed yet, but I'm being pushed in that direction."

Susan Alexander, RN, MSN, CPAN, recently put forced air under the microscope for a completely different reason: the cost of disposables. Even though the cost of a warming blanket was considered quite manageable, given the benefits, her staff found a way to save a few dollars anyway — $7,500 per year, to be precise.

"We looked at a different vendor and negotiated with them that if we buy X amount of blankets we would get the blowers for free," says Ms. Alexander, the director of nursing for Reading (Pa.) Hospital SurgiCenter at Spring Ridge. "We were buying the same volume and had the same end result, only at a lower price."

— Bill Donahue

Less pain, faster healing
Logan (Utah) Regional Hospital uses forced-air warming blankets pre-operatively, but it's "not a high-use item," says Kimberly Klinkowski, RN, MSN, CNOR, the hospital's director of surgical services. "It gets to be minus-23 here sometimes, so people want to be warm." She thinks it would be a different story if the hospital were in balmy Florida as opposed to the frigid Mountain States.

"For the most part, we don't do big procedures where pre-warming would be required," Ms. Klinkowski says. "If cases go longer than an hour, we will put warming devices on the patient in the OR. If it's under an hour, it's negotiable, depending on the case."

In other words, patients are warmed reliably only in PACU, based on the patient's temperature. Ms. Klinkowski does, however, consider forced-air warming a tidy way to limit expenses. Each forced-air warming blanket costs roughly $10, she says, which she considers "pretty cheap" compared to ongoing costs of readily available alternatives.

Take warmed cotton blankets, for example. A study in the Journal of PeriAnesthesia Nursing shows that using forced-air warmers can save $1,235 per year over the warmed blankets, which bear the weight of additional ongoing costs, including laundry and delivery.

"There's the recovery benefit, too," says Ms. Klinkowski, adding that it can be difficult to quantify. "When you're not shaking, it promotes healing. There's less pain and you heal faster when the body temperature is maintained. And that's a good thing for everybody." OSM