October 15, 2020

It's not just about creating a program for active patient warming. It's also about altering long-held perioperative mindsets.

When Anita Volpe, DNP, APRN, began working at New York-Presbyterian Queens Hospital in Flushing, N.Y., prewarming patients was simply not done. That alarmed her, because she had been tasked with reducing the facility's rate of surgical site infections (SSIs) among colorectal surgery patients, which was a negative outlier compared with other facilities in the state. When she asked OR leaders why they weren't prewarming patients, they essentially told her that patients were warm enough.

That initial response hit Dr. Volpe hard. As the director of surgical outcomes, research and education for the hospital's department of surgery, she was tasked both with properly introducing new warming methods and fighting a cultural battle.

Dr. Volpe offers compelling statistics in support of patient warming: Research shows 70% of surgical patients develop inadvertent perioperative hypothermia (IPH); patients who lose just one degree of body heat are at increased risk of a morbid event; and IPH is associated with an increased incidence of post-op infection. "When it comes to maintaining normothermia, there's simply no excuse for not actively prewarming your patients," she says.

Dr. Volpe collaborated with nursing, surgical and anesthesia leaders to develop a colon bundle for the facility, and active patient warming was a major new component. To ensure staff followed standardized warming protocols, she explicitly laid out the many risk factors of IPH in the policy, and instructed staff to pay extra attention to patients who exhibit them during pre-op screening. Pediatric and geriatric patients are most at risk, she says, with other susceptible patient populations including individuals with BMIs of 17 or below, and those on psychotropics, antidepressants or thyroid supplements. Procedure type and anesthesia technique also play a role.

The policy calls for continued active warming when patients enter the OR. Depending on the situation, staff may also need to increase ambient room temperature or use warmed irrigation solutions. The policy requires continued assessment and monitoring in the PACU to make sure patients' body temperatures remain at or above 36°C for their entire stay.

Dr. Volpe also enforced a single temperature monitoring method, which meant standardizing on either oral or axillary temperature readings. Sometimes both were being performed on the same patient. "These methods simply aren't equitable, and an inconsistent method of temperature-taking could impact the effectiveness of your warming practices," she says. "Pick one and stick with it."

In Dr. Volpe's view, active warming is the only effective method of maintaining normothermia. Her facility's guideline, for example, requires active prewarming for a minimum of 30 minutes for patients scheduled to undergo procedures lasting 30 minutes or more.

"Despite active warming's clear benefits, plenty of surgical facilities still give patients a warmed blanket in pre-op and consider that acceptable," she says. "Cotton blankets might make patients feel warm and comfortable, but research shows the heat they give off lasts for only about 10 minutes and does not impact core body temperature."

Dr. Volpe also notes this passive warming method increases linen costs and inventory, and that staff must dedicate time to loading blanket warming units and reapplying blankets in pre-op. "That's a lot of inefficiency for no gain in clinical outcomes," she says.

Ultimately, says Dr. Volpe, active warming can reduce SSI costs and improve outcomes. "To gain buy-in, consider that you'll be saving money on postoperative morbidity," she says. "Warm patients wake up quicker because they metabolize anesthetics at an increased rate. They're able to fight off infection because their tissue oxygenation levels are higher. They heal better and they're more comfortable."

Today, Dr. Volpe proudly notes her hospital is a positive outlier, with SSI rates well below the state's average. Patient warming was a big part of that reversal. "Your ultimate responsibility is to ensure patients achieve the best possible outcomes," she says. "If you don't have a standardized patient warming protocol in place that includes active prewarming, that responsibility isn't being met."

Researchers says patient warming is an inexpensive and easily implementable intervention.

If you haven't yet fully embraced patient warming technologies and methodologies, you might not be caring for your patients as well as you could be. A systematic review and meta-analysis of nine studies and 3,627 patients published this year examined the efficacy of perioperative warming interventions on rates of surgical site infection (SSI). The study focused specifically on the occurrence of SSIs after procedures, but also examined rehabilitative length of stay, attributable SSI-related mortality and incidence of readmittance.

Authors of the study reported a "significantly reduced risk ratio" for SSI in patients who received warming, along with "limited further data" supporting active warming over passive warming. They found lengths of post-op stays and wound healing scores demonstrated greater outcomes for surgical patients who received perioperative warming, and determined that the introduction of warming interventions consistently correlated with reduced patient-reported pain experiences and downstream care expenditures.

Overall, the researchers found a statistically significant correlation between perioperative warming interventions and SSI prevention. As a result, they said their findings strongly support the recommendation of standardized perioperative warming implementation. They urged continued investigation into comparing the relative efficacy of active and passive methodologies through studies across more diverse and substantial patient population sizes.

The authors noted that active warming requires more buy-in, awareness and monitoring from perioperative staff than passive warming techniques or no warming at all. Ultimately, they said surgical staffs should warm your patients. As a largely inexpensive and easily implementable measure, perioperative warming should be routinely used across surgical procedures with moderate-to-strong strength of recommendation in the absence of contradictory clinical findings, they wrote.

Proper temperature management, skin and nasal decolonization play important roles in safety and effectiveness in the OR

Patient safety – as well as offering the highest level of comfort possible for each patient – continues to drive the evolution of what constitutes efficient and effective surgeries in today's environment. Surgical teams are focused on delivering the best care for every patient and every procedure and in every situation.

While the goal has always been for patients to move through surgery safely and begin the road to recovery without complications, the current pandemic era has made clinicians look even more closely at current processes.

Today's focus is on developing additional steps that may help to reduce the risk of complications and, in turn, reduce readmissions as much as possible. Of course, there are already methods in place to reduce the risk of complications by following evidence-based practices, applying consistent protocols, and defining what constitutes a high-risk patient and/or procedure today.

"We are in an environment where we have always worked to reduce risk," says Kim Prinsen, RN, MSN, clinical applications specialist for 3M Medical Solutions. "There are additional protocols we can follow for all patients, like patient temperature management and skin and nasal decolonization, that can further reduce risk." In fact, these protocols clearly play important roles in the pre-op and patient preparation and lead to successful outcomes.

In the area of temperature management, for example, it is highly important to maintain the patients' core temperature before, during and after surgery. Even a minor drop in core body temperature can result in unintended hypothermia. This is a common, yet preventable complication associated with an increased risk of surgical site infection (SSI)1,2, longer length of a potential hospital stay3 as well as other costly, potentially deadly consequences.

Another area of focus is skin and nasal decolonization, which contributes to the overall patient experience. A recent article by Drs. Engelman and Arora (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7153524/) recommends routine universal decontamination, rather than nasal swabbing and screening urgent and emergent surgical patients for S. aureus to reduce the risk of exposure to healthcare workers posed by this practice. 3M^™ Skin and Nasal Antiseptic is a simple, one-time application that reduces nasal bacteria, including S. aureus by 99.5%, in one hour and maintains this reduction for at least 12 hours. This recommendation to address staff safety as well as patient safety comes in addition to the CDC's recommendations for nasal decolonization, at a minimum, for high risk surgical procedures.

The numbers don't lie: Cost savings add up and outcomes improve.

In 2017, a staggering 70% of Parkland Hospital's procedures included a hypothermic incident. The Dallas institution wanted to determine if prewarming patients helps keep them normothermic during and after surgery, so it conducted a small study over a four-week period. It prewarmed patients for 30 minutes in cotton blankets warmed to 130°F. In the OR, forced-air warming, warmed IV fluids and warmed irrigation fluid were used. Finally, warmed blankets were draped on patients during transport to the PACU.

Parkland documented patients' temperatures in pre-op, when they entered the OR and the PACU, and 30 minutes after arrival in the recovery unit. Of the 63 patients involved in the study, 20% were hypothermic in pre-op, 32% in the OR, 41% in the PACU and 7% after 30 minutes in recovery. These percentages were all well below 70%, the national average of inadvertent perioperative hypothermia (IPH) in 2018.

"We would have loved to use active warming measures in pre-op, but our budget couldn't handle the investment," says Justin Buchert, MSN, MEd, MS, RN, a quality specialist for surgical and trauma services at Parkland. "We instead opted for the warmed blankets because our hospital already owned two refrigerator-sized warming units, and they were at our disposal."

Parkland's literature review revealed that the average cost of an IPH event is $7,000. Besides that, the hospital determined patients would have shorter lengths of stay due to patient warming, which further cut costs. Parkland ultimately identified $2.35 million in potential savings from the study.

"Our study proved warming patients throughout the entire surgical process ultimately pays off big," says Mr. Buchert, who adds that a secondary benefit to maintaining normothermia is a reduction in patients' stress levels.

Potential multimillion-dollar savings weren't enough to move the needle at Parkland, however. "Considering our study's relatively low cost, you'd expect the hospital's stakeholders would have been all in on enhancing our patient warming protocols. They weren't," says Mr. Buchert. "Changing mindsets is hard. Most OR staff members are Type A personalities. We have our way of doing things, and change becomes personal. We understood getting the results we needed would involve changing mindsets because it involved changing routines." In addition, those changes to the routine would need constant, consistent reinforcement.

Interestingly, to foster buy-in, the rollout of the warming protocol wasn't made to the entire staff at once. "Our approach was one on one," says Mr. Buchert. "If I talked to a nurse, the message was: This warming protocol is directly improving patient care. It is a level higher than what we're doing now." He also reminded each staffer that the warming protocol was evidence-based, and that patient warming had been approved by numerous organizations and the Joint Commission.

"If you're considering a prewarming program that will require multi-level buy-in, tailor your approach to each stakeholder's role," advises Mr. Buchert. "Your surgeons need to be approached differently than OR staff. If we spoke to physicians, the message was fact-filled: Patients can go home earlier, there will be a lower chance of surgical site infections and you will reduce recovery times, which could ultimately allow you to do more cases."

A recent online poll revealed the many benefits of maintaining normothermia.

When Outpatient Surgery recently polled its readers about patient warming, a majority of the 420 respondents (63%) said they "always" warm patients, while just 3% said they never do, indicating widespread adoption of warming protocols in surgical facilities. As far as the devices these facilities use for warming, over 80% of respondents reported they use both active forced-air warming and warmed blankets, depending on the situation. In addition, a majority of respondents said they warm the patient throughout the entire perioperative episode.

We also asked respondents about how patient warming has specifically changed outcomes, and received a wealth of insight. Increased patient satisfaction and shorter PACU stays were the most recurrent themes, but respondents also mentioned other benefits: less medication given, lower SSI rates, calmer and less anxious patients, decreased post-op shivering, quicker discharges and overall better outcomes. Some facilities have been warming patients for years or even decades; others were in the process of trialing warming techniques. Some facilities have measured specific improvements; others rely on positive anecdotal experiences to tout the method.

Here's a sampling of what readers told us:

• "Patients respond more quickly, spend less time in PACU and are discharged from the facility comfortably." – Loren R. Kennett, RN, BS, MBA, director of nursing, Zion Eye Institute and Surgery Center in St. George, Utah.
• "Patients are more comfortable, are able to fall asleep easier, and have less pain when they are warm." – Karen Hilliard, RN, department director of operating room, Washington County Regional Medical Center in Sandersville, Ga.
• "Helping patients keep warm and comfortable lessens anxiety and aids in pain management." – Evalee Malespini, RN, surgical services manager, Midvalley Ambulatory Surgery Center in Basalt, Colo.
• "Patients are more comfortable in PACU when forced-air warming and warm blankets are utilized. They awaken and are ready for discharge sooner when warmed." – Pamela Borello, BS, RN, CNOR, CSSM, Michigan Cosmetic Surgery Center in West Bloomfield, Mich.
• "Patients are more satisfied when they are warm and comfortable, especially when they feel so vulnerable," – Sue Tachon, RN, BSN, nurse administrator, Elite Surgical Center in Wayne, N.J.
• "I feel patient warming has decreased our PACU times. Also, it gives the patient a better outlook on their whole experience at our ASC." – Nancy J. Mandel, RN, operating room coordinator, Miracle Hills Surgery Center in Omaha, Neb.
• "Patients wake up quicker and more stable in PACU, and they love being warmed in pre-op with only a thin gown on, especially when wait times are extended." – Tammy Stanfield, BSN, RN, CCRN, administrator and director of nursing, North Pines Surgery Center in Conroe, Texas.