Warming Up to Normothermia

Educating staff about the importance of keeping patients warm can lead to enthusiasm about how to do it even better.

The intraoperative normothermia compliance rate at our 25-OR facility was 56% in September 2021, far lower than the numbers from our preoperative bays and recovery rooms. The causes were nuanced and the solutions were layered, but we simply had to do something to improve the warming numbers for patients while they were in the OR.

Multiple inventions, fantastic results

We threw the book at the problem, with great results from multiple interventions. Here’s how we increased compliance to 72% by May 2022, a goal we’ve managed to sustain — including three months when the rate was more than 75%. Patient satisfaction rates increased by 3% during that same nine-month period as well.

• Creating awareness. One of the things I’ve learned with this project is we too often underestimate a patient’s temperature as being an important vital sign. We think of it as something to be monitored and tended to in pre- and post-op, but not necessarily something that warrants a heavy focus in the operating room. Because there are so many other crucial tasks the intra-op teams are working on, warming can get overlooked. Suggesting that it be made a priority in the OR is often met with the perception that one more thing is being added to nurses’ already full plates.

That’s a lot to overcome when it comes to getting staff buy-in, so we quoted the research from the literature that shows the subsequent negative effects of not maintaining patient normothermia. Inadvertent perioperative hypothermia has negative effects on SSIs, wound healing, myocardial ischemia events, hospital stays and patient comfort. Treating related complications costs an average of about $5,000. While most suggest 30 minutes of pre-warming to keep core temperatures greater than 36°C, 10 minutes can significantly reduce hypothermia rates.

• Filling gaps and new interventions. The first thing we had to do was make sure our data was correct. It turned out that while we still needed to do more to warm patients intraoperatively, the numbers weren’t as bad as we originally thought. That’s because we would take patients’ temperatures when they arrived at our facility, but often not before they left pre-op for the ORs.

Of course, in the meantime, they had changed from their clothes into a gown, been administered cold IVs and were subjected to other factors that decreased their core temperatures from when they walked inside from the warm Houston weather. Now, we take temperatures shortly before patients are rolled into the OR, so we know the data we’re working with isn’t setting the OR staff up for failure as we measure how well they keep patients warm. We also use new technology to provide continuous non-invasive core temperature monitoring that follows the patient throughout the perioperative experience. This assists in real-time temperature data capture and helps to keep our data clean for analysis by ensuring each area is measuring with the same tool.

Once inside the ORs, we found challenges with the temperatures of our IV fluids. We needed a way to warm the fluids in every room but couldn’t afford the most expensive devices for each room. I found a new product that uses a hot plate-like device on an IV bag to quickly warm it that was inexpensive enough to purchase for each room. We also purchased fluid-warming cabinets for our core.

Warming, fundamentally, is a nurse intervention. That’s exciting and empowering.

The key to these interventions was the solutions were staff-friendly. Placing the warming devices in every room made using them easy for the nurses to use. I had to strategize with a lot of colleagues about where to locate the cabinets, because our 25-OR setup is connected by one long hallway. I needed staff input in order to put the cabinets in locations where their contents would actually be used. Forced-air warming gowns and warmed linen blankets were the primary interventions in pre-op and post-op areas. Pre-op bays and the OR rooms were pre-warmed, as were the OR beds. Intraoperatively, IV fluids were continuously warmed and active warming systems were used as well as tactics to limit patient exposure during positioning, preparation and conclusions of cases.

• Observe and educate. Direct observation during rounds was a key to our success. During rounds, I’m able to make sure new processes are being followed, can provide help and support during warming efforts and can make suggestions during challenging cases, which includes any patient in the lithotomy position. When I restock the warmers, I look at the temperature readings on the IV bag warming cabinets and use the opportunity to explain to staff that the fluid bags are 70°F before they’re put into the warmer. This turns into an educational moment when staff take the time to realize the effect continuously putting cold bags of saline into a 98.6°F body has on patients, which is something we don’t think enough about. This is especially true on scope cases such as cystoscopy, arthroscopy and laparoscopy procedures, where large amounts of irrigation are utilized.

I’m given time at staff meetings to talk about warming-related literature. During morning huddles, I can speak about new interventions we’re using or any new issues we might be having. We also partner with manufacturers to have their reps come in to train staff. These ongoing education efforts make our progress sustainable. By constantly talking about the issue in huddles, the solution never ends, just as the need to warm doesn’t go away.

We use a variety of methods to warm patients in the three perioperative phases of care. We have so many ORs and perform more than 1,100 varied procedures a month, so there’s no one fix. We offer the nurses — the experts in the room — a buffet of options, a tool belt with lots of choices at their fingertips that allows them to customize the appropriate care for their patients. Warming, fundamentally, is a nurse intervention. That’s exciting and empowering.

• Maintaining momentum. Having the best intraoperative warming rates has become a competitive sport at our facility. We get numbers from our six sister hospitals and compare their weekly normothermia compliance averages to ours. I make sure to let our teams know when we’ve beaten the others, or when they’ve done better than us. Within our hospital, I have compliance numbers broken down by service line, so each line challenges themselves to compete against the other specialties and against each other. I’ve even had employees ask if their cases were the reason their specialties’ rates recently declined, saying they want to do better individually, so they’re even competing against themselves.

While many patients love to be warmed, we still have conversations beforehand to prepare them to be warmed slightly outside of their comfort zone. Patients’ core temperatures must be high enough to withstand the constant bombardment of interventions such as the brisk transport to the OR, the cold bolus of IV fluids and their exposure while being prepped with alcohol-based solutions and positioned. They need to be “toasty,” the word we use when we have those preoperative conversations with patients to remind them of the importance of warming and to get them prepared for warming equipment they’re going to see when they arrive. We even get the families involved, asking them to make sure their loved ones plug their warming device back in after they’ve gone to the bathroom because we need to keep the number on the machine high.

TOASTY WARM Active warming blankets and devices that heat up IV bags reduce the complications that can occur from failing to maintain patients’ core temperatures.

• Spreading the message. We had representatives from pre-admit, pre-op, OR, recovery and anesthesia on our warming committee to address the issue and each of these stakeholders became champions for their respective units.

Each of them brought their perspective and their particular challenges surrounding the issue, and we came up with collaborative solutions. They, in turn, took the solutions back to their respective huddles, so we were actually intervening at each phase of care, even though the scope of the project was designed to focus on intraoperative warming. Members of the pharmacy and materials management departments attended as needed, as did biomedical partners and vendor reps.

• Next steps. It’s not easy to determine which intervention works the best, as we use multiple and they’re combined by our nurses into customized treatments for our patients. There are interventions out there we don’t currently use, however, and the next layer for us could be choosing one and isolating its use with our lithotomy, hysterectomy or colorectal procedures to see if the new tool can help us increase compliance with these challenging cases. We’re also inserting the normothermia focus into our Enhanced Recovery After Surgery (ERAS) program and adding it to the checklist.

Constant collaboration

The key to success is realizing the issue never dies. It’s why we continually educate, communicate and collaborate on ways to sustain our successes.

I’ve enjoyed speaking about this issue with nurses from across the country. They’re looking to improve performance on this issue at their facilities and some have ideas for how they can help us here in Houston. None of us have it all figured out, but by collaborating, we can make huge gains for our patients. OSM