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A Warming Trend
Our reader survey shows that more facility managers are warming patients throughout the perioperative course to curb unintended hypothermia.
Dan O'Connor
Publish Date: June 10, 2008   |  Tags:   Anesthesia

Good things happen when you keep patients warm, according to our national online survey of 306 facility managers, and we don't just mean such pre-op niceties as keeping patients comfortable and reducing their anxiety. We're talking about such major post-op benefits as decreasing anesthesia emergence times, reducing nausea and vomiting, preventing infection and lessening pain (and pain meds) — all of which contribute to faster, smoother discharges and give credence to the saying that nobody appreciates normothermia like patients and PACU staff.

"It's like a cascade of preventive measures," says Anne Haddix, RN, administrator and director of surgical services at Southwest Surgical Suites in Fort Wayne, Ind.

• • •

"A cold patient is an unhappy patient. That's not the memory I want them to take home from their surgical experience."

• • •

2008 Patient Warming Reader Survey

Here's a quick look at key results from our online patient warming survey of surgery facility managers.

Special thanks to the 306 readers who participated.

When Do You Warm Patients?

Pre-operatively

55.4%

Intraoperatively

90.6%

Post-operatively

80.2%

"The goal would be to eliminate the need for post-op warming," says Don Thorner, BSN, manager of surgical services at West Branch Regional Medical Center in West Branch, Mich.

Which of These Factors Make You Warm Patients?

Duration of surgery*

58.9%

Surgical procedure

53.2%

Ambient OR temperature

44.3%

Patient's age

42.6%

We warm all patients

39.4%

Patient's ASA status/pre-existing medical conditions

32.3%

Type of anesthesia

30.5%

Patient's anxiety level

18.1%

Patient's BMI

10.3%

Patient's gender

3.9%

Note: Respondents could check all that apply.
* For those who checked "duration of surgery" in response to this question, one hour was about the average length a procedure must be before they'd warm a patient.

What Is Your Rationale for Warming Patients?

Make patients comfortable

92.9%

Prevent hypothermia and its clinical complications

88.7%

Prevent patient shivering

66.3%

Reduce recovery/PACU times

62.8%

Ward off surgical site infections

48.2%

Reduce costs

18.8%

Note: Respondents could check all that apply.

What Type of Patient Warming Device Do You Use?

Cotton blanket pre-warmed with a blanket warmer

82.6%

Forced-air warming system

80.6%

Warming gown

16.7%

Thermal body wrap

3.1%

Spinal underbody blanket (thermal mattress or bed pad on which the patient lies)

10.1%

Radiant warming device

9.0%

Warm fluids

8.3%

Series of pads that strap around the patient's limbs/body

0.7%

Which Anesthesia Regimens Warrant Patient Warming in Your Facility?

General anesthesia using inhalational agents

89.7%

Moderate to deep sedation using IV agents

54.2%

Regional anesthesia with sedation

42.1%

Light sedation with IV agents

25.2%

Note: Respondents could check all that apply.

Do You Warm Laparoscopic Gas Before Insufflation?

Yes

11.4%

No

48.4%

We don't perform laparoscopy

29.9%

"We noted a reduction in fogging of the scopes and patient comfort post-op in laparoscopic Nissen fundoplications and long scope cholecystectomies," says Mr. Thorner.

Our online survey found that patient warming is no longer the exception but is increasingly becoming the rule at ambulatory surgical facilities across the country. Some say it's because the dangers of unintended hypothermia are well known. Other say the warming trend is due to the benefits and patient satisfaction surveys that mention warming as memorable. When you compare this year's survey results with our February 2005 ("Patient Warming Gets Proactive") survey, you'll find that they're comparable in terms of when and how surgical facility managers warm.

  • When you warm. In 2005, 99 percent of survey respondents said they warmed patients at least sometimes and 55 percent said they warmed nearly every surgical patient routinely. In 2008, 87.8 percent say they warm patients at least sometimes and 42.4 percent say they always warm patients.
  • How you warm. In 2005, 88 percent used a forced-air warming system and 86 percent used pre-warmed blankets. In 2008, 82.6 percent use pre-warmed blankets and 80.6 percent use a forced-air warming system.

"A warm blanket is so easy," says Lynda Dowman-Simon, RN, OR manager at St John's Clinic: Head & Neck Surgery in Springfield, Mo. "It pleases the patient, the parents and the nurse, too. Something about that little bit of warm cloth eases the patient's mind and decreases stress levels along with keeping them toasty."

"The forced air warmer we use is versatile to warming the upper or lower body as desired," says the director of ambulatory surgery at a Colorado medical center. "The blankets can follow the patient to PACU from the OR if still clean — which reduces waste. Even though the use of warmers increase case costs, they help to make patients more comfortable in PACU, and speed up their discharge."

More of our survey respondents warm patients intraoperatively (90.6 percent) than post-operatively (80.2 percent) or pre-operatively (55.4 percent). However, our survey also revealed that an increasing number of facilities are warming patients throughout their perioperative course, not just once they arrive in the OR when they are perhaps already below normothermia.

"We keep them warm in all phases," says Joanne Crynes, director of QRM perioperative and anesthesia services at St. Vincent's Hospital in New York, N.Y.

"Pre- and post-op areas are outfitted only with warmed blankets. Intraoperatively, we use a forced air warming device," says one respondent.

It's well known that, once a patient is on the table, hypothermia can happen quickly. During surgery, the greatest drop in core temperature occurs in 30 to 60 minutes, when 1.6 ?C is typically lost. Plus, anesthetic agents themselves interfere with the body's ability to regulate temperature.

"Keeping a patient comfortable pre-, peri- and post-operatively lets the patient have a higher level of comfort," says Jay A. Shorr, VP of operations at Advanced Cosmetic Laser Center in Tamarac, Fla. "In addition, the recovery stage is what the patient may remember most about his experience, leading to much better patient satisfaction."

• • •

"I have worked where we utilized blanket warmers and a forced-air warming system. The patients would always comment that the warm blanket was like a hug. It is such a small thing we can do to comfort the patient and prevent complications."

• • •

Why Don't You Warm?

Here's a sampling of the reasons why some of our survey respondents say they don't use warming devices:

  • "Patients leave clothes on for cataract surgery. We do use blankets, which are sufficient for a 10-minute procedure."
  • "Our facility is an office-based surgical practice that only administers local anesthesia."
  • "We are a very small office-based facility. (Patients) do not get cold."
  • "We only do gastrointestinal endoscopy and minor colorectal cases. We have rapid OR turnover. Warming is limited to warmed blankets used pre-op and post-op."
  • "We use thermal blankets over each patient from head to toe, but we don't have blanket warmers. Our patients stay in their own clothes so they tend not to get chilled. It also helps that we don't do general anesthesia and our cases are quick. We tuck the blanket in around the upper torso and kind of ???swaddle' the patients. This makes them feel secure while we remind them to keep their hands down at their sides. The blanket keeps them warm but also serves as a gentle reminder not to move and not to reach up to touch their face."
  • "We're small. We don't freeze our patients and therefore do not need to warm them. We do provide blankets for the cold patient."
  • "We only perform topical MAC for ophthalmic cases."
  • "It's not an issue. Our center performs endoscopic procedures only."

Southwest Surgical's surgeons' standing orders stipulate that every patient undergoing a procedure expected to last 90 minutes or longer (the threshold used to be four hours) wears a forced-air warming blanket before, during and after the case. No exceptions. The cost: $5 to $7 a blanket.

The thinking is as such: Studies have shown that normothermic patients have fewer infections and the surgery center's own experience has shown that warmed patients are less likely to have pain, which in and of itself reduces the incidence of nausea and vomiting. It all adds up to happier patients who spend less time in recovery.

Two keys to Southwest Surgical's success:

  • warming every patient expected to be in the OR for more than 90 minutes, regardless of surgeon preference; and
  • warming patients from the time they arrive in pre-op to when they're ready for discharge, not just in the OR. Often, patients begin losing body temperature in pre-op and arrive in the OR hypothermic.

"I don't think [other facilities] warm patients as aggressively as we do," says Ms. Haddix. "I haven't seen other centers start warming patients in pre-op and do it all the way through the course of their stay. We warm patients right from the start. We never let their body temperature drop below normothermia."

There's more. The ORs at Southwest Surgical are kept warm (76 ?F to 78 ?F) and the OR tables are pre-heated with warm air about 10 to 15 minutes before the patient enters the room. Anesthesia and nursing staff monitor the patient's temperature throughout the surgical procedure.

"Surgeons have bought into the fact that room temperature needs to be elevated for patient comfort," says Ms. Haddix.

• • •

"Happy, warm patients simply do better."

• • •

For three years now, Advocate Good Samaritan Hospital in Downers Grove, Ill., has been recording each patient's temperature upon admission to the PACU. "We discovered that we had our own high-risk patient population, including hernia, Ob/Gyn, laparoscopic, orthopedic and cysto patients," says Debbie Bennett-Carey, BSN, clinical operations assistant for surgical services.

After educating the surgical services staff about the importance of normothermia and the direct relationship with decreasing surgical site infections, Advocate Good Samaritan began increasing its intraoperative use of a forced-air warming system. The result? "Prolonged PACU stays due to hypothermia have decreased and not a single patient who had an SSI last year had a temperature below the recommended normothermia range," says Ms. Bennett-Carey.

A quicker discharge is one of the leading reasons to warm, according to our survey. Nearly two-thirds (62.8 percent) of respondents cited reduced recovery/PACU times as a reason for warming. "Our PACU times and post-op temps are much improved using the warming system when we have a general anesthesia case," says one reader.

"Quicker discharge times with less overtime," says James Babeshoff, CRNA, MSN, staff anesthetist at Mercy Medical Center in Clinton, Iowa.

The two leading reasons to warm: Make patients comfortable (92.9 percent) and prevent hypothermia and its complications (88.7 percent). "I haven't done a QA study on this, but I can tell you from experience that a patient who is warm will be much more relaxed and have less post-op surgical pain than one who is tense and shivering," says Billi Hitz, BSN, administrator of the Columbus Surgery Center in Columbus, Neb. "Think about it: What do you do when you're standing outside and you're cold? You tense your muscles up. Now think of tensing your muscles up after having abdominal surgery. Not fun."

• • •

"There's a cost involved for the blankets and warming unit, but what have they prevented that would have been more costly?"

• • •

Many of those who indicated that they warm patients sporadically (8.8 percent) or not at all (4.1 percent) either do short procedures, such as ophthalmology or GI, or blame it on a surgeon.

Shirley Ramey, RN, nurse manager of the ASC of Burley in Burley, Idaho, is one such respondent. They don't warm eye patients at her facility. And she says one of her ENT physicians doesn't want a warming blanket on his patients because he "dislikes the ???poof' under his drapes."

Some wait for the patient to complain of being cold before offering a warming device.

"We use (a forced-air warming gown) if patients state pre-operatively that they're cold. In that case, we'll use it all the way through their admission," says Judy Perrin, RN, CNOR, administrator of the North Georgia Eye Surgery Center in Gainesville, Ga.

Others offer all patients warm blankets, but use forced air only if patients can't get warm in PACU.

"The anesthesia provider decides when to use patient warming devices. He's responsible for maintaining patient body temperature during and immediately after surgery," says George Tway, RT, administrator of the Galileo Surgery Center in San Luis Obispo, Calif.

Bruce P. Kupper, MHA, CEO of Stony Point Surgery Center in Richmond, Va., keeps his ORs warmer to save on warming blankets. "We were going through 450 blankets per week at $1 per blanket," he says. "Increasing the room temperature to 68 ?F decreased our costs." Others don't dare touch the thermostat. "It makes staff uncomfortable and doesn't increase the patient's temp to any significant degree," says one reader. "We're unable to regulate OR temp on a short-term basis," says another. "We don't increase the ambient OR temperature to make the patients more comfortable because it often makes the staff that is scrubbed in and gowned uncomfortable. We can make the patients more comfortable by supplying them warm blankets when needed," says a third.

• • •

"We had a 30 percent hypothermia rate in PACU before initiating additional warming techniques. After three weeks, all PACU patients were normothermic."

• • •

One thing our survey made clear is that patient warming practices are still very much all over the board, meaning patients are frequently transferred to recovery in a hypothermic state. Given the serious complications associated with hypothermia and the known benefits of normothermia, why aren't all patients routinely warmed? "Wouldn't it be nice to have an evidence-based protocol in place so you knew when and how to warm patients?" asks Mary Ann Nicometo, BA, director of surgical services at DuBois Regional Medical Center in DuBois, Pa.

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