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Is Forced Air Warming Losing Steam?
Why some surgical facilities are seeking alternatives for maintaining normothermia.
Bill Donahue
Publish Date: January 9, 2017   |  Tags:   Supply Management
forced-air warmer HOT AIR? Lawsuits allege that forced-air warmers have caused surgical site infections.

Each surgical facility seems to have its own method of patient warming. Some use intravenous fluid warmers and warmed cotton blankets, while others opt for one or more of the host of warming devices — forced-air warming blankets and gowns, underbody heat mattresses and conductive-fabric warmers among them — to maintain normothermia.

There's a lot at stake. Numerous studies suggest that even a mild case of hypothermia can have adverse health consequences, including an increased risk of infections. But one mode of patient warming — the highly popular forced air — faces increasing scrutiny over allegations that it can actually cause surgical site infections. Detractors suggest that a forced-air warming unit can disrupt the flow of sterile air inside an OR and stir up contaminants from the floor, thereby increasing the potential for SSIs.

A flood of lawsuits filed against 3M, the maker of the industry's most-used warming system, the FDA-approved Bair Hugger, allege the forced-air system has caused some patients to develop deep-joint infections that have resulted in tragic outcomes, such as amputation and multiple follow-up surgeries, including the removal of implants. 3M has refuted the claims as "baseless" and offered numerous clinical studies to prove the technology's safety and efficacy. ECRI Institute, a highly-regarded laboratory for testing medical products, found "insufficient evidence to establish that the use of [forced-air warming] systems leads to an increase in SSIs compared to other warming methods."

Where there's smoke, there's fire
So has the debate affected the industry's faith in forced air, which has been used to warm hundreds of millions of patients in hospitals and surgery centers around the world? Based on interviews with surgical facility leaders across the country, not really, though some are currently investigating alternatives to forced air in light of the allegations.

Nalan Narine, MD, an anesthesiologist with Loma Linda University Medical Center-Murrieta (Calif.), takes a balanced approach to patient warming: forced-air warming blankets, as well as an underbody water blanket, warm IV fluids and airway humidification, plus a plastic head cover, "because the head represents the biggest part of heat loss," he says. He thinks forced air could one day be a "thing of the past," supplanted by other modalities. He also poses a bigger question.

forced air AIR TIME Despite allegations over the safety of forced air, most surgical facilities believe it remains a superior option for patient warming.

"This is all very controversial, but does warming a patient decrease SSIs or infection rates? I don't know that it does," he says. "There are some very good reasons to warm patients — comfort level is one of them — but I think we're going to be seeing a lot of changes to perioperative warming in the OR."

Going with the flow
As the infection preventionist for Imperial Calcasieu Surgical Center in Lake Charles, La., Sherry White, RN, BSN, CNOR, is highly sensitive to anything that might contribute to an SSI. She doesn't consider forced air a threat to her track record: zero infections in the past two years. Her facility uses forced-air warming blankets in the OR and PACU for patients who are under anesthesia for procedures lasting 45 minutes or longer. As a supplemental measure, the center offers warmed cotton blankets in pre-op, the PACU and the discharge area.

Later this year the center intends to test the efficacy of patient-adjustable warming gowns that use the same forced-air technology. She believes it will provide flexibility for greater patient comfort.

"[The gown] goes directly against the skin," Ms. White says, "so if they go to move the patient, it's not going to slip off, compared to the forced-air warming blankets."

She hopes the warming gowns, which the center expects to trial in the second quarter, will help to decrease the number of cotton blankets used per patient — likely trimming laundry costs as a result. Such a reduction would be especially helpful on high-volume days.

"The blanket warmer can hold only so many blankets," she says. "We have to constantly restock, and some days we just hope we've got enough linens to get through our day."

Jeanie Skibiski, CRNA, RN, MHA, DNAP, can relate. She says the forced-air warming gown has helped her facility, Mercy Orthopedic Hospital in Ozark, Mo., reduce costs associated with laundry and utilities, while contributing to greater patient satisfaction.

"A lot of times the room temperature would be at 66 [degrees] and the OR nurses would pile on the blankets," says Ms. Skibiski. "The circulators know I like the heater system versus piling on the blankets but one of the biggest reasons is that patients like being able to adjust their own thermostat."

Conducting an alternative
Ohio Valley Surgical Hospital in Springfield, Ohio, employs both forced-air and conductive lightweight fabric warmed by low-voltage electricity to keep patients normothermic. Jeannette Cline, BSN, RN, the center's OR manager, says they use the conductive-fabric warmers — similar to an electric blanket — "more frequently" than the forced-air counterparts, especially when doing total joints.

Likewise, James K. Dello Russo, MD, an anesthesiologist with a HealthCare Partners surgery center in Long Beach, Calif., often uses a conductive-fabric warmer. He considers it highly flexible, he says, especially "when turning the patient from supine to prone and back again." Depending on the patient, he says, other safeguards to retain heat in patients include warming IV fluids and humidifying airway gases.

"I have to find a reason not to use it," says Dr. Dello Russo, who has also used forced-air warming blankets from 2 different manufacturers. "It might be a knee or shoulder procedure that takes 5 to 10 minutes, or maybe a D&C [dilation and curettage]. Sometimes not even a D&C is short enough for me to not warm the patient."

Balanced approach
For Megan Dill, MSN, CRNA, patient warming is anything but "one size fits all." As an independent nurse anesthetist with Premier Anesthesia Services of SW PA in Pittsburgh, Pa., Ms. Dill works primarily with a two-surgeon plastic surgery practice.

"It can be a high-anxiety type of environment, and the forced air provides that little bit of TLC," she says. "We use an under-the-body warmer, and we've had patient surveys tell us they really appreciate that we're trying to keep them warm and comfortable."

When she first started working with the surgical practice, patients were warmed only in the recovery room. The practice has since shifted gears, and Ms. Dill estimates the practice now actively warms 95% of patients whose procedures last 30 minutes or more. This, in turn, has dramatically improved recovery times — especially with liposuction patients.

"Pre-op has always been environmentally warm, and we provide a blanket as well," she says, "but we're now looking at pre-op warming versus starting intraoperatively."

Although she currently uses a fluid warmer, Ms. Dill has one more item on her warming wish list for 2017: a temperature-controlled warming cabinet for IV fluids.

Then there's the Surgery Center of Idaho, a multispecialty facility focused primarily on urology. Patients enduring shorter procedures receive warmed cotton blankets, beginning in pre-op. The surgical team will continually monitor the patient's temperature and, if needed, use a "mummy wrap" to maintain normothermia, says Samantha Owens, BSN, RN, who oversees regulatory compliance and infection control for the Meridian, Idaho-based facility.

Last year, the facility invested in a forced-air warming system, which was doable because the system's manufacturer provided the unit at no cost, meaning the center now has to pay only for the blankets — a cost of less than $30 each. The center uses the forced-air warming blanket for longer procedures, including vasectomy reversals and some prostate cases, which Ms. Owens says can take more than 4 hours, and the system follows the patient from the OR to the PACU.

"It really depends on the length of surgery — case by case and patient by patient," she says. OSM