April 14, 2021

Locking up access to the thermostat protects patients exposed to the elements during surgery.

CREDIT: Miriam Dowling-Schmitt KEEPER OF THE KEY Assigning only one person access to and control of the OR's thermostat protects patients while maintaining order in the room.

Surgical team members who work hard under hot OR lights often lower the thermostat to keep from overheating. However, their efforts to stay cool during surgery could cause the patients in their care to become hypothermic.

"We've conducted a lot of staff education to make sure they understand patients' needs come before their own," says Miriam Dowling-Schmitt, director of quality at Spectrum Healthcare Partners in Southport, Maine.

Patients lose a significant amount of heat through the surface of exposed skin and open incisions, and cool environments further increase the rate of heat loss. Surgical drapes offer some thermal protection, but active warming methods and maintaining the ambient OR temperature within the AORN-recommended range of 68°F to 73°F help keep patients normothermic.

This all might sound reasonable to the layperson, but administrators know that surgeons and staff are known to argue over and fiddle with OR room temperatures. To avoid arguments breaking out between simmering surgeons and shivering scrub techs, Ms. Dowling-Schmitt suggests covering the thermostat with a lockable plastic box and assigning one staff member to hold onto the key.

That staff member can adjust the thermostat upon request, but also is charged with making sure the room never becomes too warm or too cold. Giving a single person complete control over the thermostat ensures OR temperatures remain consistent, according to Ms. Dowling-Schmitt.

Putting the thermostat under lock and key was part of the enhanced patient warming protocols implemented at one of the surgery centers Spectrum Healthcare Partners manages. Staff there remain vigilant in ensuring patients are normothermic throughout their stay, reports Ms. Dowling-Schmitt. "When staff realize patient warming impacts outcomes, a light goes on," she says. "Their efforts have been extremely gratifying."

Guidelines provide administrators and staff insight into the roles these key team members play in the fight against IPH.

The Association of Surgical Technologists advises that body temperatures should be recorded during all phases of the perioperative episode of care.

The Association of Surgical Technologists (AST) guidelines for maintaining normothermia in patients, while crafted through the prism of the role surgical techs play, can easily be used to educate all members of OR teams. They provide numerous take-home points that build an effective patient warming protocol.

You can download the guidelines here. Here's an overview of the highlights:

• Education is paramount. The patient, along with attending family or friends, should receive preoperative education on the importance of maintaining the warmth of surgical patients, as well as how the patient will be kept warm during the perioperative process. The guidelines also explain that surgical techs should undergo continuing education about the adverse effects of inadvertent perioperative hypothermia (IPH), as well as methods for preventing and treating it.
• Know the roles. The buck stops with the anesthesiologist when it comes to assessing the patient's IPH risk level. Meanwhile, the primary scrub tech should be responsible for providing the surgeon with warm irrigating fluids in the interest of IPH prevention.
• Warming is a continuous process. All patients should be adequately warmed in pre-op and recovery, as well as during transfer to and from the preoperative holding area. Body temperatures should be recorded during all phases of the perioperative episode of care.
• Employ several techniques. AST encourages the use of active warming technology as opposed to traditional warmed cotton sheets, and says the OR's thermostat should only be adjusted in concert with other patient-warming techniques. The guidelines also state IV fluids and blood products should be warmed prior to transfusion, and skin preparation antiseptics should be warmed before use.
• Document everything. The patient's medical record should list all of the measures taken to prevent IPH and maintain normothermia during the entire surgical episode. If IPH occurred or a warming device malfunctioned, document the incident and review the case in order to identify solutions that can improve future outcomes.

Using AST's guidelines to develop and implement policies and procedures can help provide administrators and risk management professionals as well as perioperative staff a leg up on preventing potentially dangerous and expensive IPH complications.

You're still breathing surgical smoke – even with smoke evacuation. 

Credit: Augustine Surgical^™
Dr. Scott Augustine demonstrating how surgical smoke is lifted into the breathing zone of the surgical staff by a vortex caused by forced-air patient warming (videos: https://hotdogwarming.com/stop-blowing-it/).

Recent research has revealed that even if smoke evacuation is utilized, surgeons, anesthetists and the entire OR staff are still at risk of inhaling the viruses and carcinogens contained in surgical smoke.¹ Why is this the case? The culprit is rising waste heat from commonly used hot-air patient-warming devices.

Smoke evacuators remove approximately 50 percent of surgical smoke,^2,3 but hot-air patient warmers prevent OR ventilation from quickly removing the rest. Instead of being pushed to the floor and out the side vents by the OR ventilation system, the smoke is sucked into a vortex, circulating in the breathing zone and holding for 45 seconds or longer.

What creates this vortex in the OR? A vortex is similar to what is a common weather pattern forming between a hot front and a cold front. Hot-air warmers produce approximately 950 watts of heat that escape from an upper body blanket near the patient's head. The waste heat rises against the anesthesia screen and is pulled across the top of the screen into the vacuum that naturally forms under the surgical light.

The energy in the waste heat counteracts with the cool, downward-moving ventilation airflow, creating a vortex - or what could be described as a mini tornado - under the surgical light. In fact, ten published studies have shown that this mini tornado can suck contaminates off the floor and mobilize them up and into the sterile field, putting the patient at risk.⁴

One research study in particular is unique in that it shows that the vortex can also suck up surgical smoke, mobilize it and hold it in the breathing zone of the surgeon and assisting staff for 45 seconds or more after each use of the cautery. Dangerous smoke is trapped in this vortex - exactly where the surgical team is standing and breathing. To view a full video of this research, click here: https://hotdogwarming.com/stop-blowing-it/

Furthermore, research has shown that the surgical smoke produced in an operating room is the equivalent of approximately 30 cigarettes being smoked in a day.⁵ Even if the smoke evacuator removes 50 percent, the remaining 15-cigarette equivalent should be a serious concern. Like cigarettes, surgical smoke contains dangerous substances – carcinogens such as benzene, hydrogen cyanide and formaldehyde. Unlike cigarettes, however, surgical smoke also may contain bioaerosols and viruses. Surgical smoke in the breathing zone is clearly a risk to the surgical staff. ^{6, 7}

"This research shows that the only way to avoid breathing surgical smoke is to avoid hot-air patient warmers," says Dr. Scott Augustine, CEO of Augustine Surgical, who conducted the research.¹

It is well known that warming surgical patients is critical for optimizing surgical outcomes. The team at Augustine Surgical has invented air-free HotDog patient warming, a reusable semi-conductive polymer blanket and mattress system that is more effective and less expensive than hot-air warming. Most importantly, it does not produce waste heat, allowing the ventilation system to safely clear the un-evacuated surgical smoke.

Note: For more information please go to https://hotdogwarming.com/stop-blowing-it/

Preventing perioperative hypothermia improves outcomes and avoids the costs of associated complications.

The science on the benefits of maintaining normothermia is in, and the professional recommendations on the issue are clear: All patients should receive some sort of hypothermia prevention method in order to achieve good outcomes. But that's not the entire story to the nearly 100 facility leaders surveyed by Outpatient Surgery Magazine who said patient warming also makes good economic sense.

Here are six interesting takeaways from the survey:

• The cost is largely unknown. Most facilities said they don't calculate the cost because it simply doesn't matter to them. The few that did, however, put the cost at $5 to $30 per case. The fact that active warming keeps patients happy and helps foster better clinical outcomes completely justifies this expenditure in their eyes.
• Patient satisfaction is priceless. Many respondents noticed higher satisfaction scores and fewer complaints of unmanaged pain after they switched to active warming practices. Charles Golden, MSN, CRNA, of IMG Anesthesia Services in Nashville, Tenn., perhaps said it best: "A warm patient is a happy patient."
• Clinical benefits abound. The majority of those surveyed said warming prevents complications from hypothermia, makes patients less anxious, results in less shivering, produces shorter recovery periods and faster discharges, and reduces infections. All of these benefits push overall surgical costs down while potentially expanding patient volume.
• Warming remains underutilized. About 37% of respondents said they do not routinely warm patients. Some who don't employ the technique have understandable reasons for not doing so, such as caring for patients during quick cataract surgeries at eye centers. For clinicians such as Anita Volpe, DNP, APRN, director of surgical outcomes, research and education at New York-Presbyterian Queens, however, any implementation of patient warming protocols that is less than 100% is deficient.
• Which patients should be warmed? Responses indicate that length of surgery is the deciding factor, but other oft-stated considerations include procedure type, OR room temperature, patient age, anesthesia method, patient ASA status, pre-existing medical conditions, BMI and gender.

The survey results were clear: In addition to happy and healthy patients, the economics of patient warming equates to good business as well.

Consistent readings are required to implement practices that prevent perioperative hypothermia.

Surgical staff members must use a standardized method to measure patients' core body temperatures before, during and after surgery in order for clinical leaders to assess the effectiveness of active warming protocols.

The lack of a consistent approach was an issue at the Joint and Spine Center at The Christ Hospital Health Network in Cincinnati, where patients' temperatures were taken with oral thermometers in pre-op, esophageal probes or strip sticker thermometers in the OR, and temporal scanners in the PACU. The variability of temperature-taking techniques made it impossible to accurately compare readings taken at each phase of care, which made it unnecessarily difficult to identify where patient warming was most effective and where it needed to improve.

"We realized it's important to decide on a single temperature-taking method, and to use it consistently," says Amy Yarbrough, BS, BSN, RN, CNOR, an assistant clinical nurse manager at the center. As a result, staff now place a small continuous temperature monitoring sensor on patients' foreheads in pre-op. The sensor remains in place as patients move to the OR and the PACU, automatically recording temperatures along the way. "It's a simple, convenient and standardized way to capture accurate readings during the entire surgical process," says Ms. Yarbrough.

Mandating a consistent method for temperature-taking was part of the facility's overall effort to improve the warming of patients undergoing open abdominal procedures, lateral hip revisions and spinal fusions lasting longer than two hours — during which large areas of skin are exposed. "The initiative allowed us to enhance our warming practices and provided an opportunity to inform staff about a fundamental element of safe patient care," says Ms. Yarbrough.