Great Reasons to Actively Warm Patients

Check your satisfaction and safety boxes with these expert tips to actively warm every patient before every surgery.

Patients undergoing even short surgical procedures can have inadvertent changes in body temperature that can cause hypothermia. 

Research has proven that these temperature fluctuations can come with harmful physiological effects that alter patients’ outcomes, stresses J.D. Buchert, MSN, M.Ed., MS, RN, workforce safety manager for quality and safety operations at Parkland Health in Dallas.  

“Too many times, I have walked into a preoperative holding room and been told by a patient they are cold,” says Mr. Buchert. “A patient typically has a decrease of 1° F in body temperature upon induction. If that patient is entering the operating room already cold, their temperature drop can have devastating effects because there is typically not enough time to bring that patient’s temperature back to normothermic range.”

Two main causes of hypothermia

Unplanned hypothermia occurs when a patient’s core body temperature dips below 98.6° F. It’s common knowledge that surgical patients are at an increased risk of hypothermia due to the effects of anesthesia. This is for two primary reasons — as explained in AORN’s Guideline for Prevention of Hypothermia.

First, undergoing anesthesia blocks the body’s behavioral responses (such as moving to a warmer space) and autonomic responses (vasoconstriction and shivering).

Second, general anesthesia decreases metabolic heat production by about 15% to 30%, and slightly increases cutaneous heat, which exaggerates temperature loss. The combined result is a 0.9° F to 2.7° F drop in temperature.

This intraoperative temperature drop has been found to create a cascade of negative and even deadly effects, as noted by AORN, including myocardial events, increased blood loss and need for blood transfusion, reversible coagulopathy, impaired renal function, decreased drug metabolism, and increased peripheral vascular resistance. In recovery, unplanned hypothermia has been found to increase wound infections. It also increases the liklihood of poor wound healing, postoperative pain, postoperative protein catabolism, altered mental status, pressure ulcers, longer recovery times, prolonged hospitalization, and death.

The many benefits of active warming

Active warming strategies, such as forced-air warming blankets, intravenous fluid warming, and circulating-water mattresses are widely recognized as more effective than passive insulation methods such as prewarmed cotton blankets, according to the AORN Guideline.

A 2017 systematic review showed this by comparing randomized controlled trial results of active versus passive warming to prevent hypothermia in surgical patients receiving neuraxial anesthesia. The review found active warming worked better at reducing the incidence of inadvertent perioperative hypothermia. However, it also found that even with active warming, inadvertent perioperative hypothermia still occurred.

Mr. Buchert agrees that warming every patient, no matter the duration of the surgery, is the best course for facilities. He suggests more consistent active warming is needed for patient populations in the ASC setting because these patients tend to have shorter procedure times that may preclude them from receiving active warming due to a facility’s policy.

Certain facilities may use the 60-minute-or-longer threshold to determine the warming method, with procedures lasting less than 60 minutes using passive warming or no warming and procedures longer than 60 minutes using active warming.

While cost control may be a reason behind only using active warming for longer procedures, Mr. Buchert says it’s important to consider the range of costs associated with unplanned hypothermia. First, active warming is less expensive than unplanned hypothermia, as demonstrated in a 2021 study. The study found that intraoperative hypothermia was associated with higher risks of bleeding, surgical site infection and shivering at a cost of $363.80 per patient, while the extra investment in active warming was $291 per patient.

It’s also important to consider the costs to an ASC associated with delayed recovery, Mr. Buchert points out. “A patient experiencing unplanned hypothermia in the PACU can take up valuable space needed for outgoing patients,” he says, adding that the negative impact unplanned hypothermia can have on patient satisfaction creates another major issue.

AORN EXPO

Learn proven patient warming strategies in San Antonio

LIVE EDUCATION The 2023 AORN Annual Conference & Expo, which takes place from April 1-4 in San Antonio, will include practical education sessions on maintaining perioperative normothermia.

If you are planning to attend AORN’s 70th annual conference in San Antonio, April 1–4, and want to learn some practical pointers on maintaining normothermia in your patients, make time in your schedule for an education session by Jennifer Rose, BSN, MSML, RN, CNOR, titled “Brrr I Said It’s Cold in Here: Maintaining Perioperative Normothermia With Interprofessional Collaboration and Multifactorial Interventions.”

You can also review the evidence behind AORN recommended practices for maintaining patient normothermia in the AORN Guideline for Prevention of Hypothermia at aornguidelines.org or in the AORN Guidelines for Perioperative Practice (subscription required).

—Carina Stanton

Warm patients = satisfied patients

As administrators are well aware, any safety event associated with hypothermia ultimately leads to some level of patient dissatisfaction, which can affect the patient satisfaction score, says Mr. Buchert. He stresses that warming and patient satisfaction go hand-in-hand because patients want to be heard, respected and feel safe. An essential aspect of meeting these patient needs, according to Mr. Buchert, is considering those needs and asking, “Is my patient warm?”

Mr. Buchert has learned the importance patient satisfaction plays in a healthcare system because it ultimately helps to measure the quality of the healthcare provided. From a business perspective, patient satisfaction scores can also factor into reimbursement rates that meet specific thresholds in the quality equation.

If a patient was cold, they will likely indicate this if surveyed. In a 2019 study on patient thermal comfort, authors noted that more than one-third of surgical patients surveyed gave negative marks for their overall surgical experience due to feeling cold.

Such remarks from patients can be a powerful catalyst to reevaluate warming approaches that also improve care delivery. “With patient satisfaction outcomes, healthcare systems can establish trends to aid in focusing on the improvement of the clinical quality of care and service quality of care,” says Mr. Buchert. “This voice of the patient helps us to improve our practice to better serve our patients.”

Create warming and temperature-monitoring systems

Active warming for patients is clearly the right thing to do, but Mr. Buchert says, “There must be systems in place for active warming and temperature monitoring to support a streamlined workflow, especially with the fast-paced schedules ASCs keep.”

A normothermia bundle could be a worthwhile approach for standardizing active warming and helping patients maintain normothermia, according to findings from a 2022 study by Russell et al.

Too many times, I have walked into a preoperative holding room and been told by a patient they are cold.
J.D. Buchert, MSN, M.Ed., MS, RN

They tested a normothermia bundle in a same-day surgery setting that included a written policy for the complete perioperative phases of care to standardize patient temperature monitoring and active warming with a FAW blanket. This was indicated according to a chart that was posted in the preoperative unit.

The researchers found a significant reduction in cases of inadvertent perioperative hypothermia when the bundle was applied. However, they also found a lack of adherence to recommended temperature monitoring guidelines for the patient during intraoperative care, which they suggested could be disguising cases of hypothermia.

Such research, according to Mr. Buchert, reinforces the need for every perioperative staff member to make sure the surgical patient is warm and feels safe throughout their entire surgical experience.

This requires careful attention from preoperative holding all the way through recovery 
and discharge.

“This will aid in positive patient outcomes and also touch on the patient being heard, respected and safe, which should reflect in the patient satisfaction scores,” he says. OSM