TAKE THE TIME Perioperative hypothermia is associated with poor outcomes for patients, yet it's preventable in most cases.

The evidence is overwhelming: Patients that are warm have far better surgical outcomes than those that aren't. They have fewer infections, faster emergence from anesthesia, better comfort and shorter stays in recovery. Warm patients are also more satisfied, so thrilled that they didn't shiver through surgery that they'll write you a thank-you letter. "It's extremely comforting and reassuring to be kept warm. Such a small gesture goes a long way," says Yanara Reda, RN, BSN, OR team leader at the Rockland and Bergen Surgery Center in Montvale, N.J. And yet despite the many proven benefits, the practice of warming is highly variable, dependent on such factors as the length and type of procedure, the mode of anesthesia, the patient's age and even the warming device(s) you use, according to last month's Outpatient Surgery Magazine online survey of 100 surgical facility leaders. Some key findings of our survey:

1. How often do you warm? More than half (53.0%) of our survey respondents warm every patient wheeled into their ORs and nearly one-third (30.0%) warm patients "sometimes." Quite often, the determining factor in whether our respondents actively warm patients is the duration of the procedure: 45 minutes for some, 60 minutes for others and, for a smaller subset, a case has to run at least 2 hours before they'll warm. "Any surgeries longer than 59 minutes," says Mechelle Kemp, BSN, manager of perioperative services at Elkhart (Ind.) General Hospital. "If they are having general anesthetic or the procedure is expected to last over 30 minutes," says Karen Rustermier, RN, BSN, CNOR, of the Nebraska Medical Center in Omaha, Neb.

One of the facility managers who reserves warming for longer procedures explains her rationale: "Most of our surgeries are under 30 minutes in length. We do warm the cases we know are going to last longer, such as shoulders, knees and any laparoscopy." Ms. Reda says time should be of no concern. "When you're naked under a thin layer of cotton, you feel vulnerable," she says. "Vulnerability doesn't have a time frame."

If you're looking for a magic number to hang your warming policy on, consider 60. You should employ active warming to maintain normothermia in all patients — regardless of age — who are undergoing surgery lasting 60 minutes or longer under general or neuraxial anesthesia, according to the Surgical Care Improvement Project and the Physician Quality Reporting Initiative. According to the guidelines, you should record a body temperature equal to or greater than 36°C within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time. Keep in mind that hypothermia can still occur in patients during cases lasting less than 60 minutes. While these patients aren't considered high risk, they can and will feel cold, so warming as a comfort measure is still recommended during shorter procedures.

2. When do you warm patients? Then there's the question of when to warm: in pre-op, during the case or in recovery. At the Chickasaw Nation Medical Center in Ada, Okla., patients choose whether they'd like to be pre-warmed. "We connect patients to a forced-air warming gown and let them decide to use it or not pre-operatively," says Surgery Center Manager Ralania Tignor, BSN, RN, CNOR. "Intraoperatively, anesthesia decides." Here's how our survey broke down — 32.7% warm pre-operatively, 56.1% warm intraoperatively, 37.8% warm post-operatively and 39.8% warm throughout the patient's stay.

"I would prefer pre-op warming, but it is not yet available at the facility that I work in," says Dennis Thompson, MD, clinical professor of plastic surgery at Olive View-UCLA Hospital in Sylmar, Calif.

The University Medical Center in Las Vegas, Nev., is initiating a patient warming initiative that includes patient-controlled pre- and post-op forced air warming, says Ren Scott, MSN/Ed, RN, CNOR, clinical educator of surgical services. "Patient warming throughout the perioperative experience will improve patient outcomes and increase patient satisfaction/comfort," he says.

3. What's your rationale for warming? This was close. At 85.9%, "make patients comfortable" edged out "prevent hypothermia and its clinical complications," which 82.8% of respondents chose. Other reasons prominently mentioned include "reduce recovery times," "ward off surgical site infections" and "prevent patient shivering."

Besides increasing patient comfort and hastening recovery from anesthesia, warming has many proven clinical benefits, chief among them that it prevents hypothermia and maintains normothermia to reduce the likelihood of such post-operative complications as infection, bleeding and hematoma formation. Warming your patients not only increases comfort and satisfaction, but leads to measurably faster discharges.

4. How do you warm? There's no shortage of ways to warm a patient. Between convective (forced-air) warmers, table pads, blanket cabinets, heated fluids, underbody warming mattresses and other methods, you've got a lot of options to help you keep your patients between 36°C and 38°C. Here are the most popular warming methods our survey respondents employ (our survey asked them to check all that they used). In order, our respondents prefer forced-air warming systems (83.8%), cotton blankets pre-warmed with blanket warmers (76.8%), warming gowns (23.2%), underbody warming mattresses (7.1%), radiant warming devices (6.1%) and thermal body wraps (2.0%).

Charlene Goff, RN, director of nursing at the Pasadena (Calif.) Plastic Surgery Center, matches the warming device to the case. She says short cases are good with pre-warmed cotton blankets and longer cases do better with forced-air systems. She'll also deploy the forced-air warmer if a patient asks for more than 2 blankets. The efforts are well worth it, she says. "Patient satisfaction has increased 50% and length of recovery has been reduced," says Ms. Goff. "It's easier to get patients up and moving when they're warm and comfortable."

Patti Lynn Trapp, RN, director of operative services at Avera St. Mary's Hospital in Pierre, S.D., heartily endorses her fluid-warming device, which she was introduced to, she says, after she'd been using the warming gown and the forced-air warming blanket. "It's very inexpensive, easy to use and efficient," she says of the IV fluid warmer. "We're now using it more often. Patients are warm, but not sweaty."