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New resource for preventing perioperative hypothermia
New resource for preventing perioperative hypothermia Kelly Putnam, Managing Editor
U
nintentional perioperative hypothermia occurs when proper measures are not taken to ensure that surgical patients’ body temperatures remain in the normal range when undergoing surgery. Although the reported incidence of perioperative hypothermia can vary according to the patient population, type of surgery, clinical setting, and definition of hypothermia used, one study of 255 patients undergoing major colorectal surgery found that 74 percent of patients experienced mild intraoperative hypothermia.1 Adverse clinical outcomes associated with perioperative hypothermia include increased risk for surgical site infections,2 major cardiac events,3 need for blood transfusions,4 and death.5 In addition, extended postoperative recovery can increase the length of hospitalization4 and costs of care.6 Despite its negative consequences and preventable nature, perioperative hypothermia continues to occur because many hospitals fail to adopt evidencebased guidelines for prevention. AORN recently released the new “Tool Kit for the Prevention of Perioperative Hypothermia,” which provides a collection of resources for perioperative nurses to develop and implement prevention programs at their own institutions.7 Victoria M. Steelman, PhD, RN, CNOR, FAAN, collaborated with AORN staff members to develop the tool kit and spoke to Periop Briefing about the need for this resource and her ongoing research regarding its effectiveness.
Failure to adopt best practices General anesthesia is a major contributor to hypothermia. Under anesthesia, body heat is redistributed from the periphery to the core because of vasodilation and a blunting of the normal autonomic temperature regulation responses. Cool temperatures in the OR, the exposure of large areas of the patient’s body during prepping and the procedure, and the use of cool IV and irrigation fluids combine with the physiologic responses to anesthesia to increase the risk of
hypothermia. Surgical patients require active warming to maintain a state of normothermia in which body temperatures remain above 36° C (96.8° F). Simply preventing heat loss with the use of passive warming techniques, such as warmed cotton or reflective blankets, are not effective ways to prevent perioperative hypothermia. Active warming techniques, such as forced-air warming, radiant warming, circulating water garments, and energy transfer pads, are more effective.8 Forcedair warming systems consisting of a fan blowing warmed air through a hose into a disposable blanket, which can vary according to the requirements of the specific surgery, are safe and commonly used.9 In the “Guideline for prevention of unplanned perioperative hypothermia,” AORN recommends that patients be prewarmed for at least 15 minutes before the induction of anesthesia and continuously warmed intraoperatively to maintain normothermia; intravenous solutions should be prewarmed to near 37°C (98.6° F) when administered in large volumes.10 “We looked at how well the evidencebased practices have been adopted at a community hospital, an academic hospital, and a federal hospital and they all failed implementation,” said Steelman. “They didn’t do it in a comprehensive way and it fizzled out; it didn’t work.” Several factors contribute to the inadequate implementation of best practices for preventing perioperative hypothermia. Team members may suffer from a lack of awareness regarding the need to begin active warming preoperatively or a lack of necessary equipment for temperature monitoring or for warming of patients or fluids. A study analyzing the implementation of best practices to prevent hypothermia in adult surgical patients identified the need for multidisciplinary communication, concerns regarding an increased workload, and the burden of changing documentation as barriers to improving practice.11 An additional concern is that the desired outcome has been poorly defined; reporting metrics
http://dx.doi.org/10.1016/S0001-2092(15)00617-1
© AORN, Inc, 2015
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for body temperature do not always require the patient to be normothermic. “One of the first things that we did was study the difference between compliance with that quality performance measure and normothermia, and found that even for the patients that the quality performance measure was met we still had over 7 percent hypothermia rates,” said Steelman. “There’s a big gap between that quality performance measure and doing the right thing for patients.”
Development of the AORN tool kit To address the issues surrounding the adoption of evidence-based practices for the prevention of perioperative hypothermia, Steelman collaborated with AORN to create a collection of educational and practice-based resources for perioperative team members.7 The tool kit includes a webinar and a Microsoft PowerPoint® presentation that describe the basic physiology of hypothermia, adverse outcomes associated with its occurrence, and evidence for various interventions. The customizable PowerPoint presentation also includes places for individual users and instructors to insert video clips of key perioperative leaders from their own institutions voicing support of the educational program to emphasize the importance of this issue and promote buy-in from team members. Templates and tips for documentation are also available for audits, electronic medical records, and health care failure mode and effect analysis. The tool kit also includes a 10-step guide for successful implementation. The Agency for Healthcare Research & Quality funded the development and refinement of the tool kit. Steelman is conducting ongoing studies12 to investigate the effectiveness of the tool kit using a modified model for promoting action on research implementation in health services.13 This modified model was used to identify facilitators of successful implementation of evidence-based interventions for prevention of perioperative hypothermia, which include the standardization and availability of equipment, education of personnel, cost analyses, and updated policies. Preliminary data from Steelman’s ongoing research at a community hospital indicates that the incidence of perioperative hypothermia decreased from 7.7
P8 | Periop Briefing
percent to 0.8 percent after implementation of the recommended practices using the tool kit.12 “We’ve been able to dramatically reduce the rates of hypothermia; I believe it can be completely prevented now,” said Steelman. The tool kit is currently available on the AORN website and content will be updated to reflect ongoing research and to address specific patient populations.8 For instance, additional resources will be created for emergency department personnel to help initiate preoperative warming for patients being transferred to the OR; this can be particularly important for patients with major trauma who may suffer impaired coagulation when hypothermic, increasing their risk of death. The unique set of barriers to the prevention of hypothermia in the emergency department stem from the brief window of time in which a patient is cared for before being transferred to the OR and the rarity of trauma patients who require urgent transfer to the OR, which can make it difficult to incorporate best practices into the care of these patients.
Conclusion Perioperative hypothermia is a preventable condition with safe and effective interventions; however, failure to recognize its occurrence or employ evidence-based practices for prevention can lead to serious adverse outcomes for patients. Proper implementation of these interventions has been hampered by a number of factors, including a lack of knowledge regarding best practices. The new AORN tool kit for prevention of perioperative hypothermia provides a collection of resources to help perioperative team members establish a program for temperature monitoring and active warming at their institution. Editor’s note: PowerPoint is a registered trademark of Microsoft Corp, Redmond, WA. References 1. Mehta OH, Barclay KL. Perioperative hypothermia in patients undergoing major colorectal surgery. ANZ J Surg. 2014;84(7-8):550-555. 2. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgicalwound infection and shorten hospitalization. N
Engl J Med. 1996;334(19):1209-1215. 3. Biccard BM, Rodseth RN. What evidence is there for intraoperative predictors of perioperative cardiac outcomes? A systematic review. Perioper Med (Lond). 2013;2(1):14. 4. Sun Z, Honar H, Sessler DI, et al. Intraoperative core temperature patterns, transfusion requirement, and hospital duration in patients warmed with forced air. Anesthesiology. 2015;122(2):276-285. 5. Billeter AT, Hohmann SF, Druen D, Cannon R, Polk HC. Unintentional perioperative hypothermia is associated with severe complications and high mortality in elective operations. Surgery. 2014;156(5):1245-1252. 6. Mahoney CB, Odom J. Maintaining intraoperative normothermia: a meta-analysis of outcomes with costs. AANA J. 1999;67(2):155-163. 7. Prevention of Perioperative Hypothermia (PPH) Tool Kit. AORN. http://www.aorn.org/toolkits/ hypothermia/. Accessed July 8, 2015. 8. Warttig S, Alderson P, Campbell G, Smith AF. Interventions for treating inadvertent postoperative hypothermia. Cochrane Database Syst Rev.
© AORN, Inc, 2015
2014;11:CD009892. 9. Wu X. The safe and efficient use of forced-air warming systems. AORN J. 2013;97(3):302-308. 10. Guideline for prevention of unplanned perioperative hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:479-490. 11. Munday J, Hines SJ, Chang AM. Evidence utilization project: management of inadvertent perioperative hypothermia. The challenges of implementing best practice recommendations in the perioperative environment. Int J Evid Based Healthc. 2013;11(4):305-311. 12. Steelman VM. Vaughn T, Shane D, Lemke JH, Jenning SE, Schaapveld AG. Evaluating the prevention of perioperative hypothermia safety toolkit. Poster presented at: AORN Surgical Conference & Expo; March 7-11, 2015; Denver, CO. 13. Rycroft-Malone J. The PARIHS Framework—A framework for guiding the implementation of evidence-based practice. J Nurs Care Qual. 2004;19(4):297-304.
August 2015 Vol 102 No 2 • Periop Briefing | P9
PERIOP BRIEFING
PERIOPERATIVE HYPOTHERMIA
U
nintentional perioperative hypothermia occurs when proper measures are not taken to ensure that surgical patients’ body temperatures remain in the normal range when undergoing surgery. Although the reported incidence of perioperative hypothermia can vary according to the patient population, type of surgery, clinical setting, and definition of hypothermia used, one study of 255 patients undergoing major colorectal surgery found that 74 percent of patients experienced mild intraoperative hypothermia.1 Adverse clinical outcomes associated with perioperative hypothermia include increased risk for surgical site infections,2 major cardiac events,3 need for blood transfusions,4 and death.5 In addition, extended postoperative recovery can increase the length of hospitalization4 and costs of care.6 Despite its negative consequences and preventable nature, perioperative hypothermia continues to occur because many hospitals fail to adopt evidencebased guidelines for prevention. AORN recently released the new “Tool Kit for the Prevention of Perioperative Hypothermia,” which provides a collection of resources for perioperative nurses to develop and implement prevention programs at their own institutions.7 Victoria M. Steelman, PhD, RN, CNOR, FAAN, collaborated with AORN staff members to develop the tool kit and spoke to Periop Briefing about the need for this resource and her ongoing research regarding its effectiveness.
Failure to adopt best practices General anesthesia is a major contributor to hypothermia. Under anesthesia, body heat is redistributed from the periphery to the core because of vasodilation and a blunting of the normal autonomic temperature regulation responses. Cool temperatures in the OR, the exposure of large areas of the patient’s body during prepping and the procedure, and the use of cool IV and irrigation fluids combine with the physiologic responses to anesthesia to increase the risk of
hypothermia. Surgical patients require active warming to maintain a state of normothermia in which body temperatures remain above 36° C (96.8° F). Simply preventing heat loss with the use of passive warming techniques, such as warmed cotton or reflective blankets, are not effective ways to prevent perioperative hypothermia. Active warming techniques, such as forced-air warming, radiant warming, circulating water garments, and energy transfer pads, are more effective.8 Forcedair warming systems consisting of a fan blowing warmed air through a hose into a disposable blanket, which can vary according to the requirements of the specific surgery, are safe and commonly used.9 In the “Guideline for prevention of unplanned perioperative hypothermia,” AORN recommends that patients be prewarmed for at least 15 minutes before the induction of anesthesia and continuously warmed intraoperatively to maintain normothermia; intravenous solutions should be prewarmed to near 37°C (98.6° F) when administered in large volumes.10 “We looked at how well the evidencebased practices have been adopted at a community hospital, an academic hospital, and a federal hospital and they all failed implementation,” said Steelman. “They didn’t do it in a comprehensive way and it fizzled out; it didn’t work.” Several factors contribute to the inadequate implementation of best practices for preventing perioperative hypothermia. Team members may suffer from a lack of awareness regarding the need to begin active warming preoperatively or a lack of necessary equipment for temperature monitoring or for warming of patients or fluids. A study analyzing the implementation of best practices to prevent hypothermia in adult surgical patients identified the need for multidisciplinary communication, concerns regarding an increased workload, and the burden of changing documentation as barriers to improving practice.11 An additional concern is that the desired outcome has been poorly defined; reporting metrics
http://dx.doi.org/10.1016/S0001-2092(15)00617-1
© AORN, Inc, 2015
August 2015 Vol 102 No 2 • Periop Briefing | P7
PERIOP BRIEFING
LEAD FEATURE
PERIOP BRIEFING
PERIOPERATIVE HYPOTHERMIA
for body temperature do not always require the patient to be normothermic. “One of the first things that we did was study the difference between compliance with that quality performance measure and normothermia, and found that even for the patients that the quality performance measure was met we still had over 7 percent hypothermia rates,” said Steelman. “There’s a big gap between that quality performance measure and doing the right thing for patients.”
Development of the AORN tool kit To address the issues surrounding the adoption of evidence-based practices for the prevention of perioperative hypothermia, Steelman collaborated with AORN to create a collection of educational and practice-based resources for perioperative team members.7 The tool kit includes a webinar and a Microsoft PowerPoint® presentation that describe the basic physiology of hypothermia, adverse outcomes associated with its occurrence, and evidence for various interventions. The customizable PowerPoint presentation also includes places for individual users and instructors to insert video clips of key perioperative leaders from their own institutions voicing support of the educational program to emphasize the importance of this issue and promote buy-in from team members. Templates and tips for documentation are also available for audits, electronic medical records, and health care failure mode and effect analysis. The tool kit also includes a 10-step guide for successful implementation. The Agency for Healthcare Research & Quality funded the development and refinement of the tool kit. Steelman is conducting ongoing studies12 to investigate the effectiveness of the tool kit using a modified model for promoting action on research implementation in health services.13 This modified model was used to identify facilitators of successful implementation of evidence-based interventions for prevention of perioperative hypothermia, which include the standardization and availability of equipment, education of personnel, cost analyses, and updated policies. Preliminary data from Steelman’s ongoing research at a community hospital indicates that the incidence of perioperative hypothermia decreased from 7.7
P8 | Periop Briefing
percent to 0.8 percent after implementation of the recommended practices using the tool kit.12 “We’ve been able to dramatically reduce the rates of hypothermia; I believe it can be completely prevented now,” said Steelman. The tool kit is currently available on the AORN website and content will be updated to reflect ongoing research and to address specific patient populations.8 For instance, additional resources will be created for emergency department personnel to help initiate preoperative warming for patients being transferred to the OR; this can be particularly important for patients with major trauma who may suffer impaired coagulation when hypothermic, increasing their risk of death. The unique set of barriers to the prevention of hypothermia in the emergency department stem from the brief window of time in which a patient is cared for before being transferred to the OR and the rarity of trauma patients who require urgent transfer to the OR, which can make it difficult to incorporate best practices into the care of these patients.
Conclusion Perioperative hypothermia is a preventable condition with safe and effective interventions; however, failure to recognize its occurrence or employ evidence-based practices for prevention can lead to serious adverse outcomes for patients. Proper implementation of these interventions has been hampered by a number of factors, including a lack of knowledge regarding best practices. The new AORN tool kit for prevention of perioperative hypothermia provides a collection of resources to help perioperative team members establish a program for temperature monitoring and active warming at their institution. Editor’s note: PowerPoint is a registered trademark of Microsoft Corp, Redmond, WA. References 1. Mehta OH, Barclay KL. Perioperative hypothermia in patients undergoing major colorectal surgery. ANZ J Surg. 2014;84(7-8):550-555. 2. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgicalwound infection and shorten hospitalization. N
Engl J Med. 1996;334(19):1209-1215. 3. Biccard BM, Rodseth RN. What evidence is there for intraoperative predictors of perioperative cardiac outcomes? A systematic review. Perioper Med (Lond). 2013;2(1):14. 4. Sun Z, Honar H, Sessler DI, et al. Intraoperative core temperature patterns, transfusion requirement, and hospital duration in patients warmed with forced air. Anesthesiology. 2015;122(2):276-285. 5. Billeter AT, Hohmann SF, Druen D, Cannon R, Polk HC. Unintentional perioperative hypothermia is associated with severe complications and high mortality in elective operations. Surgery. 2014;156(5):1245-1252. 6. Mahoney CB, Odom J. Maintaining intraoperative normothermia: a meta-analysis of outcomes with costs. AANA J. 1999;67(2):155-163. 7. Prevention of Perioperative Hypothermia (PPH) Tool Kit. AORN. http://www.aorn.org/toolkits/ hypothermia/. Accessed July 8, 2015. 8. Warttig S, Alderson P, Campbell G, Smith AF. Interventions for treating inadvertent postoperative hypothermia. Cochrane Database Syst Rev.
© AORN, Inc, 2015
2014;11:CD009892. 9. Wu X. The safe and efficient use of forced-air warming systems. AORN J. 2013;97(3):302-308. 10. Guideline for prevention of unplanned perioperative hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:479-490. 11. Munday J, Hines SJ, Chang AM. Evidence utilization project: management of inadvertent perioperative hypothermia. The challenges of implementing best practice recommendations in the perioperative environment. Int J Evid Based Healthc. 2013;11(4):305-311. 12. Steelman VM. Vaughn T, Shane D, Lemke JH, Jenning SE, Schaapveld AG. Evaluating the prevention of perioperative hypothermia safety toolkit. Poster presented at: AORN Surgical Conference & Expo; March 7-11, 2015; Denver, CO. 13. Rycroft-Malone J. The PARIHS Framework—A framework for guiding the implementation of evidence-based practice. J Nurs Care Qual. 2004;19(4):297-304.
August 2015 Vol 102 No 2 • Periop Briefing | P9
PERIOP BRIEFING
PERIOPERATIVE HYPOTHERMIA