MTG Raising the Bar with Patient-focused Warming ...thermoflect.com/pdf/Mind_the_Gap.pdf · and present patient-focused warming strategies ... Open-Cavity Surgery and Cold skin prepping

Welcome to Mind The Gap: Raising the bar with patient-focused warmingstrategies.

The AORN Seal of Recognition has been awarded to the Thermoflect Heat Reflective Technology Recommended Practice Program on 1/21/2015 and does not imply that AORN approves or endorses any product or service mentioned in any presentation, format or content. The AORN Recognition program is separate from the AORN, ANCC Accredited Provider Unit and therefore does not include any CE credit for programs.

© 2015 Encompass Group, LLCAll Rights Reserved | Lit. No. AC14295 rev. 03/15

1. Explain preoperative heat loss and the benefits of prewarming. 2. Identify the significance of cutaneous heat loss and measures for prevention. 3. Discuss perioperative patient temperature management risk categories. 4. Describe the prevalence of hypothermia in the postoperative environment and the gap. 5. List typical warming measures and their contribution to cutaneous warming. 6. Describe steps to implement a patient-focused warming strategy that uses the most effective measure or combination of measures available to preserve cutaneous heat.



In this education module, we will explore the challenges associated with effective temperature management for the patient. Although it may seem a simple problem, we have found it to be anything but that. This course will review the benefits of prewarming patients to prevent hypothermia, discuss the impact of cutaneous heat loss, and present patient-focused warming strategies aimed at improving outcomes.



Recommended practices for the prevention of perioperative normothermia, including AORN and ASPAN Guidelines, identify normothermia as a core temperature range of 36 C to 38 C (96.8 F to 100.4 F).1,2 We will start our discussion where the patient and first opportunity for prevention begin, the preoperative environment.

This diagram illustrates how typical heat loss occurs preoperatively. According to a 2010 study by Leeth, et al, most patients arrive in the pre-op area normothermic.3 The top row of figures shows the patient arriving normothermic and immediately beginning to lose heat during prep and transport. Without early intervention, the patient can arrive in the OR hypothermic and compromised. In contrast, the lower portion of the diagram, shows how prewarming (or banking heat) allows them to arrive at the OR normothermic. When a patient arrives in the OR, in a hypothermic status, it can be difficult and sometimes impossible to restore normothermiabefore transport to PACU.

The responsibility for maintaining perioperative normothermia generally belongs to the operating room, anesthesia or postoperative care teams. However, as Sophia Mikos-Schild explains in her CE course, “Perioperative Patient Safety: Hypothermia, Hypoglycemia and Handoffs, “Nurses in each area of the perioperative setting can influence patient outcomes. Nurses can have a positive impact in the preoperative holding area during admission, in the OR during surgery, and in the PACU with recovering patients. None of the settings are islands to themselves, but rather they affect patient outcomes in the total continuum of care.”4

We should strive to maintain the patient’s warmth to ensure they maintain normothermia. Following recommended protocols, including prewarming interventions, can help improve patient outcomes. To bring this more into focus, let’s review how the anesthetized patient loses heat.

Citations:1 - AORN. Recommended practices for the prevention of unplanned perioperative hypothermia. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc.; 2012:365-378. 2 - ASPAN’s Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia3 - Leeth, D. et al, Normothermia and patient comfort: a comparative study in an outpatient surgery setting4 - Perioperative Patient Safety Hypothermia, Hypoglycemia and Handoffs, Sophia Mikos-Schild, RN, EdD, MSN, MAM/HROB, CNOR, Sophia Mikos-Schild, RN, MSN, EdD, MAM/HROB, CNOR, is the Magnet Coordinator at Presence St. Mary and Elizabeth Medical Center in Chicago, Ill.



Redistribution Temperature Drop [RTD] is the primary cause of unintended perioperative hypothermia and is responsible for up to 81% of the total decrease in temperature within the first hour.5 As RTD occurs during the first hour immediately following anesthesia induction and results in a decrease in body temperature occurring as heat is exchanged from the body’s core compartment to the peripheral tissues.

At this point, the body looses heat through four mechanisms, the largest contributors being radiation and convection which account for 70% of the total heat loss.6 Therefore, protecting the patient from heat loss due to radiation and convection is essential to minimize the impact of RTD.

Relevant to this, Sessler states in his Perioperative Thermal Manipulations text in Miller’s Anesthesia“Cutaneous heat loss is roughly proportional to surface area throughout the body. Consequently, the amount of skin covered is more important than which surfaces are insulated. It does not make sense, to cover the head and leave the arms exposed because the arms have more surface area than the head and, account for more heat loss.”7

He continues to say “The easiest method of decreasing cutaneous heat loss is to apply passive insulation to the skin surface.” Passive insulation can be accomplished with reflective warming measures, which warms the skin surface and reduces heat loss due to radiation and convection.

Now that we have reviewed how heat is lost, we will take a look at some factors that contribute to overall risk assessment.

Citation: 5- Sessler, Daniel MD, “Perioperative Heat Balance,” Anesthesiology, vol. 92, no. 2, pp. 578-96, 2000 6- Ramaswamy, Dr.K.K., “Perioperative hypothermia, prevention and management; Week 17,” Tutorial of the Week, no. 117, OCTOBER 2008. 7- Sessler, Miller’s Anesthesia 7th Edition, Perioperative Thermal Manipulations, Cutaneous Heat Loss



When assessing risk, we need to understand that all patients are at risk and therefore need to be protected. For the purposes of this education, we have identified three key risk categories which include: the patient, the procedure and the environment. Each of these has contributing factors that can impact the overall risk for a particular patient.

Patient Related risks include: Age, Body Weight and Metabolic DisordersProcedure Related risks include: Open-Cavity Surgery and Cold skin prepping solutions, Duration and Anesthesia, Infusions (including Cool Fluids, Blood and Blood Products), and Cool Irrigation SolutionsEnvironmental risks include: the Cold Surgical Environment, Airflow, Cold OR Table8

(Carol – NEJM 1996 reference)

The CDC National Center for Health Statistics reported 79.4 million surgical procedures were performed in the US during 2006.9,10 Based on the findings of Moola and Lockwood in 2011, 50-90% of patients experienced unplanned perioperative hypothermia.11 Conservatively speaking, that means patients undergoing 39.7 million procedures were impacted despite aggressive patient warming protocols.

Patient warming strategies do not come in a “one size fits all” package. Each patient should be evaluated for the strategy that best meets their particular needs. According to the article Keeping Patients Warm Throughout Surgery by Shari Burns, CRNA, MSN, EdD, “The secret to making sure your patients stay warm is to combine measures to maintain body temperature from the time patients enter your facility through discharge. This offers the greatest likelihood of minimizing body temperature change and maximizing comfort in surgical patients”.11

Citations:8- National Collaborating Centre for Nursing and Supportive Care, “The management of inadvertent perioperative hypothermia in adults,” in Clinical practice guideline, National Institute for Health and Clinical Excellence [NICE], April 2008,p. 126. 9 - U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES, Centers for Disease Control and Prevention National Center for Health Statistics, National Health Statistics Report - 2006 National Hospital Discharge Survey ((Total Procedures (46) less Misc (13.8))10 - U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES, Centers for Disease Control and Prevention National Center for Health Statistics, National Health Statistics Report - Ambulatory Surgery In the United States, 2006 ((Total Procedures (53.3) less Misc (6.1)) 11 - Moola S., Lockwood C. ; Effectiveness of strategies for the management and/or prevention of hypothermia within the adult perioperative environment; Int J Evid Based Healthc, 2011 Dec;9(4):337-45. doi: 10.1111/j.1744-1609.2011.0022712 - Burns, Shari; Keeping Patients Warm Throughout Surgery, Outpatient Surgery Magazine



Protecting patients is a proactive choice and should begin as soon as they arrive in the preoperative area. Once they become hypothermic, they are exposed to a higher risk of associated adverse outcomes. Prevention is better than a cure! If we can maintain the patient’s temperature throughout the perioperative process it is far more beneficial to their experience and less likely that more aggressive warming measures will be needed to raise the patient’s temperature subsequently.

Prewarming patients with reflective warming products, which warm the skin surface and reduce cutaneous heat loss is an important preventative measure to consider.

This graph illustrates the outcomes of a study performed by Leo Leliveld, CRNA at Erasmus Medical Center in The Netherlands where the implementation of prewarming with heat reflective gowns was beneficial to the patient. The study included a total of 60 patients undergoing orthopedic surgery for the duration of 15 to 90 minutes of actual surgery time. The control and subject groups each contained 30 patients. The control group was issued a standard hospital gown and the subject group was issued a heat reflective gown.13

As shown, both groups were normothermic upon admission and demonstrated a temperature increase upon arrival to Holding. The heat reflective gown group maintained the initial increase in average temperature through PACU. Additionally, there was an increase in patient temperature at discharge with no additional warming measures required.

However, the average temperature of the control group with the cotton patient gown decreased from 36.3 to 35.7⁰ Celsius upon arrival to PACU. In addition, 16 of the 30 patients in the control group, required active thermal management to achieve an average temperature of 36.1⁰ Celsius.

Citation:13- Maintenance of normothermia during relatively minor orthopaedic surgical procedures on the extremities ; L. Leliveld, Anaesthesiology Department ; Surgical Day Treatment Department, Erasmus Medical Centre, Rotterdam, The Netherlands



Evidence demonstrates prevention is better than a cure, therefore, we need to bank the patient’s heat!

According to AORN Recommended Practices, patients should be prewarmed prior to induction of anesthesia for a minimum of 15 to 30 minutes, also known as banking heat. “Warming the patient's skin and peripheral tissues before induction of general or major regional anesthesia prevents redistribution hypothermia. The temperature of the peripheral tissues is increased and vasodilatation triggered. This results in a smaller core to periphery temperature gradient and minimizes the effect of anesthesia-induced vasodilatation.” 14

AORN recommendations include implementing passive thermal care measures such as reflective warming preoperatively. The illustration on the left depicts a typical patient without prewarming. The warm core blood has moved to the periphery, picking up cooler blood and decreasing the core temperature. Once the core heat shifts to the periphery, it is lost through the surface of the skin which is also illustrated by the blue lined figure.

On the right, the patient’s heat has been banked through prewarming the skin surface with reflective warming,allowing the core temperature as well as the periphery to remain stable and the patient to arrive normothermic into the OR.

Citation:14- AORN. Recommended practices for the prevention of unplanned perioperative hypothermia. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc.; 2012:365-378.





SCIP INF-10 propelled us to take the first step in facing the challenge of patient temperature management. It targeted procedures with an anesthesia time of 60 minutes or longer and this is an important fact to keep in mind.

Compliance for this measure required one of three boxes to be checked. It did not require normothermia be achieved, just aggressively pursued. These three requirements were15

1. Achieve a normothermic temperature within 30 minutes prior to anesthesia end time2. Or Achieve a normothermic temperature within 15 minutes after anesthesia end time3. Or implement active warming measures

This measure has since been retired as of January 2014.16 The measure was deemed “topped out”. This means that nearly all hospitals have achieved a similar high level of performance on these measures.17

According to Sappenfield, et al, “Merely complying with the Surgical Care Improvement Project (SCIP) measurement is inadequate for optimizing perioperative outcomes.”18 SCIP INF-10 being “topped out” does not mean that 100% of patients achieved normothermia.

Livaudais defined “topped out” as “there was no meaningful difference in performance between providers and little opportunity for further improvement”.19 However, the prevention of hypothermia must still continue as a priority for all patients.

As seen in the chart on the right, the 2006 data provided by CDC Health Statistics Reports, reported the majority of surgical procedures (47.2 million) were performed on an outpatient basis.20,21 These procedures had a median OR time of 50 minutes. We established this patient population in our earlier course as “The Gap”. We have made progress but still have work to do.

Citations:15 - Specifications manual for national hospital inpatient quality measures, version 4.1. C enters for Medicare & Medicaid Services (CMS), The Joint Commission; 2012 Jul. various p.16- Joint Commission, Core Measure Changes That Impact Accountability Measures, Issued September 201317- CMS Medicare Quality Initiatives, Frequently Asked Questions Hospital Value-Based Purchasing Program Last Updated March 9, 201218 – Sappenfield, Joshua, Hong, Caron M., Galvagno, Samuel M.,Perioperative temperature measurement and management: Moving Beyondthe Surgical Care Improvement Project19–Livaudais, Gerard ,MD, MPH, Quantros Subject Matter Management, Inpatient Prospective Payments Systems Quality Reporting Requirements for FY 2014 and Beyond20 - U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES, Centers for Disease Control and Prevention National Center for Health Statistics,National Health Statistics Report - 2006 National Hospital Discharge Survey ((Total Procedures (46) less Misc (13.8))21 - U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES, Centers for Disease Control and Prevention National Center for Health Statistics,National Health Statistics Report - Ambulatory Surgery In the United States, 2006 ((Total Procedures (53.3) less Misc (6.1))

Despite an increased awareness and more robust patient warming protocols, we continue to see a significant number of patients delivered to the PACU hypothermic. The 2012 study by Luis et al, revealed 32% of patients arrive in the postoperative area hypothermic, including those using forced air warming.22

The number of patients affected is clearly significant and demonstrates there are still far too many patients in “The Gap”. The 15.1 million outpatient and 10.3 million inpatient procedures in this demographic need improved patient warming strategies.23,24 To see a significant change, we should implement the most effective measure or combined measures to proactively address the needs of all patients.

Citation22 - Luís, Clara, Moreno, Carlos, Silva, Acácio, Páscoa, Rosália, Abelha, Fernando; Inadvertent PostoperativeHypothermia a t Post-Anesthesia Care Unit: Incidence, Predictors and Outcome23 - U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES, Centers for Disease Control and Prevention National Center for Health Statistics, National Health Statistics Report - Ambulatory Surgery In the United States, 2006 ((Total Procedures (53.3) less Misc (6.1)) 24 - U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES, Centers for Disease Control and Prevention National Center for Health Statistics, National Health Statistics Report - 2006 National Hospital Discharge Survey ((Total Procedures (46) less Misc (13.8))

Graph Citations† Luís, Clara, Moreno, Carlos, Silva, Acácio, Páscoa, Rosália, Abelha, Fernando; Inadvertent PostoperativeHypothermia a t Post-Anesthesia Care Unit: Incidence, Predictors and Outcome†† U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES, Centers for Disease Control and Prevention National Center for Health Statistics, National Health Statistics Report - Ambulatory Surgery In the United States, 2006 ((Total Procedures (53.3) less Misc (6.1))††† U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES, Centers for Disease Control and Prevention National Center for Health Statistics, National Health Statistics Report - 2006 National Hospital Discharge Survey ((Total Procedures (46) less Misc (13.8))



There are many warming measures to choose from. What’s the difference? The difference can be made by selecting the right warming measure or combination of measures at the right time.

Traditional linens and apparel are common staples in the perioperative environment. They serve the basic functions of comfort and modesty but provide little or no therapeutic benefit. As demonstrated in a study by Sessler and Schroder, cotton bath blankets only provide temporary comfort for the patient and the warming benefits are minimal and relatively short lived.25 (warming dissipates in less than 10 min)

Forced air is one of the most common active warming measures used intraoperatively. This technology is now available in the preoperative environment as a warming gown. Although it is recommended these products be activated during pre-op, since it is a comfort focused system, therapy is controlled by patient preference. This can then present the opportunity for prewarming benefits to be minimized. Additionally, when the gowns are used as an upper body blanket intraoperatively, the majority of the skin remains exposed and unprotected. A 15 month study published by Leijtens, et al, in June 2013, showed 26.3% to 28% of patients using forced air warming developed perioperative hypothermia.26

Reflective warming products combine the function of traditional linen with intrinsic warming and insulating properties. When used preoperatively they warm the skin surface and bank the patient’s heat. They are more effective and efficient than traditional linens.27 In addition, laboratory testing demonstrates when reflective and forced air warming products are used as a combined measure, the efficacy of forced air warming can be improved up to 15%.28

Citations:25 - Heat Loss in Humans Covered with Cotton Hospital Blankets Daniel I. Sessler, MD, and Marc Schroeder,BA Department of Anesthesia, University of California, San Francisco, California26 - Leijtens B, Koëter M, Kremers K, Koëter S.; High incidence of postoperative hypothermia in total knee and total hip arthroplasty: a prospective observational study; J Arthroplasty. 2013 Jun;28(6):895-827 - A comparative study of the thermal efficiency of Thermo-Lite Clothing Versus Pre-warmed Cotton Blankets in Preventing Intraoperative Hypothermia; Joanne A Kelley, R.N., B.S.28 - Testing performed by TSCI using the following equipment: Heat Transfer Test Model, Flow Test Rig, 2x PT100 sensor for water inlet and outlet temperature, 1x copper plate with PT100 sensor for environment temperature, 1x Pico PT104 data logger, Laptop



We need to make every minute count and a simple algorithm or decision tree like this can help.

According to Roth, without prewarming, “there may not be enough time for intraoperative active warming to be fully effective.”29 This can result in reduced comfort, increased pain and nursing time as well as the need for additional warming interventions.

This decision tree demonstrates a recommended practice guideline for reflective warming products. It provides guidance for each area of care. In short duration procedures, typically 90 minutes or less, passive measures, such as reflective warming, begin to work immediately to bank heat and promote normothermia perioperatively. For longer duration procedures and/or patients who arrive hypothermic, active warming measures may need to be added to the strategy to supply an external source of heat and regain normothermia. Again, applying the right measure or combined measures, the right way at the right time is paramount.

As previously stated by Shari Burns in Keeping Patients Warm Throughout Surgery, the secret to making sure your patients stay warm is to combine measures to maintain body temperature.30

Protecting patients is a proactive choice and should begin as soon as they arrive in the preoperative area.

Citations:29 - Jonathan V. Roth, MD; Some Unanswered Questions About Temperature Management30 – Burns, Shari; Keeping Patients Warm Throughout Surgery, Outpatient Surgery Magazine



When selecting a temperature management strategy, it is important to understand the role of skin surface warming and cutaneous heat loss. According to The Cleveland Clinic Center for Continuing Education, “roughly 90% of metabolic heat is lost through the skin surface.”31 Maximizing skin coverage early and maintaining it throughout the perioperative journey helps preserve and bank cutaneous heat.

The Rule of Nines divides the body’s skin surface into sections each with a value relative to total body surface area. As illustrated, the smaller surface areas include the head and arms each of which contain 9% of the total body surface area. The larger areas which each contain 18% of the skin surface include the upper and lower torso as well as the legs.32

Citation31 – Cleveland Clinic Center for Continuing Education; Findings from the Department of Outcomes Research and Outcomes Research Consortium32 -Advanced Burn Life Support Course Provider Manual; American Burn Association 2007



Finally let’s take a look at a typical product application tool to see how using the Rule of Nines can help in selecting the most effective measure or combination of measures to preserve cutaneous heat. Color coded product application charts, like the one pictured here, establish guidelines that can serve as a simple reminder and quick reference for product selection and application.

For instance, covering the upper body during an abdominal procedure (which is common when using forced air warming products) addresses approximately 36% of the skin surface.

Combining measures, through adding reflective warming products such as a cap and lower body blanket, cover an additional 55% of the skin surface. This combination of measures maximizes skin surface coverage and protects 91% of the skin surface.

Use of this type of tool can help drive compliance by providing specific recommendations for skin-surface coverage.



We have all heard “It takes a village”. Our village is the perioperative environment. We all share responsibility to achieve our goal of patient normothermia.



Documents

MTG Raising the Bar with Patient-focused Warming ...thermoflect.com/pdf/Mind_the_Gap.pdf · and present patient-focused warming strategies ... Open-Cavity Surgery and Cold skin prepping