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Prevention of inadvertent perioperative hypothermia
Dr Nicolas Fernandes Consultant Anaesthetist Mr Patrick Ferguson Clinical Nurse Specialist, Operating Theatre Dr Helen Jones Registrar Anaesthesia
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Rockingham General Hospital, Western Australia
Background
Inadvertent perioperative hypothermia (IPH) is defined as a body temperature below 36°C in the post-anaesthesia care unit (PACU). Perioperative hypothermia is an unfortunate consequence of a variety of unavoidable factors during surgery. Although these factors cannot be avoided, measures can be taken to prevent or, at least, minimise this drop in body temperature. A number of independent studies have shown that IPH can lead to adverse events including myocardial infarction, increased bleeding, increased need for blood transfusion and wound infection. These may result in increased morbidity to the patient and financial burden on the care provider. Further expense is incurred by delayed recovery from anaesthesia and prolonged hospital stay. IPH is considered avoidable and is an Australian Council on Healthcare Standards (ACHS) clinical indicator of good perioperative care (CI3.3). The aggregate rate appears to alter in different periods, but the aim is to have an incidence below the aggregaterate.
Problem/Aim
The study hospital had struggled to keep the incidence of IPH low for many years. Given its small size and relative homogeneity of patients and staff, this seemed abnormal. Therefore, this project aimed to ideally reduce the incidence of IPH to zero or at least a level below the incidence in comparable hospitals.
Measures
The temperature recorded in the PACU is entered into the theatre management system (TMS) electronically. Unfortunately, it is very difficult for most staff members to access these data because of licensing restrictions. Therefore, to capture these data, a data collection sheet was devised, which followed the patient from admission through all the steps of the procedure to determine where there may be a drop in temperature In addition, both quantitative and qualitative data were collected in the last Plan-Do-Study-Act (PDSA) cycle, and patients were encouraged to givefeedback.
Design
In the design of the project, various contributing factors were considered: • environment. The ambient temperature plays a major part in maintaining normothermia.
However, in the study hospital, albeit small, this proved to be an insurmountable problem.
The temperature appears to be controlled by thermostats, the engineers and the external temperature. After attempting to address this issue, the authors agreed that it would not be productive, especially as the recommended theatre temperature would still predispose to IPH. • measurement of temperature.
Patient temperature was being measured using a Braun tympanic thermometer. This device when tested yielded different values on consecutive uses on the same patient. The authors concluded that, although it appeared to work well on anaesthetised patients, it was not consistent on awake patients. After trialling various devices, the authors chose the
VeraTemp (Marne) professional thermometer for the PACU. • patient. Patient factors play an important part. Age, body habitus (low weight) and comorbidity predispose to IPH. • equipment. Various pieces of equipment are used to keep patients warm. They range from passive heating devices to forced air warmers and fluid warmers.
The authors selected the Bair
Paws (3M) gown, which is a patient gown with a built-in forced air warmer that works with the existing warmer in theatre. • education. Education and raising awareness of the detrimental effects of IPH were deemed critical to the success of the project.
Further, the team was educated on the correct technique of tympanic temperature measurement. The following interventions were therefore introduced for this project: • education of staff. Awareness was raised by key personnel who worked as ‘champions’ in their respective areas • introduction of a new thermometer in the PACU • patient warming. Bair Paws gowns were purchased after demonstrating efficacy and cost-effectiveness to the Hospital
Executive Group. • Plan-Do-Study-Act (PDSA) cycles were used in the application of the interventions as follows: • In the initial cycle, the hypothesis was that the use of a forced air warming device on its own would address the issue. This process was audits, but the incidence of
IPH was nevertheless high. • Data from the first cycle showed that patients arrived at the theatre hypothermic, which made it more difficult to normalise temperature in a relatively short time. Use of a device to warm patients before they came to the theatre was explored in the second cycle. • Despite the above measures, there remained an incidence of IPH of approximately 10%. Therefore, in addition to the above, the thermometers were examined and an education programme implemented in the unit in the third cycle.
Results
A combination of staff education, patient preparation and active prewarming achieved a 100% prevention rate of hypothermia in the subgroup of patients undergoing surgery. For logistical reasons, patients undergoing endoscopy were excluded, but subsequent interrogation of the TMS data system showed the rate to be the same (i.e., zero incidence of IPH).
Conclusion
Achieving a goal depends on meticulous planning, involvement of all stakeholders, repeated PDSA cycles and perseverance.
Next steps
The next step is to repeat the study with both patient subgroups and continue to maintain the current levels with further education, scrutiny of the data and PDSA cycles.
Acknowledgements
The authors thank Ms Bernie Harrison.
