Evidence Utilisation: Management and Prevention of Inadvertent Perioperative Hypothermia

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Evidence Utilisation Management and
Prevention of Inadvertent Perioperative
Hypothermia

• Judy Munday
• RN Mater Health Services, Brisbane
• Intern Mater Nursing Research Centre

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Setting

• Post Anaesthetic Care Unit in the Combined
  Operating Suites, Mater Adult Hospital, Brisbane,
  Queensland, Australia.
• Specialities Gynaecology, General Surgery,
  Orthopaedics, ENT, Plastics, Eye surgery, Oral
  Surgery, Vascular.
• Evidence Based Clinical Fellowship Program

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Aims and Objectives

• To assess current clinical practice in the
  prevention and management of inadvertent
  perioperative hypothermia
• To promote best practice in the prevention and
  management of hypothermia utilising prewarming,
  active warming measures and consistent
  measurement of temperature

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Background

• What is Inadvertent Perioperative Hypothermia
  (IPH)?
• the unintentional cooling of a patients core
  temperature to below 36ºC during surgery (NICE
  2008)

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Adverse Outcomes of IPH

• Delayed wound healing (Kurz et al 1996)
• Increased blood loss increased transfusion
  requirements (Rajagopalan et al 2008)
• Decreased immune response (Beilin et al 1998)
• Increased wound infection rates (Kurz et al 1996)
  incidence of other infections (eg pneumonia)
• Prolonged stay in recovery (Lenhardt et al 1997),
  prolonged hospital stay, increased costs

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Audit Question

• Do the strategies for prevention and management
  of inadvertent perioperative hypothermia in adult
  theatres meet current standards of evidence-based
  practice?

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Evidence Guidelines

• JBI Review The Management and Prevention of
  Inadvertent Perioperative Hypothermia (2010)
  (Moola, Lockwood).
• ACORN - Standards for Perioperative Nursing
  (2010)
• American Society of PeriAnesthesia Nurses (ASPAN)
  (2001 2009)
• Association of Perioperative Registered Nurses
  (AORN) Recommended Practices (2007)
• NICE (2008) The Management of Inadvertent
  Perioperative Hypothermia in Adults

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Audit Criteria

• Measurement of core temperature on admission
• Measurement of core temperature in pre op holding
  area
• Prewarming (warming of patients using forced air
  warming devices immediately prior to surgery)
• Intraoperative temperature measurement if
  procedure gt30mins
• Intraoperative warming using forced air warming
  systems additional warming devices
• Measurement of core temperature on admission to
  PACU

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Audit Criteria

• Admitted to PACU with core temperature of gt36C
• Postoperative warming using forced air warming
  systems if patient found to be hypothermic (core
  temperature lt36C) on admission to PACU
• Regular temperature measurement in PACU (every
  15mins)
• Patients not discharged from PACU until core
  temperature gt 36C

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Project Sample

• Inclusion criteria
• Adult patients gt 18 years of age
• Patients undergoing general, neuraxial or
  combined anaesthesia
• Exclusion criteria
• Patients lt 18 years of age
• Patients undergoing local anaesthesia only or
  sedation
• Patients placed in induced hypothermia
• Patients bypassing PACU and transferred directly
  to ICU

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Project Sample

• Baseline audit 73 patient charts obtained from a
  random sample of 100 over a 3 month period
  Aug-Nov (charts accessed Dec-Jan 2010)
• 2nd audit 72 patient charts obtained from a
  random sample of 100 over a 6 week period (21
  Feb-1 April 2011).
• Follow up audit 79 patient charts obtained from
  a random sample of 100 over a 2 month period
  (July Aug 2011)

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Baseline audit
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Planning practice change

• Large area of practice and multiple practice
  changes to be considered
• Concentrate on several key areas to implement
  best practice changes
• Large number and different groups of staff.
• Implementing change from underneath (as an RN)
• Existing documentation does not facilitate change
  in practice.

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Planning Practice change
Criteria Problem Strategies Used
Regular temperature measurement Not measured in Pre Op holding area Obtain equipment Identify location for documentation Management support, education.
Prewarming (using forced air warming devices) Not current practice Obtain management support interdisciplinary agreement. Consider protocol equipment. Trial run commenced 11 April 30 June 2011 Interest promoted via audit and feedback
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Criteria Problem Strategies Used
Post op warming using forced air warming Audit suggests under utilised. Consider reasons for under use. Feedback forms. Education. Forced air warming blankets to be left on from OT if suitable.
Regular temperature measurement in PACU (every 15 mins) Documentation does not facilitate change. Management support. Integrate into current framework encourage documentation change. Feedback sought from staff.
Patients should not be discharged from PACU until core temperature is gt 36C Discharge temperature is 35.5 C on current documentation. Investigate ways to implement into current framework. Management support. Embed into policy.
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Second Audit Results
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Second audit - conclusions

• Positive outcomes
• New policy on hospital intranet
• Core temperatures recorded in Pre Op Holding Bay
  (increase of 38)
• 8 increase in patients reaching PACU
  normothermic
• 8 increase in postoperative warming in PACU
• 26 increase in patients discharged gt 36C

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Prewarming trial run

• Criteria modified from NICE guidance on IPH
  (2008)
• All patients with temperatures lt36C to have
  forced air warming applied in the time available
  before surgery (excluding vascular patients)
  Application of prewarming not successful. Low
  rate of application by staff
• Temperature monitoring improved rate of
  temperature monitoring in Pre Op Holding Bay
  (increase of 83 from baseline)
• Barriers lack of time/staff reluctance/current
  care model
• Strategy target specific groups/ look at model
  of care can prewarming be applied in
  Admissions?

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Increasing patient comfort

• Simple methods of increasing patient comfort and
  trying to prevent preoperative heat loss
• Increased ambient temperature in Admission
  waiting area and changing rooms
• Patient information displayed about the need to
  keep warm preoperatively

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Follow up Audit
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Conclusions Positive outcomes

• 19 increase in patients reaching PACU with
  temperature gt36C
• 28 increase in patients returning to the ward
  with temperatures gt36 C

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Conclusions further work needed

• Changes within a large practice area take time to
  implement
• Changes need sustained work to be continued
  within staff practice (for example, Pre Op
  temperature check)
• Management support will be required to embed
  changes into policy and documentation
• Further practice changes are being considered and
  further audit is planned

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Where to now?

• Focus on 3 key areas Pre Op temperature check,
  regular checks in PACU, discharge from PACU temp.
• Decision tree to guide warming practice in Pre Op
• Improving PACU documentation
• Examining accuracy of modes of temperature
  measurement

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Acknowledgements

• Thanks and acknowledgement to
• Sonia Hines, Kate Kynoch and Anne Chang (Nursing
  Research Centre)
• Donna Harrison (NUM Anaesthetics Recovery)
• David Macklyn (NUM Anaesthetics Recovery)
• Angela Bertoldi (CN, Adult PACU)
• Julie Mee (NUM, Combined Operating Theatres)
• Mary Polzella (Clinical Governance Facilitator
  Combined Operating Theatres)
• Dr Erich Schulz (Anaesthetist)