When it comes to healing, it’s not always things like medicine, that go into the patient, that make the difference; sometimes it’s what’s on top of the patient or under them that does the trick, as in the case of managing hypothermia and pressure sores.

Hypothermia can lead to a variety of undesirable consequences, according to the American Society of PeriAnesthesia Nurses (ASPAN), including "impaired wound healing, adverse cardiac events, altered drug metabolism, and coagulopathies . . ."¹ A study by Kurz et al2 noted: "Mild perioperative hypothermia, which is common during major surgery, may promote surgical-wound infection by triggering thermoregulatory vasoconstriction, which decreases subcutaneous oxygen tension. Reduced levels of oxygen in tissue impair oxidative killing by neutrophils and decrease the strength of the healing wound by reducing the deposition of collagen. Hypothermia also directly impairs immune function. . . . may delay healing and predispose patients to wound infections."²

Judson Boothe, associate marketing director, surgical solutions, Kimberly-Clark, Roswell, GA, noted, "There are more than 100 studies showing hypothermia is a critical aspect of improved clinical outcomes. All tend to correlate on the same issues." Boothe summarized the issues as follows:

• Blood loss. Patients who are cold bleed more, time to clot is longer, and risk of transfusion is greater.

• Wound infection. Hypothermia is implicated as a contributor to risk of infection in most studies on wound infection. The immune system doesn’t work as well when cold. Blood flow to the wound site is reduced; therefore, white blood cells migrate slower and in fewer numbers. Also, due to reduced tissue oxygenation (local hypoxia), those immune cells that do arrive have reduced killing capability.

• Recovery time. Cold patients metabolize anesthesia more slowly, so they come out from under anesthesia slower, spending more time in recovery and the intensive care unit (ICU). The extra length of stay can vary from hours to days, depending on the surgery performed.

• Patient comfort. Patients who wake up cold shiver, generating heat to warm themselves. Patients who wake in a normothermic state are more comfortable.

Whereas patient comfort may not cause complications and incur extra costs, it’s nothing to sneeze at. The experts who compiled the ASPAN guidelines saw fit to point out that managing hypothermia allows patients to "experience a greater level of comfort, and avoid postoperative shivering and the unpleasant sen-
sation of feeling cold."1 Boothe added: "Patients like to be warm, but they need to be warm for a better outcome."

Although the advantages of maintaining normothermia are clear, ASPAN noted: "Despite the availability of technology to prevent hypothermia, it remains an ongoing problem in the perioperative period."1 The guideline states that "every patient undergoing surgery is at risk for developing perioperative hypothermia," adding that certain factors can contribute to the risk. Very young or very old patients and female patients are at greater risk of hypothermia. Other factors that increase risk include ambient room temperature; length and type of surgical procedure; general bad health and malnutrition; pre-existing conditions such as open wounds, pregnancy, endocrine disease, peripheral vascular disease, etc.; significant fluid shifts, use of cold irrigants; and use of regional or general anesthesia.¹

The Institute for Healthcare Improvement suggests employing the following measures to prevent hypothermia³:

• Limiting heat loss in patients prior to surgery, and keeping their temperature at >36o Celsius;

• Using warming devices;

• Standardizing temperature monitoring method intraoperatively;

• Providing devices and protocol for consistent measurement of patients’ temperature;

• Appointing someone responsible and accountable for thermoregulation;

• Ensuring engineering controls that allow surgical staff to control room temperature;

• Increasing ambient room temperature (and humidity) in the operating room (O.R.);

• Increasing room temperature in the O.R. after the last patient of the day and before the first patient of the next day, so that equipment is warm even if the temperature is decreased during use of the O.R.; and

• Providing surgical staff with cooling gear/devices.

ASPAN’s guidelines also note that "Perioperative hypothermia is
a multidisciplinary/multi-
specialty problem . . . [and] requires the coordinated efforts of anesthesia providers, surgeons, and perioperative, perianesthesia, and critical care nurses."¹

Avoiding the cold shoulder . . .
and more

"There are three types of warming systems," explained Brian Stelley, senior marketing manager, temperature management, Gaymar Industries, Orchard Park, NY, "water-based (conductive), air-based (convective), and warming of blood and other fluids for infusion or irrigation. Gaymar offers all three types of warming systems. Water was the traditional way of warming in the O.R. until the late 1980s, when convective warming was introduced. At that point, air systems became the standard in most surgeries. For certain surgeries, such as off-pump cardiac, the air-based warmers may not be effective; so, the water-based warmers may be preferable. In these surgeries, it may be possible to cover a larger surface area of the patient with a conductive blanket."

"Fluid warming is a secondary means of warming, particularly if infusing large volumes of fluid, and should be used whether air-based or water-based warming systems are employed," said Stelley. "Gaymar offers dry-heat fluid warmers, which are more effective for a wide range of flow rates and have an adjustable set point for temperature, which makes it more applicable throughout the hospital."

The approach taken to managing hypothermia varies with the type and length of surgery to be performed, explained Boothe: "Managing patient temperature is a multi-level problem. For simple procedures, a patient gown, a blanket, and comfortably warm room temperature may be sufficient to prevent hypothermia. Moving up the scale, when fluids are administered, such as for irrigation or transfusion, they should be warmed. It’s important not to insult the body with cold fluids. For more complex cases that last longer than a few hours or incur a large amount of irrigation, forced-air warming should be employed. Covering 60% of a patient with forced-air warmers can keep up with body-heat loss."

"Maintaining normothermia with forced-air warming has been shown to reduce the risk of complications and costs associated with unintended hypothermia," observed Troy Bergstrom, marketing communications manager, Arizant Healthcare, Eden Prairie, MN. "Positive results may include a reduction in the rate of postoperative wound infections, a decreased likelihood of postoperative myocardial infarction, decreased ICU time, shortened length of hospital stay, and lowered mortality rates. Maintaining normothermia can reduce per patient hospitalization costs by $2,500 to $7,000 across a variety of surgical procedures."¹

For some surgical procedures, such as cardiac or orthopedic, covering 60% of the body may be impractical. Kimberly-Clark recently added Universal Thermal Pads to their Patient Warming System (PWS) as an alternative for complicated surgeries that involve exposure of large surfaces and/or large chunks of time. K-C PWS is based on the idea that the best way to warm a patient is to put them in a hot tub, because water transfers heat to the body’s core better than air, 1,500% better, claimed Boothe, adding that water’s capacity to store heat is 3,300 times higher than the same volume of air.

The K-C PWS is comprised of a control module and single-use thermal pads with a hydrogel layer that lies against the skin. Warm water is pumped through, and the effect is "like putting the patient in a whirlpool," said Boothe. "It works under negative pressure, so if the pad should be punctured it doesn’t leak, it just sucks in air. Two regular pads, covering 15% to 20% of the patient’s body, are enough to maintain the patient’s temperature. It’s 5 times more efficient than forced air, meaning the patient can be warmed faster yet with less coverage of the body."

"A warming system should employ all of these measures," said Boothe. "Forced-air is not applicable to all surgeries; neither is use of only a blanket. Hypothermia should be addressed preoperatively, and the appropriate warming tool should be matched to the surgery."

Bergstrom noted that, while the ASPAN guidelines and the American Society of Anesthesiologists’ guidelines encourage use of forced-air warming systems to prevent hypothermia, now "many tools are available to address the dangers of unintended hypothermia. Ideally every facility would warm all its surgical patients, making versatility and breadth of line two important factors [in choosing an effective warming system]. Arizant is well-positioned in these areas with the Bair Paws patient-adjustable warming system, a patient gown that offers both clinical and comfort warming throughout the perioperative process, and the Bair Hugger line of 23 forced-air warming blankets. With the advanced SmartHeat technology of our Ranger fluid-warming system, Arizant can offer patient warming for virtually all needs, from pediatric to geriatric, from brief outpatient procedures to complex cardiac procedures."

Many companies today offer not only products to address health issues but corresponding education to assist healthcare providers and purchasers in understanding the whys and wherefores necessary to arriving at wise decisions. Arizant, Kimberly-Clark, and Gaymar Industries are among those companies to whom education is important.

"Arizant’s PREVENT Hypothermia campaign, launched in September 2005, is an educational program designed to educate on normothermia’s role in reducing surgical-site infections," said Bergstrom. "By telephone (1-888-WARM-36C) or online (www.
prevent hypothermia.org) clinicians may request a complete educational kit. The 4 Simple Steps program, launched last spring, offers a step-by-step guide to preventing unintended hypothermia by improving patient-warming efforts. The 4 Simple Steps kit contains tools and information to assist in the assessment and implementation of an effective patient-warming program and for measuring its success. 4 Simple Steps kits are also available by telephone or online at the same number and
web address," offered Bergstrom.

Kimberly-Clark’s information on hypothermia also can be accessed online. Go to http://www.kc healthcare.com/KNPrograms.asp to see their Knowledge Network site and these educational modules: Surgical Site Infections: Overview and Impact—Unintentional Intraoperative Hypothermia: Consequences and Prevention; and A Business Case for Risk Reduction—Unintentional Hypothermia and the Surgical Patient, Strategies for Reducing Surgical Site Infections, and SSI: The Patient Factor.

Gaymar offers continuing education material for clinicians. "Avoidance of Inadvertent Hypothermia During Surgery" is a self-study guide available from the company (http://www.gaymar.comdoc. asp?id=370&pid=289). In addition, Gaymar conducts in-booth educational sessions at annual meetings such as AORN and offers a Temperature Effectiveness Analysis program (http:/www.gaymar.com/childlist.asp?id= 501&pid=12).

On the flip side:
Relieving the pressure

Another health issue that can be related to surgery, particularly when surgery is prolonged or when prolonged hospital stay follows surgery, also incurring great cost in human suffering and healthcare dollars, is pressure ulcers.

An ounce of prevention . . .

Prevention of pressure ulcers requires constant watchfulness. The Wound, Ostomy, and Continence Nurses Society (WOCN)’s guidelines⁴ recommend that patients be assessed upon admission, inspected daily, and assessed regularly. Measures that can be taken to prevent or treat pressure ulcers include but are not limited to proper care of skin for incontinent patients; maintaining the head of the bed at <30o, when possible; regular and frequent turning and repositioning for bed- and chair-bound patients; pressure-relief exercises, when possible; adequate nutrition; reducing shear; and use of pressure-reduction mattresses in the patient’s room and even in the O.R. for patients that are at risk.⁴

Adrianne "Patti" Smith, MD, medical director, vice president medical, Kinetic Concepts, Inc (KCI), San Antonio, TX, and Kathy Whit-tington, RN, MS, ET, CWCN, director, clinical development, KCI, advised: "Currently, our best means of countering the negative outcomes associated with pressure ulcer development is aggressive education, attention to details, and prevention. The risks posed by pressure ulcer development are multifold and can be lessened by reducing the incidence of pressure ulcers within a given care setting. These risks for patients include pain and suffering, quality of life restrictions, and elevated morbidity and mortality; for healthcare facilities, they include litigation, prolonged length of stay, readmissions, excessive resource utilization, and reputation."

"Pressure ulcers are one of the major costs to hospitals," added Jeanne Perla, RN, PhD, senior medical research scientist, Gaymar Industries, Orchard Park, NY. "Choosing surfaces carefully can save costs and prevent pressure ulcers."

Contributing factors and product solutions

There are several types of surfaces that can help to prevent pressure ulcers and to relieve pain and pressure once they’ve developed. Perla described four types: foam mattresses, which allow the patient to sink into it, redistributing pressure points; alternating pressure mattresses, which have air bladders that alternate every few minutes; lateral-rotation mattresses, which can turn patients from side to side; and low-air loss mattresses, which address the issue of moisture. "Sweaty skin macerates," said Perla.

Smith and Whittington added: "Tissue perfusion, moisture exposure, persistent or recurrent injury, patient nutrition, wound colonization and bioburden, and excessive heat and moisture can contribute to the development of pressure sores. These factors can increase the vulnerability of tissues to damage from direct pressure, friction, and shear forces."

"Pressure ulcers form over bony points," explained Perla, "most often the sacral area, which is the tailbone, and the heels." Because pressure ulcers are prone to infection, Gaymar will soon release the first mattress cover impregnated with silver. As a natural antimicrobial, silver can help to prevent nosocomial infection and to fight the spread of established infection.

"Gaymar also makes many deep-cell products, which are very good at managing shear. They allow the body to submerge, settling into it, redistributing the weight. Isoflex, made of Gelastic material, is the best overlay on the market to handle shear. Shear, the rubbing back and forth of bone within the tissue, is a huge factor in the formation of pressure sores," continued Perla. "The more shear, the less time it takes to develop a sore."

Gaymar Industries is funding an international committee to look at the effects of how shear affects tissue and how support surfaces can better manage shear. Institutions in Japan, Israel, Europe, and North America are participating. The Shear Force Initiative is the first project internationally focused on shear that we’re aware of," said Perla. "The task force started 2 years ago and is making amazing progress."

KCI also is involved in activities aimed at better management of pressure ulcers. "KCI is a long-standing member of the National Pressure Ulcer Advisory Panel (NPUAP) and supports the initiatives the NPUAP is working on concerning pressure ulcers," said Whittington. "KCI also develops and delivers accredited continuing education programs on pressure ulcer etiology (including O.R.-acquired), assessment and documentation, and prevention and treatment interventions. The programs are accredited for nurses, case managers, and, starting in 2007, physical therapists. The programs are available through live, faculty-led presentations and via the Internet at www.KCI1.com. KCI also has a program for nursing assistants to increase their knowledge of pressure ulcers and allow them to become a more valuable member of the pressure ulcer team."

"KCI has the only pressure ulcer
survey process that includes a second patient observation (incidence) to determine true facility-acquired pressure ulcer numbers" continued Whittington. "The incidence data, as well as the KCI national database, can be used to develop an ongoing quality-improvement process around pressure ulcer prevention. Multiple surveys allow facilities to use the data to determine the best interventions for pressure ulcer management and improving outcomes. KCI puts this process together as the Positive Outcomes Wound Care Program to assist facilities with developing pressure ulcer quality initiative."

The bottom line

Patient warming and pressure management are quality of care and quality of life issues. These are only a few of the patient-warming and pressure-management products available to help improve the facility’s quality of care and the patient’s quality of life. Cost must always be considered in making wise purchasing decisions, but bottom line, the final deciding factor should be what truly improves the patient’s status.

There’s want, then there’s need. Of course hospitals want to save money, but patients need products and care that make the most difference to their health and quality of life. It may be that whether wants or needs are met are up to you. Your input may make the difference. So, search, get the facts, and always remember the real bottom line. HPN

REFERENCES

1.American Society of PeriAnesthesia Nurses. Clinical guideline for the prevention of unplanned perioperative hypothermia. http://www.aspan.org/PDFfiles/HYPO THERMIA_GUIDELINE10-02.pdf.

2.Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 1996;334:1209-1215.

3.Institute for Healthcare Improvement. Maintain normothermia perioperatively. http://www.ihi.org/IHI/Topics/PatientSafety/
SurgicalSiteInfections/Changes/SSI+Maintain+
Normothermia+Perioperatively.htm.

4.Wound, Ostomy, and Continence Nurses Society. Guideline for prevention and management of pressure ulcers. (WOCN clinical practice guideline; no. 2) Glenview, IL: WOCN; 2003:1-52.