Complications may include slower healing, excess bleeding and blood transfusions, re-operation, more time on a ventilator, more time in the post-anesthesia care unit (PACU) or intensive care unit (ICU), surgical-site infection (SSI), and more.

Brian Stelley, senior marketing manager, Gaymar Industries, Orchard Park, NY, explained why surgical patients are at risk: "Studies have shown that SSI rate in unwarmed patients is higher than in patients who have been kept normothermic. The body’s principle defense against surgical pathogens is oxidative killing of bloodborne neutrophils. Hypothermia triggers constriction of blood vessels, decreases blood flow to tissues, and decreases oxygenation of surgical-wound tissues, allowing bacteria a more favorable environment in which to grow."

Maintaining a consistent body temperature is critical to improving outcomes, according to Kurt Huelsman, vice president and surgical segment manager, Ecolab Healthcare, Alpharetta, GA. "Surgical patients are at an increased risk for hypothermia because, when under anesthesia, the body’s systems, including the hypothalamus, which regulates internal body temperature, shut down. As body temperature drops, it becomes increasingly difficult to ward off infections. Managing the patient’s temperature throughout the entire surgical process reduces the chances of incurring an infection. This is why it is so important to recognize the opportunities before, during, and after surgery to prevent the effects of hypothermia."

Enthermics fluid warmers equipped with the optional WarmWatch package

The new normothermia measure financial incentive

A new Surgical Care Improvement Project (SCIP) measure on surgery patients with perioperative temperature management was adopted recently by the Centers for Medicare and Medicaid Services (CMS). It comes with an incentive to do better. "CMS has developed a plan to reward healthcare facilities for keeping patients normothermic during surgery," said Allison Doviak, associate marketing manager for communications, medical division, Cincinnati Sub-Zero Products, Inc., Cincinnati, OH.

It’s true. Facilities that observe the new normothermia measure successfully will reap a financial reward; those that don’t will suffer financially. Money can be a great motivator.

Robyn Whalen, marketing director of North American medical devices, Kimberly-Clark Health Care, Roswell, GA, explained how the reward-penalty system works: "As described by the CMS 2010 IPPS Final Rule, reporting of a new metric is required for all discharged patients who had a surgical procedure that lasted 60 minutes or longer. Hospitals that successfully report their metrics in FY2010 will receive an FY2011 inflation adjustment to their CMS payment level of +2.1%. Hospitals that fail to successfully report their metrics in FY2010 will have their FY2011 CMS payment inflation offset reduced from 2.1% to 0.1%."

Aside from the CMS payment, performing well is definitely its own reward in this case. It’s simple: complications cost; temperature management can help to reduce costs attributed to complications. Scott J. Orr, marketing manager, temperature management, Smiths Medical, Norwell, MA, noted: "We see an increase in temperature monitoring driven by the recent SCIP-INF-10 guidelines and the greater knowledge that patient warming can reduce costs and improve patient outcomes by preventing SSIs. Clinical evidence has shown that patients who remain normothermic throughout the surgical procedure have improved outcomes. This was not a common belief a few years ago, but, given the numerous clinical evaluations and implementation of the new SCIP-INF-10 patient-warming guideline, patient warming is now a major driver in reducing facility costs and improving patient outcomes."

What does the new normothermia measure mean, in a practical sense, for healthcare facilities? Troy Bergstrom, marketing communications manager, Arizant Healthcare, Eden Prairie, MN, explained: "It means hospitals likely will be warming patients that, in previous years, may have gone unwarmed. It’s a great thing for patients, and it will benefit hospitals, in the long run, as they avoid the costs of complications associated with hypothermia. To meet the measure, facilities need to use active warming methods or achieve the target temperature of 36°C in the operating room (OR) or PACU. Forced-air warming, which thousands of hospitals already use, is considered ‘active warming’; so, for most facilities, it’s just a matter of using it with more patients."

Whalen, Kimberly-Clark Health Care, added: "Hospitals will need to look at their outcomes and report active warming when they aren’t able to achieve the target of 96.8°F or above. According to the new CMS measures, active warming is limited to forced-air warming, conductive, over-the-body active warming, or warm-water garments. This change in definition goes into effect on April 1, 2010. Hospitals may have to reconsider what they are using as active warming in their current cases if the technologies do not fall within CMS’s new definition."

Change often is accompanied by challenges. Bergstrom, Arizant Healthcare, addressed some of those challenges: "Warming more patients may initially seem like a budgetary challenge. However, when you compare the costs of warming a patient to the estimated $2,500 to $7,000 per patient cost of treating complications associated with unintended hypothermia, warming is easily viewed as a wise investment. There also will be a need to effectively warm patients undergoing procedures that have historically been considered difficult to warm; for example, surgeries on spinal tables or those using lithotomy positioning."

Other challenges exist as well, noted Tom Parafinik, director of sales, Enthermics Medical Systems, Menomonee Falls, WI: "The obvious challenge will be to see that the patient does not become hypothermic so they will not risk not being reimbursed. There are specific, low-cost measures available to guard against perioperative hypothermia. The easiest and most cost-effective are using blanket-warming cabinets to pre-heat blankets to place on the patient. Fluid-warming cabinets should also be used to pre-heat both IV infusion and irrigation fluids."

Ecolab’s ChillBuster Mobile Patient Warming System helps stabilize patient body temperature on the move

The experts offered some good general advice for purchasers on important features and capabilities buyers should look for in temperature-management products.

Examining your current system and assessing whether it is meeting expectations is an important first step, noted Orr, Smiths Medical. "Healthcare facilities should evaluate and acquire products designed to address their specific needs. Smiths Medical Heat TQM performance-improvement program allows the use of evidence-based methods to evaluate the effectiveness of their warming methods. Just because a facility utilizes active warming products does not necessarily mean that the system is producing the expected results. Smiths Medical Heat TQM program is designed to illustrate how their current system is performing and how the Smiths Medical patient-warming portfolio can address their gaps."

Investigate the science behind the product, urged Bergstrom, Arizant Healthcare, to assure that what you buy for your hospital has been proven to perform as claimed. "With the normothermia measure now a reality, products with broad clinical flexibility and proven efficacy are more important than ever. For example, a product that can be used before, during, and after surgery, and with upper- and lower-body cases, offers a practical, economic solution as more patients are warmed. Also, hospitals should ensure products being considered have ample clinical evidence to demonstrate that they help patients achieve normothermia; after all, that’s what the measure is about. Learn the facts. Ask for efficacy studies."

Gaymar’s Medi-Temp blood and fluid warmer

Doviak, Cincinnati Sub-Zero Products, advised: "Some important things to consider in looking for the right temperature-management products are how they affect standard operating procedure. Caregivers need to keep their patients warm without additional hazards. They don’t need a product that will create excess noise, a large amount of air flow, or patient discomfort. Your temperature-management product should not interfere with patient care."

Consider temperature-management products that can be used throughout the perioperative environment, from the preoperative area through surgery and into the PACU, advised Stelley, Gaymar Industries. "There are ways of using the traditional configurations of forced-air warming blankets as well as newer products that are specifically designed for multi-area use. As always, cost effectiveness as well as clinical effectiveness is key."

Huelsman, Ecolab Healthcare, suggested looking for devices that are portable, easy-to-use, and effective. "The current standard often requires nurses to make multiple trips to and from a blanket-warming cabinet to attain warm blankets, which reduces efficiency. Additionally, using multiple blankets to warm patients increases laundry costs. Mobile patient-warming systems allow for more efficient and consistent perioperative care."

Parafinik, Enthermics Medical Systems, talked about how their product can help to manage temperature effectively: "Blanket warmers should have the capability to reach 200°F. This allows for the warmest blankets and the most economical way to prevent patient heat loss. Fluid warmers should have the ability to display not only the set temperature but also the actual internal temperature of the warming cabinet. Fluid warmers should also have a very tight temperature range to conform to fluid manufacturers’ recommendations. This will ensure optimal temperature of the fluids, which will lead to a warm patient and a good outcome."

Money always must be a consideration, even where optimal patient care is concerned. Orr, Smiths Medical, suggested perspective has a lot to do with the balance. "Patient warming should not be viewed as a singular approach but as a holistic approach designed to reduce costs and improve patient outcomes. A relatively low-cost, multifaceted approach (fluid, convective, and conductive warming) will ensure a warm patient."

Bergstrom, Arizant Healthcare, also indicated that the balance between the two may not be as difficult to achieve as one might think. "While hospitals initially may see this CMS measure as an additional financial burden, it may actually result in significant financial savings. Comparing the cost of a forced-air warming product to the estimated $2,500 to $7,000 per patient cost of treating serious hypothermia-related complications, warming more patients makes economic sense."

Parafinik, Enthermics Medical Systems, offered an illustration to demonstrate the cost-effectiveness of their product: "To use a simple analogy, using warming cabinets for blankets and fluids can be compared to cooking at home using your own oven, which is much more cost-effective than going out for meals. It also eliminates the waste associated with takeout food packaging, which can be compared to the high cost of disposables associated with other types of active warming devices. In the same way that you make a one-time capital purchase for your oven and use it over and over, so you do the same when you purchase the best-quality warming cabinets available today. Buying an Enthermics warming cabinet is an investment in ongoing cost reduction at any healthcare facility."

Stelley, Gaymar Industries, pointed out: "In the United States, most temperature-management equipment, both forced-air and fluid-warming, is placed in the hospital’s perioperative environment at no expense to the facility; so, little capital outlay is required. Water-based equipment is purchased. However, this equipment is normally kept for specialized surgical cases; each OR does not need to be equipped with one."

"Most of the cost associated with hypothermia occurs after the surgery," observed Whalen, Kimberly- Clark. "For example, the most expensive place in the hospital after the OR is the ICU; so, by moving a patient to a general floor sooner, facilities can see a large savings financially. To help assist facilities, Kimberly-Clark does a cost-benefit analysis that compares current warming practices and results with expected results by implementation of the Kimberly-Clark Patient Warming System."

The bottom line, noted Doviak, Cincinnati Sub-Zero Products, is this: "Maintaining normothermia is extremely cost-effective because it can reduce the time a patient needs to stay in the hospital to recover. The U.S. Department of Health and Human Services states that there are lower infection rates and shorter lengths of hospital stays with patients who maintained normothermia. Different procedures require different methods for success. Depending on the doctor and the circumstances, the best method of active warming may vary."

The experts also weighed in on what can we look forward to seeing in the patient-temperature—management arena in the future.

Doviak’s thoughts turned green: "As the environment continues to move to the forefront of the decision-making process, people will continue to look for sustainable products." Stelley, Gaymar Industries, added: "Technologies may become available that do not use disposables but can be cleaned and re-used, as well as technologies that cover less of the body surface than forced-air warming or water blankets and [are] therefore more convenient for the anesthesiology-surgical teams to use."

Orr, Smiths Medical, believes that a more holistic approach will prevail. "We see an increased adoption of a multifaceted approach to patient warming. Singular methods of patient warming may meet the guidelines, but an optimized, holistic solution for reduction of costs and improved patient outcomes will only be realized with a protocol that includes fluid-, convective-, conductive-warming systems and temperature monitoring."

The new normothermia measure may also influence the direction of patient-temperature management, according to Whalen, Kimberly-Clark. "As more and more attention is given to the connection between hypothermia and SSIs, and because of mandatory normothermia metric reporting, it is very possible that we may see a movement toward mandated patient temperatures for certain cases. Facilities will standardize to the best preventable solutions they have and mandate them. Most hospitals adhering to best practices are already doing that. At the end of the day, it’s all about having the right technologies in place to deliver the best patient care possible, while preventing costly negative outcomes."