Operating Room

Maintaining normothermia reaps optimal results for patient
and healthcare facility

by Susan Cantrell, ELS

Temperature is one of the four vital signs. This vital sign comes with good news and bad news. The bad news is that failing to maintain normothermia for surgical patients can have dire consequences. The good news is that hypothermia is easily preventable and cost-effective.

Unintended hypothermia carries significant risks for the patient. It can cause immune-system impairment. The specter of infection, never welcome, can use this as an opportunity to rear its ugly head at the surgical site. Failure to maintain normothermia can cause impaired wound healing, cardiac events, increased blood loss and transfusions, and more, all of which translates to longer healing times and costly, lengthened hospital stays.

3M Bair Hugger Model 635 Underbody Blanket

Troy Bergstrom, Marketing Communications Manager, 3M Patient Warming, 3M, St. Paul, MN, talked about the connection between normothermia and the patient’s health. "Temperature management and infection prevention go hand in hand. Unintended hypothermia can triple the rate of wound infection, extend the length of hospital stay, and increase mortality rates. Maintaining normothermia has long been identified as a key means of fighting surgical-site infections."

Andy Giles, Senior Product Manager, Medline Industries Inc., Mundelein, IL, talked about other serious consequences of failing to maintain normothermia. "Keeping body temperature above 36oC (96.8oF) during surgical procedures can help to reduce surgical-site infections by up to three times. Normothermic patients will also require less blood transfusions and will clear anesthesia agents more readily, thus spending less time in the postanesthesia care unit (PACU) and less time in the hospital."

An important snippet of knowledge was emphasized by Kelley Terrell, Manager, Marketing, Techstyles Nonwovens, Encompass Group LLC, McDonough, GA. "Prevention is better than a cure," she said. "Most patients arrive normothermic, and the first line of defense should be to protect this state through prewarming. The leading cause of unintended hypothermia is redistribution temperature drop, which can be up to 1.6ºC within the first hour following induction of anesthesia. This can quickly move a normothermic patient to hypothermic. This is especially significant in shorter procedures where you may not have enough time to bring the patient back to normothermia intraoperatively and they arrive in PACU compromised."

Connecting the patient’s health to the facility’s pocketbook

Failing to maintain normothermia is of utmost concern to the patient’s health, but it also is important to the facility’s financial health. Lack of reimbursement for consequences related to unintended hypothermia is an issue. Extra costs incurred by the consequences of unintended hypothermia is another.

"Hospitals are being denied reimbursement for treating hospital-acquired infections that are considered reasonably preventable," said Moore, Ecolab. "Maintaining proper body temperature for surgical patients is one more way that hospitals can improve outcomes and prevent these events from occurring."

Giles, Medline Industries, talked further about normothermia’s effect on the facility’s bottom line. "Maintaining normothermia in surgical patients can positively impact a facility’s finances in several ways. For one, a warm patient will have fewer complications and will spend less time in PACU and in the hospital, thus avoiding additional costs that may not be reimbursed. In addition, prevention of cold discomfort and shivering among surgical patients can improve HCAHPS [Hospital Consumer Assessment of Healthcare Providers and Systems] scores, leading to higher reimbursement for Medicare patients."

Bergstrom, 3M, got specific about the costs of unintended hypothermia. "Studies have suggested that maintaining normothermia can result in savings of $2,500 to $7,000 per patient, which might otherwise be spent treating the complications of unintended hypothermia. A 2008 editorial, co-authored by Hannenberg and Sessler in Anesthesia & Analgesia stated, "Maintaining normothermia is generally easy ... furthermore, the most commonly used warming systems are remarkably safe. There are few, if any, anesthetic interventions that have been proven to so markedly improve the outcome of surgery with so little effort, risk and cost."¹

"The cost of cold patients may be higher than you realize," advised Terrell, Encompass Group. "It is common for a facility to use 8 to 10 cotton bath blankets per procedure to supplement active warming. However, patients continue to arrive in PACU cold, experience delayed recovery, and require increased nursing time. This can put a patient’s health at risk as well as the facility’s budget. Proactively managing the patient’s temperature throughout the perioperative journey reduces risk to the patient and preventable cost due to non-reimbursable hospital-acquired conditions."

Advice for purchasers

Thermoflect Heat Reflective Technology from Encompass Group LLC

Heat-reflective warming

Clearly, addressing patient normothermia carries benefits for the patient and facility. The next step is to consider which type of system meets your patients’ and facility’s needs. Check out the variety of products and range of modalities, only a few of which are mentioned here.

"Most facilities have done a great job of establishing temperature-management protocols over the past few years," said Terrell. "Now is the time to use this information as a benchmark to identify opportunities for more cost-effective, efficient, and compliance-driven products."

Terrell explained how Thermoflect Heat Reflective Technology is efficient and effective for patient and facility needs. "Clinical research shows that even mild hypothermia leads to adverse effects, including increased blood loss, delayed wound healing, potential adverse cardiac outcomes, lengthened recovery and hospital stays, and increased risk of surgical-site infections. Simply substituting Thermoflect products for traditional linens is a proven stand-alone solution for procedures less than 1 hour, [which represents] 60% of outpatient surgical procedures. When used to support active warming protocols, Thermoflect products increase the performance of these products and maximize heat retention to protect the patient during holding and transport."

"Choosing more efficient and effective products to support your active warming protocols can result in significant cost savings. In a recent trial, a 165-bed hospital located in the Northeast evaluated replacing cotton bath blankets with heat-reflective warming products, ie, gowns, blankets, and caps. This resulted in an annual cost savings opportunity of $45,000. The OR [operating room] manager stated, ‘That is someone in our department’s salary. I would much rather keep a member of my staff than a bunch of blankets.’"

Ecolab’s IntraTemp Irrigation Fluid Warming System features side pocket warmers for warming extra saline bottles or IV bags.

Fluid warming

Moore, Ecolab, offered advice to purchasers who use fluid-warming products. "When evaluating temperature-management products, buyers should look for devices that improve patient outcomes, drive OR efficiency, and decrease risk to the patient and the facility. Solutions should be portable, easy-to-use, and help facilities meet clinical and quality guidelines. Current protocols may require nursing staff to make multiple trips to and from a warming cabinet to retrieve warm fluids. These fluids may be too hot to use immediately, without risk of injuring the patient, but then will cool quickly in the OR and have a cooling rather than warming effect on the patient. Having a fluid warmer that continuously warms fluid at a controlled temperature available in the OR provides a solution to these challenges."

"Ecolab offers the ORS and IntraTemp Irrigation Fluid Warming Systems, which provide immediate access to warm irrigation fluid within the sterile field. Fluid remains at a safe, consistent temperature throughout the procedure. According to AORN [Association of periOperative Registered Nurses] and ASPAN [American Society of PeriAnesthesia Nurses], the use of warm irrigation fluid should be considered during surgery. AORN also states that irrigation fluids should be at a known temperature at the time of instillation. Fluid-warming systems from Ecolab allow OR staff to control, visualize, and document fluid temperatures properly. Ecolab’s systems feature integrated portable heating basins with single-use sterile drapes. They are easy to operate, minimize the need for the nursing staff to leave the OR to retrieve warm fluid bottles, and eliminate the need to label and rotate saline bottles in warming cabinets. The IntraTemp System also features separate warming pockets for extra saline bottles or IV bags; a rigid, puncture-resistant basin drape; and volume graduation marks for easy documentation of fluid volumes."

Medline’s PerfecTemp patient warming system

Heated table pad

"Some key factors to consider in addition to cost are convenience, efficacy, and safety," advised Giles, Medline Industries. "A convenient, safe, effective warming system that is readily available and easy to employ will aid compliance and improve outcomes on all patients."

One of the most appealing qualities of Medline’s PerfecTemp is its ease of use. "Medline’s PerfecTemp patient warming system consists of an electrically heated memory foam OR table mattress pad and a control unit that controls to a patient interface temperature set by the user. Because the PerfecTemp system is always in place on the OR table, warming 100% of surgical patients is as easy as turning the system on once per day. With PerfecTemp, no additional effort is required, such as applying and removing blankets. With PerfecTemp, no waste is created, and all warming is done from underneath the patient, so there is no interference with surgical access. Warming 100% of surgical patients in a facility can lead to an overall reduction in surgical-site infections."

Medline’s PerfecTemp offers a twofold advantage. Giles cited a study by Sessler et al,² which "concluded that PerfecTemp has shown equivalent performance to forced-air warming devices in maintaining normothermia in open bowel section patients. Also, the secondary objective of the study concluded that the patients using PerfecTemp did not exhibit any pre-ulcerative conditions. The PerfecTemp OR table pad uniquely incorporates both pressure-reducing high-tech material to reduce the incidence of pressure ulcers and a warming system to combat hypothermia. This is important since the incidence of pressure ulcers in the OR may be as high as 66%,³ and they are not only harmful and painful to the patient, they are expensive for the hospital to treat. Also, facilities are not reimbursed by Medicare if the pressure ulcers are acquired in the healthcare facility."

Forced-air warming has a relatively long history in maintenance of normothermia. Bergstrom, 3M, talked about some of its attributes. "Forced-air warming takes on one of the nation’s most crucial healthcare challenges by combining efficient high performance with clinical flexibility and safety. Maintaining normothermia with forced-air warming is one of the easiest, least expensive, and most effective benefits clinicians can offer patients."

"3M provides a full portfolio of warming solutions, including 25 models of 3M Bair Hugger blankets and multiple models of the 3M Bair Paws gowns, offering a solution for virtually any warming need. 3M forced-air warming technology, utilized in 3M Bair Hugger blankets and 3M Bair Paws gowns, has been used to warm more than 180 million patients in its 25-year history. Forced-air warming is the most used and studied method of surgical warming in the country, with clinical benefits, efficacy, and safety well documented in nearly 170 studies and more than 60 randomized controlled clinical trials. A wealth of research supports forced-air warming’s use in reducing the incidence of surgical infections by maintaining normothermia.^4-6

Philips InnerCool RTx Endovascular System warms and cools from the inside out.

Warming and cooling from the inside out

Philips Healthcare, Andover, MA, offers the InnerCool RTx Endovascular System for both warming and cooling. Douglas McCannel, Product Manager, InnerCool, explained its advantages."When thinking about purchasing temperature-
management systems, the first decision is whether to consider a surface or endovascular system. An endovascular system should be the first choice if the aim is to cool as quickly as possible or if there is need to cool awake or conscious patients. Additionally, endovascular systems have little difficulty cooling very large patients. Surface systems don’t cool as quickly, and the larger the patient the longer it takes to cool them. Cooling therapy can be nurse-initiated, since a physician is not required to place the femoral catheter. Also, while a catheter can only remain in situ for up to 72 hours, the pads or blankets used with surface systems can typically be left on the patient 7 to 10 days, which makes them well suited for maintaining normothermia in neuro patients or for general fever control. Endovascular systems and consumables are more expensive than surface systems and consumables, but the tradeoff is cost versus performance." 

McCannel offered further guidance on purchasing an endovascular system. "When choosing among the types of systems, the most important consideration when deciding which endovascular system to purchase is how fast does the system cool, ie, what are demonstrated cooling rates, and does the system have an auto re-warm function that keeps the patient on a tight ramp during the re-warm period of delivering therapeutic hypothermia. Also, does the system offer catheters with built-in temperature sensing to make sure true core temperature is driving therapy? On the surface side, while most console systems perform similarly and have similar features, pad sets consisting of a chest pad and two thigh pads perform dramatically better than just using blankets. Also, some available pad sets might affect skin integrity over time, so that characteristic needs to be evaluated when assessing the pad sets offered by vendors."

ZOLL, Chelmsford, MA, is another company that manages patient temperature from the inside out. ZOLL’s Intravascular Temperature Management method circulates saline through multiple balloons of the Alsius catheter in a closed-loop design. The patient’s blood is quickly cooled or warmed as it passes over each balloon.

ZOLL’s catheter can be used instead of a triple lumen central venous catheter, because its design combines temperature management with the functions of a standard central venous catheter. The ZOLL catheter is inserted into the central venous system of the patient, femoral, subclavian, or internal jugular insertion. Simply set the target temperature and desired rate of temperature change. The Thermogard XP system adjusts the temperature of the saline flowing within the Alsius catheter balloons. Patient and system data are transferred electronically to the patient’s file every 60 seconds. It can be viewed on the system display or synchronized with your hospital monitor.

3M SpotOn temperature monitoring system

Core temperature monitoring

The 3M SpotOn system uses a single disposable sensor, placed on the patient’s forehead prior to surgery, to effect noninvasive core-temperature monitoring, providing simple and cost-effective monitoring and recording of core body temperature before, during, and after surgery. The sensor remains on the patient and can be reconnected at each point of care, eliminating the need for multiple monitoring devices. A memory chip within the sensor allows a 2-hour continuous visual display of the patient’s temperature on the control unit.

Find the match for your facility’s need

Products mentioned here are only a sampling of what is available. Searching for what sort of warming or cooling product best suits your facility’s needs is summed up in a comment by Bergstrom: "Ultimately, it comes down to a question of what technology will best position the hospital to warm every surgical patient, achieve the guideline goal of perioperative normothermia, and even improve patient satisfaction, all in a cost-effective way."
 

References

1. Hannenberg AA, Sessler DI. Improving perioperative temperature management. Anesth Analg 2008;107:1454-1457.

2. Egan C, Bernstein E, Reddy D, Ali M, Paul J, Yang D, Sessler DI. A randomized comparison of intraoperative PerfecTemp and forced-air warming during open abdominal surgery. Anesth Analg 2011;113(5):1076-1081.

3. Recommended practices for positioning the patient in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010.

4. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med 1996:334:1209-1215.

5. Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet 2001;358:876-880.

6. Barie PS. Surgical site infections: epidemiology and prevention. Surg Infect (Larchmt) 2002;3(Suppl):S9-S21.