Warm and comfortable

Managing temperature and pressure for optimal outcomes

Photo courtesy D.A. Surgical

Temperature management and pressure management are prime concerns for surgical patients. If not attended to properly, both issues can cause adverse outcomes, with increased misery for the patients, and a massive blow to the facility’s budget.

Temperature management

Plenty of research shows that maintaining intraoperative normothermia using effective temperature management equipment and best practices is much more cost-effective than treating adverse outcomes. It shortens length of stay, decreases ICU time, reduces rate of wound infection, myocardial infarction, and use of blood products. It also keeps patients alive. Adverse outcomes are costly. One study found that hypothermia averaging only 1.5°C below normal resulted in added costs between $2,500 and $7,000 per surgical patient.1

According to Al Van Duren, Director of Scientific Affairs, 3M Patient Warming, “Unintended hypothermia remains a common, but easily preventable, complication of anesthesia. Even a small drop in core body temperature can result in unintended hypothermia, which is why continuous monitoring and management of patient temperature in accordance with industry guidelines is critical.”

3M Bair Hugger Temperature Monitoring System

Van Duren explained how 3M’s Bair Hugger normothermia system works to monitor and maintain normothermia. “During the entire perioperative period, the 3M Bair Hugger temperature monitoring system provides an integrated, accurate, noninvasive, and easy-to-use temperature monitoring system that continuously measures patients’ core body temperature and provides standardization throughout the perioperative journey. It can be used with both anesthetized and awake patients and allows providers to manage patient temperature actively and avoid costly complications of unintended hypothermia.”

In response to concerns that some healthcare providers and patients were not using forced-air warming systems because they feared it could increase risk of surgical-site infection, a recent letter from the FDA states that using thermoregulation devices during surgery, including forced-air thermoregulating systems, results in less bleeding, faster recovery times, and decreased risk of infection for patients. The letter states, “After a thorough review of available data, the FDA has been unable to identify a consistently reported association between the use of forced air thermal regulating systems and surgical site infection. Therefore, the FDA continues to recommend the use of thermoregulating devices (including forced air thermal regulating systems) for surgical procedures when clinically warranted. Surgical procedures performed without the use of a thermoregulation system may cause adverse health consequences for patients during the postoperative and recovery process.”

“The FDA letter was an important reminder to healthcare providers that it continues to recommend surgical patients be warmed when clinically warranted,” noted Van Duren. “We support the statement, reiterating that using 3M’s Bair Hugger Forced Air Warming devices to maintain normothermia is a safe, effective tool to help achieve successful surgical patient outcomes.” Van Duran said the product’s vast research compendium details the clinical benefits of perioperative normothermia produced by forced-air warming. “Updated in July 2017, it now includes summaries of more than 200 studies across a wide range of surgeries providing insight on basic physiology, safety, effectiveness, or health economics of forced-air patient warming,” he said.

Cindy Wasmund, RN, Cincinnati Sub Zero, pointed out the history of normothermia is a relatively new but vital issue. “Since the 1990s and Dr. Sessler’s original work on unintended perioperative hypothermia, it has been known that patient core temperatures below 36˚C during surgery have contributed to adverse events on patients. Numerous advisory boards—such as Association of periOperative Registered Nurses (AORN), American Society of Peri Anesthesia Nurses, and National Institute for Health and Care Excellence—have created guidelines to help prevent hypothermia. These guidelines include recommendations such as pre-warming patients before surgery for at least 20 minutes, considering the unique needs of the patient, and using more than one modality for warming.”

Cincinnati Sub Zero’s WarmAir and FilteredFlo Upper Body Blanket

She cited Sessler’s study from 2015, which found “more than 50 percent of patients undergoing non-cardiac surgery and warmed with forced-air warming experienced unintended perioperative hypothermia at one hour into the procedure.2 One modality will not always work for all patients, and most often a combination of modalities is needed to help prevent hypothermia.”

Wasmund explained that Cincinnati Sub Zero offers several methods for actively warming patients. “We focus on providing products that deliver accurate temperature control, as well as providing comfort to the patient. One of these product lines is the WarmAir and FilteredFlo convective warming system, which has blankets designed to diffuse warm air provided to the patient and to filter out 94 percent of air particulates. This can help maintain a clean environment in the operating room for the patient and their caregivers.

“By keeping your surgical patients warm, “continued Wasmund, “you can cut costs associated with longer recovery periods, increased incidence of wound infections, and increased need for blood transfusions.3 By avoiding shivering, the patients will have less discomfort, which may lead to better HCAPS [Hospital Consumers Assessment of Healthcare Providers and Systems] patient satisfaction results.”

Pressure-injury management

There is bad news and good news on the pressure-injury front. “Pressure ulcers are a costly, debilitating, and avoidable complication of surgery,” noted Lumbley et al.4 Keeping prevention in mind, all surgical patients should be viewed as at risk for PIs, noted Walton-Geer, another study author. “In the OR, factors related to positioning, anesthesia, and the duration of surgery, in addition to patient-related factors, all can affect PU [pressure ulcer] development.”5

Prevention of PIs is relatively simple in many cases. By following recommended standards, chances of complications often can be avoided. Standard practice related to surgical positioning of the patient is to provide optimal visualization of, and access to, the surgical site that causes the least physiological compromise of the patient, while protecting the skin and joints.6 Unfortunately, guidelines are not always followed religiously by some.

Complications are costly. With incidence rates ranging from 0.4 percent to 38 percent in acute-care settings, “pressure ulcer treatment costs range from $2,000 to $70,000 per wound, with the average hospital’s total costs being between $400,000 and $700,000 annually … The Centers for Medicare and Medicaid Services classifies stage 3 or 4 pressure ulcers that occur after hospital admission as a ‘never event’ that will not be reimbursed by Medicare,”7 states the Agency for Healthcare Quality and Research.

Kristen Thurman, PT, CWS, Vice President, Clinical Affairs, Wellsense, observed, “Surgery-related PIs are very common because patients are immobilized for prolonged periods on a relatively hard surface.8 The use of anesthetic agents decreases muscle tone, which normally would help protect tissues from pressure exposure. This damages tissues mechanically and decreases perfusion, leading to tissue death. Postsurgery, the anesthesia prevents patients from feeling pain or pressure that would trigger them to seek relief.”

VŪ — Advanced Pressure Vizualization System, by Wellsense, Inc.

“International pressure-ulcer guidelines recommend positioning patients to reduce the risk of PI development during surgery,”9 continued Thurman. “This includes using support surfaces to offload pressure points and making sure the heels are free of the surface. Redistributing high-pressure areas pre- and postsurgery are also recommended.”

Wellsense’s solution makes it easy to spot problem areas. “Wellsense’s VŪ utilizes a 10-inch display to show where pressure exists between the patient and the operating table in real-time,” explained Thurman. “This allows staff to offload and redistribute pressure while positioning patients for surgery. Throughout the surgery, the areas of pressure, the measurement of pressure, and the duration of pressure can be recorded and reported to the postoperative staff, so those areas can be offloaded postsurgery.”

Thurman discussed how Wellsense’s VŪ can alleviate financial burden related to PIs. “Including treatment and lost revenue, each hospital-acquired PI (HAPI) can cost a hospital upward of $165,000. A 500-bed hospital performs approximately 10,329 surgeries per year.10 With a 15 percent incidence rate, they would acquire 1,549 HAPIs per year. With a low estimate of $5,000 per HAPI, the cost to the hospital is $7.7 million. With the use of Wellsense technology, hospitals can reduce the risk of HAPIs by 88 percent.”11

Marilyn Norrie, Senior Specialist, Brand/Product Marketing, Ansell, also talked about the importance of proper positioning in preventing PIs. “In the operating room, pressure ulcers can develop from improper positioning, inadequate padding and protection, incorrect use of positioning devices, and extended periods of pressure. Positioning perioperative patients on surfaces that redistribute pressure may reduce the risk for PI.”

Norrie emphasized the importance of adhering to AORN Guidelines for Positioning the Patient.12 For example, the guidelines state, “Pressure redistribution is the ability of a supportive material to distribute the load over a broader surface or contact area . . . to prevent ‘bottoming out’, it is important that support surfaces provide at least 1 inch of supportive material between the bed and the patient’s body as the patient rests on the positioning device.”13

ProForm patient positioners from Ansell

Norrie referred to the Agency for Healthcare Research Quality guidelines,7 saying, “Pressure ulcers cost $9.1 to $11.6 billion per year in the U.S. Cost of individual patient care ranges from $20,900 to $151,700 per pressure ulcer. In addition to the cost of care, for which the Centers for Medicare and Medicaid Services no longer reimburse facilities, hospitals are at risk for lawsuits related to pressure ulcers. More than 17,000 pressure-ulcer–related lawsuits are filed every year, with a typical settlement cost being approximately $250,000.”14

Ashley Emerick, Marketing Communications Manager, Xodus Medical, Inc, described how The Pink Pad and DermaProx address prevention of PIs. “Using a material designed specifically for direct skin contact can drastically reduce skin redness, which is one of the early signs of a developing pressure ulcer. Both The Pink Pad and DermaProx material are soft, open-cell, breathable, and moisture-wicking to mitigate risk of pressure ulcers and promote safer patient positioning. The Pink Pad and DermaProx utilize the latest material advancements to yield safer, consistent results, which are extremely important for the patient and the facility’s pocketbook.”

Emerick referred to comments from experienced users of The Pink Pad and DermaProx. Pam Goss, Robotics Coordinator, UCSD Thornton Hospital, La Jolla, CA, said, “The Pink Pad material is incredibly comfortable. It molds to the patient’s contours and grips the skin while reducing pressure and shear.”

Xodus Medical’s Surgical BackPacks (left) and Pink PadXL (right) positioners

Maria Kramer, Director of Neurosurgery at a large level-1 trauma center in Pittsburgh, PA, believes, “DermaProx is far superior to the foam products we used before. Unlike traditional table covers, DermaProx helps prevent skin tears and shear. Unlike foam pads, DermaProx removes moisture, preserving skin pH, and preventing irritation and breakdown.”

“The material is designed to wick away moisture and preserve skin integrity. It’s truly a no brainer — better for the patient and better for facility economics,” said Joe Jung, Department Administrator, Perioperative Services, Kaiser Permanente Los Angeles Medical Center.

The surgical table may be where PIs begin, but care following surgery is equally important, noted Barrett Larson, MD, Leaf Healthcare CEO and co-founder. “Pressure injuries are areas of damage to the skin and underlying tissue caused by prolonged pressure in combination with friction and shear. Whereas these injuries typically occur in patients with reduced mobility, such as those confined to a bed or chair, patients who have had surgery are at particularly high risk.”

Compliance is critical

Insufficient adherence to guidelines on turning patients at regular intervals to relieve pressure contributes to injury, explained Larson. “Pressure-ulcer prevention guidelines recommend patients be turned frequently to prevent the effects of sustained pressure. However, studies show compliance with turn protocols ranges between 15 percent and 66 percent. Compliance is typically worse for critically ill patients, where some studies have found that less than 5 percent of these patients are repositioned sufficiently. In busy clinical settings, patient turning takes a back seat to immediate needs. But the cumulative impact of sustained pressure is clear: Hospital-acquired PIs are one of the most common and preventable hospital-acquired conditions, affecting up to 10 percent of hospitalized patients and adding $11 billion to annual U.S. healthcare costs.”

The Leaf Patient Monitoring System

Larson described how the Leaf Patient Monitoring System has been clinically proven to prevent PIs by identifying patients who could benefit from repositioning and pressure-relief maneuvers. “Pressure injuries are particularly common in surgical patients because of the prolonged immobility that occurs in the perioperative period,” he said. The Leaf Patient Monitoring System uses a wireless sensor that adheres to a patient’s chest, monitoring all patient movement. Movement data is collected and tracked. “The Leaf system can be used to optimize positioning in the preoperative and postoperative period to help mitigate any ischemic tissue injury that may have occurred intraoperatively due to prolonged positioning.”

Randy Schwartz, Vice President of Marketing, Mölnlycke Health Care, said their company offers two critical components for pressure-ulcer prevention: prophylactic dressings and positioning devices. “Prophylactic dressings used as part of a pressure-ulcer prevention protocol have been shown to offer significant benefits and are supported by an international practice guideline. Mepilex Border dressings from Mölnlycke have more than 70 pieces of published and peer-reviewed evidence supporting their effectiveness in preventing pressure ulcers.”

Schwartz referred to a specific, recently completed observational study of pressure-ulcer prevention that “provided real-world health economic evidence from a cohort of 1.03 million patients. The study showed that the prophylactic use of Mepilex Border Sacrum reduced per patient treatment costs by $77, yielding a 64 percent savings.”16

Mepilex Border sacrum dressing, and Z-Flo fluidized positioner from Mölnlycke

Mölnlycke also offers unique fluidized positioners that help achieve pressure redistribution as well as neutral body alignment,” said Schwartz, providing an example: “Small Z-Flo Fluidized Positioners can be used to offload the occiput and promote a patent airway. When the head rests on a flat surface, it creates intense pressure on a small area. The fluidized positioner distributes that weight and pressure across a larger area, while also protecting the patient by filling in the gap under the neck.

“Boosting, turning, and positioning immobilized patients are important interventions in pressure-ulcer prevention,” Schwartz averred. He cited a study performed at New York’s St. Francis Hospital, a 300-plus bed, acute-care hospital. “A performance improvement project using Mölnlycke turning and positioning products reduced caregiver injuries and claims related to patient handling by 55 percent compared with the prior year and decreased specialty bed rentals by 66 percent, saving $58,000.”17

Among D. A. Surgical’s offerings are advanced foam contoured positioners,” said Dan Allen, the company’s founder. “[The positioners] now exist for operating-room table surfaces that provide volumetric re-distribution of pressure away from bony prominences. New technologies are so effective that comparative interface pressure-map testing clearly demonstrates that use of flat gel overlays interferes with advanced engineered foam technology and, in doing so, increases interface pressures at bony prominences.”

Allen also noted that D. A. Surgical offers “fluid-immersion simulation technology for high-risk patients that creates an environment conducive to normal tissue metabolism.”

D.A. Surgical’s fluid immersion pad with monitor readings

Convincing decision-makers

Allen offered good advice for those seeking products to help prevent operating-room–acquired pressure ulcers (ORAPUs). “Prevention requires comparative historical data, a great deal of initial investment, and intelligent research.” He suggested researching independent clinical articles, qualifying user testimonials, observing simulated use to determine efficacy, performing side-by-side comparative analysis, and then reviewing the summary of data before presenting your conclusions to the powers that be.

“The good news is that ORAPUs are now an avoidable tragedy,” declared Allen. “The technology to prevent ORAPUs exists. Initial investment in obtaining the available generational technology improvements necessary to prevent ORAPUs comes at no small cost. Chief nursing and medical officers must understand that there is a direct correlation between investing in prevention and long-term patient outcomes. I have been in the industry for nearly 40 years,” Allen said, “and I continue to be appalled that there is not more investment in prevention, unless—or until—the hospital gets involved in legal entanglement.”


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  2. Sun Z, Honar H, Sessler DI, et al, Intraoperative core temperature patterns, transfusion requirement, and hospital duration in patients warmed with forced air. Anesthesiology. 2015 Feb;122(2):276-285.
  3. Torossian A. Thermal management during anaesthesia and thermoregulation standards for the prevention of inadvertent perioperative hypothermia. Best Pract Res Clin Anaesthesiol. 2008;22(4):659-668.
  4. Lumbley JL, Ali SA, Tchokouani LS. Retrospective review of predisposing factors for intraoperative pressure ulcer development. J Clin Anesth. 2014 Aug;26(5):368-374.
  5. Walton-Geer PS. Prevention of pressure ulcers in the surgical patient. AORN J. 2009 Mar;89(3):538-548.
  6. Association of Surgical Technologists Education and Professional Standards Committee. AST Standards of Practice for Surgical Positioning. (https://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/Standard%20Surgical%20Positioning.pdf)
  7. Agency for Healthcare Quality and Research. Using tools and guidelines to significantly reduce hospital-acquired pressure ulcers. https://www.medscape.com/viewarticle/722042_3. Last accessed November 30, 2017.
  8. Chen HL1, Chen XY2, Wu J. The incidence of pressure ulcers in surgical patients of the last 5 years: a systematic review. Wounds. 2012;24(9):234-241.
  9. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.
  10. American Hospital Association. AHA Hospital Statistics. AHA; Chicago, IL; 2015.
  11. Walia GS, Wong AL, Lo AY, et al. Efficacy of monitoring devices in support of prevention of pressure injuries: systematic review and meta-analysis. Adv Skin Wound Care. 2016 Dec;29(12):567-574.
  12. Guillen MA, Bell M, Bowling C, et al. CVOR Hospital Acquired Pressure Ulcer Reduction Project. Poster presented at Anaheim, CA. Association of PeriOperative Registered Nurses Annual Meeting. April 2-7, 2016.
  13. Association of periOperative Registered Nurses. 2017 Guidelines for Perioperative Practice. AORN: Denver, CO; 2017.
  14. Scott-Williams S. Prevent patient positioning problems: practical advice to reduce injuries from prolonged pressure and improper positioning. Outpatient Surgery Magazine. 2006:VII (12):50-54. http://www.outpatientsurgery.net/surgical-facility-administration/patient-safety/prevent-patient-positioning-problems–12-06. Last accessed November 30, 2017.
  15. Larson B, et al. Impact of turn compliance on probability of hospital-acquired pressure injuries (HAPI): a multi-center analysis. National Pressure Ulcer Advisory Panel Biennial Conference; New Orleans, LA; 2016. Poster.
  16. Padula WV. Effectiveness and value of prophylactic 5-layer foam sacral dressings to prevent hospital-acquired pressure injuries in acute care hospitals. An observational cohort study. J Wound Ostomy Continence Nurs. 2017;44(5):1-6.
  17. Trevellini AC. Connecting the dots: pressure ulcer prevention and safe patient handling. Wound Ostomy and Continence Society annual meeting; 2015. Poster.


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