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A team approach to the prevention of unplanned postoperative hypothermia

AORN Journal, May, 2007 by Jason Bitner, Leana Hilde, Kenneth Hall, Tammy Duvendack

Hypothermia is a common occurrence in certain types of surgical patients. Although planned hypothermia may be part of the care plan for some patients undergoing neurological or cardiovascular surgery, (1) unplanned postoperative hypothermia frequently is a problem for patients undergoing surgery, particularly for patients undergoing total joint replacement procedures.

The American Society of PeriAnesthesia Nurses defines normothermia as a core temperature ranging between 96.8[degrees]F and 100.4[degrees]F (36[degrees]C and 38[degrees]C) and hypothermia as a core temperature lower than 96.8[degrees]F (36[degrees]C). (2) Hypothermia may result in longer patient stays in the postanesthesia care unit (PACU) as well as increased risk of intraoperative blood loss, postoperative wound infections, and myocardial ischemia. (3) Other complications may include altered drug metabolism and coagulopathies.

More Articles of Interest: Unplanned perioperative hypothermia; Recommended practices for the prevention of unplanned perioperative hypothermia; Comparison of three rewarming methods in a postanesthesia care unit; Hypothermia/warming protocols: why are they not widely used in the OR?; Is postanesthesia care unit length of stay: increased in hypothermic patients?

Collaboration between clinical staff members (eg, preoperative, orthopedic, intraoperative, PACU) and personnel in the performance improvement (PI) department at Methodist Medical Center of Illinois, Peoria, Ill, (MMCI) was initiated because of concerns about hypothermia in patients undergoing total joint replacement. Anecdotal information from staff members along with an event form review indicated a number of reported cases of unplanned hypothermia in this population. This afforded the opportunity to conduct a proactive review of the process in a high-volume, high-risk population. The high volume of procedures, large number of older adult patients, and large surface area exposed during these procedures put this group at a higher risk for unplanned hypothermia.

The project team hypothesized that use of a preoperative forced-air warming blanket, in addition to intraoperative warming, would improve patient outcomes by decreasing postoperative hypothermia, thus reducing PACU length of stay and patient morbidity. In this project, staff members from PI and clinical nursing applied evidence-based practice to improve patient outcomes.

The PI process is used to study and develop processes for improvements related to patient care. There are several PI models, each with similar principles of continuously improving processes to deliver care. The foundation of the PI process at MMCI is the "plan-do-check-act" (PDCA) model. This is a never-ending cycle of improvement, which includes planning, implementing the plan, checking the results of the plan, and taking corrective measures or otherwise acting on the results.

THEORETICAL MODELS

A preoperative forced-air warming blanket intervention is compatible with many nursing theories. Using the Neuman Systems Model/in which the patient is viewed as an open system that reacts and adapts to both internal and external stressors, (5) nurses set goals to minimize stressors and prevent mal-adaptation by influencing variables. Minimizing the effects of certain variables will strengthen a patient's line of defense and thus promote a state of wellness. Nurses can minimize stressors by proactively maintaining normothermia.

According to Orem's Self-Care Deficit Theory, in which the patient's self-care deficits are the result of environmental situations, (6) the nurse must attend to the needs that a patient is unable to meet by himself or herself. Patients in the perioperative environment are unable to meet or have difficulty meeting many of their own needs. By warming the patient preoperatively, the nurse assists the patient in meeting his or her physiological needs. Considering this, Wagner states that "attention to patient temperature is the responsibility of all perioperative care providers." (7(p38))

Roy's Adaptation Model, in which the goal of nursing is to promote patient adaptation, (8) views humans as biophysical adaptive systems that react to stress. (9) Preoperative warming helps humans adapt by minimizing complications such as shivering, which can cause cardiac stress. (10)

LITERATURE REVIEW

The project team undertook a literature review covering publications from 1984 to 2005 using both the Cumulative Index to Nursing and Allied Health Literature (ie, CINAHL) and PubMed. Keywords used in the literature searches included

* preoperative warming,

* intraoperative warming,

* postoperative warming,

* perioperative hypothermia,

* intraoperative hypothermia,

* postoperative hypothermia,

* preoperative temperature,

* intraoperative temperature,

* postoperative temperature, and

* warming blankets.

These terms also were used in searches with modifiers including total hip, knee, and joint arthroplasty as well as total hip, knee, and joint replacement. The team then reviewed the references listed in the research articles retrieved in the search results to identify additional publications to be included. Only articles published in English were included in the review.

Many significant findings were noted in the literature.

* "All surgical patients are at a risk for wound infection and this risk increases if tissue perfusion is poor after surgery." (11(p879)) Melling et al" illustrated that a 14% postoperative infection rate was reduced to 5% by applying a 30-minute period of preoperative warming.

Health Care Industry

A team approach to the prevention of unplanned postoperative hypothermia

AORN Journal, May, 2007 by Jason Bitner, Leana Hilde, Kenneth Hall, Tammy Duvendack

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