Running head: FINAL SUMMARY REPORT 1

Final Summary Report

Angela Wetli

Bon Secours Memorial College of Nursing

Synthesis of Nursing Practice

Nur 4242

Wendi Liverman

March 26, 2017

I pledge.

Final Summary Report

Introduction

It is the responsibility of the entire operating room team to ensure that

each surgical patient is safely cared for and given the best experience

possible. The St Francis Eastside perioperative team prides themselves on

excellent care. One patient safety issue that needs to be addressed is

maintaining the surgical patients temperature throughout surgery and not

allowing the patient to become hypothermic. Unplanned hypothermia can

be a serious adverse event for perioperative patients. In addition to causing

discomfort for the patient, hypothermia may contribute to complications,

including myocardial events, incision-site infection, and slower healing time,

among others, and may result in a longer hospital stay (Bashaw, 2016, p.

305). There are several recommended interventions to help maintain a

normal body temperature for surgical patients including administering warm

IV fluids to the patients. Currently the St Francis Eastside does not have a

fluid warmer in the preop unit. The goal of this change project is to prove

that a fluid warmer is needed in preop in order to administer warm IV fluids

to surgical patients rather than room temperature fluids.

Currently at St Francis Eastside there are multiple interventions used to

maintain the surgical patients temperature during surgery. A warming gown

is placed on each patient that has a surgery time of greater than 60 minutes.

This warming gown can be attached to a heating system beginning in preop

and continuing on until recovery. Also, every effort is made to keep each

patient covered as much as possible during surgery in order to keep them

warm. However, one intervention that is not used is warm fluids during preop

in order to maintain the core body temperature throughout the surgery.

Researchers found that warmed intravenous fluids kept the core

temperature of study participants about a half degree warmer than that of

participants given room temperature intravenous fluids at 30, 60, 90, and

120 minutes, and at the end of surgery (Campbell, Alderson, Smith, &
FINAL SUMMARY REPORT 3

Warttig, p. 3). There are patients that come to the recovery room that have a

decreased body temperature, or hypothermia following surgery despite the

current interventions used.

Explanation of Project

The current practice in the preoperative area of St Francis Eastside is

to use room temperature IV fluids on each surgical patient in the preop area.

There is a fluid warmer on the unit, but it is located in the center OR core. It

not convenient for the preop nurses. The temperatures of 8 patients were

take using room temperature fluids. The patients temperature preop and

then the temperature following the surgery. Four of the eight patients in the

study were hypothermic upon entering the recovery room. This process

currently needs improvement. This change project will show the need to

update this process and purchase a fluid warmer for the preop area. It has

been calculated that the administration of 1 liter intravenous fluid at room

temperature (21C) decreases core body temperature by .25C (John, Ford,

& Harper, 2014, p. 624). The table below shows the temperatures of eight

patients using the current practice of room temperature IV fluids.

Table 1

Surgery Type Length of Preop Temp Postop Temp Postop

Surgery Infectiom
Hysterectomy 1.5 hours 98.1 97.0 None reported
Gallbladder 1.5 hours 97.8 98.0 None reported
D&C Ablation 1.25 hours 99.2 98.5 None reported
D&C 1.75hours 98.7 97.8 None reported
Laparoscopic
FINAL SUMMARY REPORT 4

Salpingectomy
Sleeve 2 hours 97.5 97.1 None reported
Gastrectomy
Breast 1 hour 97.9 96.1 None reported
Lumpectomy
Abdominal 1.5 hours 98.6 97.0 None reported
Laparoscopy

Total Knee
1.75hours 98.3 98.8 None reported
Arthroplasty

The new process that was tested during this project was to provide

warm IV fluids for 8 select patients that had a surgery time of greater than

60 minutes. The original test phase was planned to include only

hysterectomy patients. One barrier that was encountered during this initial

test cycle was there was very few hysterectomy patients scheduled during

this week. Other surgical patients had to be included in the test. The preop

temperatures would be recorded. The warm IV fluids were to be administered

during the preop portion. Then the postoperative temperature was to be

taken to ensure that the patients were not hypothermic.

The warm IV fluids were taken from the operating room fluid warmer,

which is not very convenient to preop staff. It requires the preop nurse to

place an OR hat and mask on in order to go to the OR center core to get the

warm fluids. There are limited number of fluids and they are also being used

by the OR staff to administer during the cases. This was also a barrier to the

project because the fluids needed to be restocked more often and there was

not a person assigned to this task. The preop nurse had to ensure that the
FINAL SUMMARY REPORT 5

fluids were replaced in order to have enough stock. The overall process of

having to retrieve a warm fluid for each patient from the OR area makes the

nurses in preop less efficient. If a fluid warmer was purchased for the preop

area, these barriers would no longer pose a problem.

Research shows that there are multiple methods for maintaining a

patients temperature during surgery, including administering warm fluids to

patients that will receive greater than 500ml of fluid. This would include all

surgical patients at St Francis Eastside. Warming fluids to near 37 degrees

celcius (98.6 degrees Fahrenheit) prevents heat loss from the administration

of cold IV fluids and should be considered as an adjuct to skin surface

warming (Health Services Advisory Group, n.d., p. 23).

The predictions that were made prior to the implementation were that

1) Warm IV fluids will help decrease hypothermia postoperative for

hysterectomy patients. 2) There will be no patients that enter PACU with a

temperature of <97.5 degrees Farenheit. 3) Warm IV fluids will decrease

patient shivers postoperatively. 4) Warm IV fluids will decrease postop

infections.

Implementation

Eight patients were chosen based on the scheduled surgery time.

Temperatures were taken by the preop nurses and recorded. Warm IV fluids

were were given to each of these patients. Each preop nurse had to prepare

the warm fluids from the OR fluid warmer for each individual patient. This

process makes the preop team less efficient. Following surgery the each of
FINAL SUMMARY REPORT 6

the patients temperatures were taken by the recovery room staff and

recorded. The temperatures were recorded as follows in the following table.

Table 2

Surgery Type Length of Preop Temp Postop Temp Postop

Surgery Infection
Hysterectom 1.5 hours 97.3 98.5 None reported
y
Diagnostic 2 hours 98.6 98.3 None reported
Laparoscopy
ENT 1.5hours 97.3 97.0 None reported
A&P repair 2 hours 97.7 97.8 None reported
Robotic 2 hours 98.2 100.3 None reported
myomectom
y
ENT 1.75hours 98.0 97.8 None reported
D&C 1 hour 98.6 97.1 None reported

As shown in the table, there are two patients that were admitted to the

recovery room with temperatures of <97.5, which is considered hypothermic.

Despite administering warm fluids in the preop area, these patients were still

too cold. Of all of the patients reported only 1 patient had significant

postoperative shivers in the recovery room. None of the patients that were

monitored have reported any postoperative infections according to the

Infection Control nurse at St Francis Eastside.

FINAL SUMMARY REPORT 7

The change did lead to an improvement, however it did not achieve

the predicted goal. The goal was to have 100% of the patients entering

recovery room without any signs of hypothermia. There were still two

patients that were too cold after surgery. However, there was only one

patient that was shivering after surgery, which is an improvement. There are

multiple patients throughout a typical day that have complaints of shivering

when in recovery room. Also, there have been no reported postoperative

infections reported by these patients.

Another barrier that was encountered was the cost to provide the

preop with a fluid warmer. According to Formost Medical Equipment supply a

counter top fluid warmer is $6484. A floor standing fluid warmer, which

would be ideal, costs $8218. The supervisor over the preop unit stated that

this was not in the current capital budget for this year. However, the preop

charge nurse suggested that there was a fluid warmer that was not being

currently used in a different department. She was able to get the approval to

move the unit to St Francis Eastside.

There is a plan to do at least two more cycles. The surgical patients

that have a surgery time of greater than 60 minutes will be included. The

fluid warmer from the OR will be stocked more frequently by the preop

nurses in order to provide adequate fluids for preop and the operating room.

The temperatures will be taken in preop and upon entry to recovery room.

The postop infections will continue to me monitored by the infection control

nurse and any reported infections will be documented.

FINAL SUMMARY REPORT 8

Conclusion

In conclusion, there were barriers that were faced during the planning

and implementation of the test cycle. The patients that were to be included

in the test had to be altered and the administering the warm fluids was a

challenge because of the placement of the current fluid warmer. However,

the change in process did show improvement in the patients temperatures

on admission to the PACU. Using warm fluids on the preop patients did

improve the percentage of patients with hypothermia. The prediction before

the test was that 100% of the patients would have a normal temperature

following surgery. This was not the case since two of the patients still had a

low temperature, but the overall percentage did improve. The percentage of

patients that had postop shivers was also decreased. There were no

postoperative infections reported with any of these patients during the

month of March as indicated by the Infection Control nurse.

The change in process will be implemented by the nurses in preop and

the managers of the department have approved the change. The process will

begin once the fluid warmer is in the preop area. The budget was not

approved to buy a new fluid warmer, but the preop charge nurse was able to

find a fluid warmer in another department that was not being used.

Engineering was called to the department to approve placement of the fluid

warmer and an equipment check was done on the actual warmer. The

engineering staff concluded that a new electrical outlet needs to be added to

the area where the warmer will be placed. An estimate will be given to
FINAL SUMMARY REPORT 9

management regarding the cost of the electrical outlet and approval is

pending.

References

Bashaw, M. (2016, March). Guideline implementation: Preventing

hypothermia. AORN Journal, 103, 305-313.

http://dx.doi.org/10.1016/j.aorn.2016.01.009

Campbell, G., Alderson, P., Smith, A. F., & Warttig, S. Warming of intravenous

and irrigation fluids for preventing inadvertent perioperative

hypothermia. Cochrane Database of Systemic Reviews, 2015, Issue 4.

Art.No.:CD009891. DOI: 10.1002/14651858.CD009891.pub2

FINAL SUMMARY REPORT 10

Health Services Advisory Group. (n.d.). Turn up the heat: Avoiding surgical

complications with adequate patient warming. Retrieved from

https://www.medlineuniversity.com/lms/course/1010000371/?

tabId=62&moduleId=144&GoBackTo=D06550C

John, M., Ford, J., & Harper, M. (2014, February 1). Peri-operative warming

devices: performance and clinical application. The Association of

Anaesthetists of Great Britain and Ireland, 69, 623-638.

http://dx.doi.org/10.1111/anae.12626