Declaration: The writing of this report and the co-ordination of the multidisciplinary meeting (‘WISE advisory board meeting’) which has informed its content has been funded by 3M. The opinions in this report are those of an expert panel of key opinion leaders and are not necessarily those of 3M.

Warming in Surgery Exposed (WISE) Report Foreword by Dr John Andrzejowski Sheffield Teaching Hospital NHS Foundation Trust

“ As healthcare workers, we are meticulous in providing optimum conditions for our patients and frequently have to use equipment and disposables that cost vast amounts of money to achieve this. The NICE CG65 guidelines on IPH afforded all of us the opportunity to make a real difference to patient care without spending vast amounts of money: applying simple warming measures in all three phases of perioperative care can change patients’ outcome.”

WISE REPORT | DECEMBER 2015

FOREWORD

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“This report strives to ascertain why these guidelines have not been more widely adopted and helps both patients and clinicians to make a difference using innovative educational and implementation tools.

Ideally, using warmed fluids and forced air warmers should become as routine as ECG monitoring or applying eye protection after inducing anaesthesia. All theatre staff are empowered to make a difference in avoiding IPH, starting with asking about warming measures in the WHO checklist.

We should remember that 36°C is not even considered normothermic in most biology textbooks. It was chosen by NICE simply since this was the temperature above which clear evidence was available for patient benefit. Aiming for 36°C is therefore not over-exacting or asking for the unachievable! In high risk cases, there is increasing evidence that prewarming and the use of additional underbody mattresses might help when intraoperative forced air warming alone is insufficient.

The Royal College of Anaesthetists ACSA accreditation process includes questions on hospitals’ approach to IPH and for those trusts looking to save money, simple changes in practice such as taking blankets that have been used intra-operatively (providing they are not soiled) into the recovery area might improve guideline compliance.

NICE will issue further guidance on perioperative thermometry and preoperative warming when the guidelines are reviewed in 2016… watch this space!”

Dr John Andrzejowski | Sheffield Teaching Hospital NHS Foundation Trust

This report contains opinions and quotes from the following experts:

• Dr John Andrzejowski Consultant Anaesthetist, Sheffield Teaching Hospital NHS Foundation Trust

• Dr Mark Harper Consultant Anaesthetist, Brighton and Sussex University Hospitals Trust

• Dr Peter Jenks Director of Infection Prevention and Control, and Consultant Microbiologist, Plymouth Hospitals NHS Trust

• Mr Benedict Rogers Consultant Orthopaedic & Trauma Surgeon, Brighton & Sussex University Hospitals NHS Trust

• Dr Jennie Wilson on behalf of OneTogether Associate Professor, Healthcare Epidemiology, Richard Wells Research Centre, University of West London

EXECUTIVE SUMMARY

Keeping a patient warm before, during and after surgery is a cornerstone of patient care. Patient temperature management is not just a question of keeping a patient comfortable while they are in the hospital. If not properly managed, a patient’s core temperature may drop below normal levels, which can lead to ‘inadvertent perioperative hypothermia’ (IPH).

IPH occurs when a patient’s core temperature drops below 36.0°C before, during or after surgery. There are many factors that may lead to this at all stages of surgery; for example, the body finds it harder to regulate a steady temperature when under anaesthesia. Measures must be put in place to avoid IPH, as this is associated with poor outcomes for patients including an increased risk of surgical site infections.

Guidelines from the National Institute for Health and Care Excellence (NICE) were published in 2008 and aim to assist healthcare professionals with identifying which patients may be at risk of IPH, so they are able to act accordingly. This report reveals, however, that the uptake of these guidelines is not as expected.

The Warming in Surgery Exposed (WISE) report identifies the possible barriers leading to a lack of compliance with NICE guidelines. Included in the report are recommendations as to how these barriers may be overcome. Key points include simplification of the existing guidelines, and general education for both patients and healthcare professionals as to the importance of perioperative patient warming. With these recommendations, and by encouraging healthcare professionals to take action, we hope that long lasting change can be created in patient temperature management, with the ultimate aim of improving patient care.

Warming in Surgery Exposed (WISE) Report | December 2015 3

During the first 30 to 50 minutes of general or regional anaesthesia, a patient’s core temperature can drop by an average of 1.6°C leaving the patient at risk of hypothermia. The body finds it harder to regulate a steady temperature when under anaesthesia due to the effects of redistribution temperature drop. It is possible to develop hypothermia at any stage of surgery. In addition to induction of anaesthesia, other reasons why a patient might develop IPH include: 1,2

• Operating theatres are often kept cool and patients are usually only dressed in thin hospital gowns

• The nature of the surgery may directly affect temperature, for example, if large cavities are left open to cool air

• Cold fluids may be used, either intravenously, or to flush out the surgery site

A number of individual factors may also affect a patient’s ability to stay warm:

“ There is a huge difference in the ability to retain temperature between elderly patients and young patients. Patients with poor nutrition or low BMI may also have trouble staying warm.” – Mr Benedict Rogers

Why is it important to maintain a patient’s core body temperature?

At a time when NHS budgets are particularly constrained, it is worth noting the considerable and avoidable costs of IPH. An analysis from National Collaborating Centre for Nursing and Supportive Care has discussed the cost associated with complications caused by IPH.3 NICE notes that there is sufficient evidence of clinical effectiveness and cost effectiveness for the methods of patient warming discussed in their guidelines.1

While the cost of IPH is clearly an important motivation to avoid cases of perioperative hypothermia, perhaps the most compelling reason is the serious and negative health implications hypothermia can have for patients. Hypothermia is associated with an increased risk of:

• Wound infection• Myocardial ischemia and cardiac disturbances• Coagulopathy• Prolonged and altered drug effect• Increased mortality• Shivering and thermal discomfort• Delayed emergence from anaesthesia

By taking steps to avoid IPH, healthcare professionals can reduce the risk of these complications, which have the potential to cause long-term reductions in a patient’s quality of life.4

What is inadvertent perioperative hypothermia?

Hypothermia is typically defined as a patient core temperature of below 36.0°C.1

‘Inadvertent perioperative hypothermia’ (IPH) is the term used to describe when a patient’s core temperature drops below 36.0°C before, during or after surgery. IPH is a common but preventable complication of surgery that can have serious consequences for patients.1

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INTRODUCTION TO PATIENT WARMING

How is a patient’s temperature maintained?

A number of different healthcare professionals are involved in keeping a patient safe before, during and after surgery. Hospitals differ in who is responsible for managing patient temperature in the operating theatre.

“ There is a growing body of evidence to suggest that pre-warming should be considered for all patients, this may be considered in the updated NICE guidelines.” – Dr John Andrzejowski

The NICE guidelines provide comprehensive recommendations as to how patient temperature during surgery should be monitored. Firstly, patients should be categorised according to their risk level of developing IPH. This allows healthcare professionals to choose the best method of temperature management in order to minimise the chance of a patient getting cold during surgery.6 Similarly, how regularly a patient’s temperature should be taken during a surgery varies, depending on a range of factors including the complexity of the procedure and how long the surgery is expected to take.7

“ Predicting the variables for trauma patients is much more difficult than for patients undergoing elective surgery. As a result, trauma patients may not be warmed as effectively or as systematically as elective patients, despite usually having a greater need.” – Mr Benedict Rogers

If it is agreed that a patient needs to be warmed perioperatively, the healthcare professional will assess the best method to do so. Methods include the use of forced air warming to treat hypothermia and maintain normothermia, and the use of fluid warmers to reduce the cooling effect of administering cold irrigation and intravenous bloods and fluids.

There are also things the patient can do to ensure they stay warm perioperatively. Simple things such as bringing additional clothing with them to the hospital to keep warm prior to, and after their operation can make a big difference. This report considers the role of the patient in the ‘overcoming compliance barriers’ section.

The NICE guidelines, detailed in CG65 [www.nice.org.uk/guidance/cg65], provide comprehensive recommendations for when and how patients should be warmed perioperatively. This report reveals evidence that implementation of NICE’s guidelines falls short in practice.

“ Hip fractures, for example, are vital cases for patient warming and are often missed – especially since these patients may be elderly or have low BMI, making it harder for them to stay warm.” – Mr Benedict Rogers

Studies have suggested that maintaining normothermia improves patient outcomes, including:5

• Reduced rate of wound infection• Decreased likelihood of myocardial

infarction• Decreased ICU time• Shortened length of hospital stay• Lower mortality rates• Reduction in the use of blood products• Reduced probability of need for transfusion

Warming in Surgery Exposed (WISE) Report | December 2015 5

A recent national survey conducted by Dr Alice Elvy and Dr Rattan Alexander (Worcestershire Acute Hospital NHS Trust) assessed whether hospitals in the UK are compliant with the NICE guidelines for patient warming. Worryingly, 40% of clinicians surveyed were not aware of the NICE guidelines on patient warming. Further to this, results indicated that only 16.8% of clinicians used the NICE guidelines for their patient warming criteria, while 10.5% of this group thought the guidelines were not necessary at all. When asked, respondents cited time pressures and financial barriers as the reason for a lack of compliance with the guidelines.8

The results of this particular survey suggest the need for further discussions on how to interpret and implement the NICE guidelines effectively.8

Evidence for perioperative warming practice – the OneTogether partnership

In work undertaken by the OneTogether partnership, operating theatre and infection control practitioners have reported several barriers to improving practice in relation to perioperative warming (see box) (Wilson et al 2015).

Barriers to improving perioperative warming practiceSource: Wilson et al 2015

• Lack of resources for equipment• Lack of leadership, ownership,

and defined responsibilities• Difficulty in standardising practice• Faulty/inaccurate equipment• Staff do not perceive importance• No time allocated to training

29% of hospitals do not have a patient temperature management standard

Percentage of respondents reporting compliance with NICE guidance for temperature monitoring

Before the induction of anaesthesia

Intra-operatively In recovery

52% 73% 76%

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WHAT IS THE CURRENT SITUATION?

The OneTogether partnership has also asked 52 operating department practitioners attending workshop how perioperative warming was managed at their hospital. Their responses indicated that only three-quarters routinely applied temperature monitoring in recovery and during the operation and only 53% had clear procedures in place to ensure the patient was warm prior to induction of anaesthesia. In addition, some reported that action was not always taken in response to a low temperature, suggesting a lack of clarity about the importance of preventing hypothermia and knowledge of the NICE guidelines.

Patient information was also a concern, with only 36% of respondents reporting that patients are provided with information verbally and in writing about the importance of keeping warm.9

“ Before patients are transferred to the theatre, I am not sure what warming measures are being taken.”

“Patient temperatures are recorded prior to entering the theatre but no remedial action is taken.”

“ Not all recovery nurses and anaesthetists comply with the expectation of monitoring temperature at 30 or 15 minute intervals during surgery – however this is improving.”

“ Temperature is not measured consistently for minor cases – quite often it is recorded at beginning and end of surgery.”

THE ONETOGETHER PARTNERSHIP

The OneTogether Partnership is anindependent group of multi-disciplinaryhealthcare professionals, including representatives from the Association of Perioperative Practitioners (AfPP), Infection Prevention Society (IPS), Royal College of Nurses (RCN), and the College of Operating Department Practitioners (CODP).

The group is focused on increasing the profile of infection prevention and evidence supporting practice to prevent surgical site infections. They aim to engage and inform healthcare professionals and improve patient outcomes.

The findings supports the need for more effective implementation of the necessary guidelines. The audit also provides an insight into the reasons for lack of compliance with the guidelines. This topic is considered in more detail in the following section, ‘Overcoming compliance barriers’.

From the evidence presented, it is clear that responsibility for temperature management needs to be defined in order for improvements to be made. Similarly, patients need to be educated on the need to take warm clothing to the hospital in order to keep warm before and after surgery. It is also important to empower patients to speak to their healthcare professional if they are cold or uncomfortable at any time.

“ Key findings from the self-assessment provided insight that, although people are aware of guidelines, they are uncertain of the detail and there is variability in compliance” – Dr Jennie Wilson

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QUOTES FROM ONETOGETHER’S AUDIT

Despite NICE’s provision of detailed guidelines on perioperative patient temperature management, we have seen the evidence to suggest that adherence to the guidelines is far from optimal. There are many reasons why guidelines are not being followed and patients are not being warmed properly.

CHALLENGE PROPOSED SOLUTION

Confusion in the interpretation and implementation of the guidelines: how and who

Simplify the guidelines

How – Qualitative data from the OneTogether’s survey suggests that there is confusion in the interpretation of the guidelines. This leads to improper implementation and sporadic uptake across the country.9

Who – The survey also reveals confusion regarding who holds the responsibility for managing a patient’s temperature perioperatively. There is also a lack of consistency in the handover of responsibility before and after surgery.9

“ If clear standards and responsibilities are not set, it makes it difficult for the team to take responsibility, ownership and action.” – Dr Jennie Wilson

“ Simplifying the guidelines to highlight areas where patient warming is most often missed would be beneficial for HCPs” – Mr Benedict Rogers

• A self-assessment tool, developed by the OneTogether Partnership, which allows healthcare professionals to assess practice in their operating theatres and ensure correct procedures are being followed

• A decision support flow diagram to help healthcare professionals to interpret the complex guidelines and ensure clear standards are being set through enhanced understanding

These reasons include:3,6,8

• Healthcare professionals may have gaps in their understanding and interpretation of the guidelines leading to improper implementation

• It may be unclear on who holds the responsibility for patient temperature management among a multidisciplinary team

• Patients do not feel empowered to discuss temperature management or to speak to their healthcare professional when they are cold

• Financial, technical and time constraints

A multidisciplinary advisory board meeting was held in April 2015 with the aim of identifying the key barriers to implementation of NICE’s guidelines. Attendees of this meeting, which included Consultant Anaesthetist, Infection Control and Theatre professionals, discussed possible solutions to the identified challenges. The overall aim of the meeting was to help patients, patient carers and clinicians to reduce the risk of IPH during surgery, with the ultimate goal of improving patient outcomes. The group also enlisted the input of a Consultant Orthopaedic Surgeon to comment on the outcomes of the advisory board meeting.

The challenges and solutions are detailed below and opposite.

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OVERCOMING COMPLIANCE BARRIERS

CHALLENGE PROPOSED SOLUTION

Lack of awareness regarding the importance of patient warming

Provide the evidence and educate

“ NICE guidelines were launched seven years ago and are not as high profile today; new anaesthetists coming through the system may not be fully aware of the guidance.” – Dr John Andzrejowski

There is a lack of understanding among some healthcare professionals regarding the benefits of maintaining an optimum patient body temperature perioperatively. This is despite strong evidence that IPH is associated with poor patient outcomes. It has also been suggested that patient temperature management and warming is not regarded as important as other clinical responsibilities.1,4

This is supported by the national survey which also showed a lack of awareness and compliance to the NICE guidance on temperature management.8

“ HCPs working in trauma units would benefit from education, since it is a more challenging environment. Quite often hospital staff have many other factors to deal with, and patient warming is not front of mind.” – Mr Benedict Rogers

The WISE multidisciplinary advisory board noted the need for new clinical outcome trials, to specifically assess the benefits of maintaining a constant patient body temperature before, during and after surgery.

The findings of these trials could be used as a platform for an educational programme for healthcare professionals. This would support their understanding of patient temperature management as an important and integral issue in surgical practice.

It is also important that patients are properly educated as to the importance of staying warm during an operation. Patients must also be made aware of the risks if they are not properly warmed. A patient leaflet that empowers patients to seek the best standard of care for themselves would have great value.

“ Raising awareness of guidance is key” – Dr Peter Jenks

Patients are not aware of their role in temperature management

Empower patients

While it is the responsibility of healthcare professionals to provide a safe environment for patients undergoing surgery, patients also have a role to play. Patients often do not know what to expect and more importantly, what to ask for, when it comes to keeping warm while in hospitals. As a result, some patients may be left to suffer in silence.

The WISE multidisciplinary advisory board came to the consensus that patients should be empowered to discuss how they will be kept warm and comfortable before, during and after surgery.

Increasing patients’ strength of voice may urge healthcare professionals to improve their practice in patient temperature management. This report has prompted further action to work with the Patients Association and other patient groups to explore how the patient could be further empowered.

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CONCLUSION

Maintaining the optimum patient temperature before, during and after surgery is an important step to improving patient outcomes. Achieving this requires the collaboration of a wide range of healthcare professionals. While time, financial and technical factors all clearly play a role in creating barriers to compliance; the general lack of understanding among both healthcare professionals and patients is likely to be one of the biggest barriers to consistent implementation of NICE’s guidelines on temperature management.

There are a number of solutions that can be put into place to overcome these barriers. Simplifying the NICE guidelines to streamline the decision-making process would leave less room for individual interpretation. This is key to improving healthcare professionals’ implementation of the guidelines. General education regarding the value of keeping a patient warm and comfortable would also be beneficial, both among healthcare professionals and patients themselves.

Work is already underway to improve patient care, such as the self assessment tool that has been developed by the OneTogether Partnership. Since the multidisciplinary advisory board took place, NICE has also provided further clarity on the recommendations for the prevention of inadvertent perioperative hypothermia (CG65) in the form of an online pathway tool.

As this report has outlined, there is still scope for continued improvements in patient temperature management, to ensure the best possible care is delivered. It is without question that a collaborative effort between healthcare professionals and patients is the most effective approach to ensure long lasting change.

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TOOLS AND RESOURCES

• Learn more about the OneTogether partnership: www.joinonetogether.org

• Request a hard copy of the OneTogether surgical pathway poster: ssingh@mmm.com

• View the NICE pathway for inadvertent perioperative hypothermia: http://pathways.nice.org.uk/pathways/inadvertent-perioperative-hypothermia

• Explore 3M patient temperature management solutions, including temperature monitoring, forced-air warming and fluid warming: www.3m.co.uk/patientwarming

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REFERENCES

1 Sessler DI. Current concepts: Mild Perioperative Hypothermia. New Engl J Med. 1997; 336(24):1730-1737

2 Sessler, DI. Perioperative Heat Balance. Anesth. 2000;92:578-596

3 National Collaborating Centre for Nursing and Supportive Care (UK). The Management of Inadvertent Perioperative Hypothermia in Adults [Internet]. London: Royal College of Nursing (UK); 2008 Apr. (NICE Clinical Guidelines, No. 65.) 7, RISK FACTORS FOR INADVERTENT PERIOPERATIVE HYPOTHERMIA. Available online: http://www.ncbi.nlm.nih.gov/books/NBK53804/ Accessed August 2015

4 Sessler DI, Kurz A. Mild Perioperative Hypothermia. Anesthesiology News. October 2008: 17-28

5 Mahoney CB, Odom J. (1999), Maintaining intraoperative normothermia: A meta-analysis of outcomes with costs. AANA Journal. 1999; No. 67, pp. 155-163

6 National Institute for Health and Care Excellence. The management of inadvertent perioperative hypothermia in adults. NICE clinical guideline 65. Available online: https://www.nice.org.uk/guidance/cg65. Accessed August 2015

7 WISE multidisciplinary team advisory board meeting consensus. Meeting held April 2015

8 A. Elvy and R. Alexander. National Patient Warming Survey. Abstract presented at AAGBI GAT annual scientific meeting 2014

9 OneTogether self-assessment tool workshop, November 2014. Results presented by Dr Jennie Wilson at WISE multidisciplinary advisory board on behalf of OneTogether, April 2015 (not published)

10 Wilson J, Topley K, Stott D, Neachell J, Gallagher R (2015) The OneTogether collaborative approach to reduce the risk of surgical site infection: identifying the challenges to assuring best practice. Journal of Infection Prevention 2015, 16(3): 118–125.

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