Costs of inadvertent perioperative hypothermia in Australia: A cost-of-illness study

Barriers and facilitators to evidence-based perioperative hypothermia management for orthopaedic patients: A systematic review

AIM

To assess barriers and facilitators to the implementation of guidelines for the prevention of inadvertent perioperative hypothermia in orthopaedic patients.

DESIGN

Systematic review.

DATA SOURCES

Nine databases: PubMed, Embase, CINAHL, Cochrane CENTRAL, PsycINFO, ProQuest Dissertations and Theses, Scopus, Web of Science and Trip Clinical Evidence Database.

METHODS

Primary studies published in English between January 2008 to July 2022 were screened. Study selection, quality assessment, and data extraction were completed independently by researchers. Data were extracted using the Consolidated Framework for Implementation Research and mapped to the Expert Recommendations for Implementing Change strategies.

RESULTS

Eighty-seven studies were included in the review. The most frequently reported barriers and facilitators related to evidence strength, relative advantage, and cost of implementing perioperative hypothermia prevention guidelines. The top four ERIC strategies were: Identify and prepare champions; Conduct educational meetings; Assess for readiness and identify barriers and facilitators; and Inform local opinion leaders.

CONCLUSION

This review provides synthesized evidence regarding barriers and facilitators to perioperative hypothermia guidelines for patients undergoing orthopaedic surgery.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Our work provides theory guided strategies to promote implementation of perioperative hypothermia prevention to assist nurses caring for patients undergoing orthopaedic surgery.

IMPACT

Findings provide professionals caring for patients undergoing orthopaedic surgery with theory-informed strategies to improve perioperative hypothermia prevention. Reducing perioperative hypothermia will improve outcomes for patients undergoing orthopaedic surgery.

REPORTING METHOD

The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020.

NO PATIENT OR PUBLIC CONSULTATION

Due to the study design, no patient or public consultation took place.

The Effect of Prewarming on Perioperative Hypothermia: A Systematic Review and Meta-analysis of Randomized Controlled Studies

PURPOSE

One of the methods for maintaining perioperative normothermia is prewarming. This study was conducted to investigate the effect of a preoperative prewarming intervention on perioperative body temperature.

DESIGN

Systematic review and meta-analysis.

METHODS

A literature review was conducted using PubMed, CINAHL, Cochrane Central, Science Direct, Springer Link, Scopus, Web of Science, and Ovid databases. Randomized controlled trials that investigate the effect of prewarming on body temperature in the prevention of perioperative hypothermia were included. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. Methodological quality was assessed using the Cochrane Collaboration "risk of bias" tool. Meta-analysis was performed with Comprehensive Meta-Analysis, version 2. Moderator analysis and publication bias assessment were performed. Funnel plots were analyzed using Orwin's fail-safe N, Trim, and Fill test method to investigate the source of heterogeneity.

FINDINGS

A total of 907 studies were found. The systematic review included 27 studies. Of these, 23 were included in the intraoperative meta-analysis, and 16 were included in the postoperative meta-analysis. According to the meta-analysis results, the prewarming intervention was effective in maintaining normothermia in the intraoperative (Hedge's g = 0.972, 95% confidence intervaI = 0.674 to 1.270) and postoperative (Hedge's g = 0.818, 95% confidence intervaI = 0.520 to 1.114) periods.

CONCLUSIONS

The findings of this systematic review and meta-analysis showed that preoperative prewarming played a significant role in providing and maintaining perioperative normothermia.

A Warm Air Blanket is Superior to a Heated Mattress in Preventing Perioperative Hypothermia in Orthopedic Arthroplasties, a Time-Series Analyses

BACKGROUND

Hypothermia is a common perioperative problem that can lead to severe complications. We evaluated whether a heated mattress (HM) is superior to a warm air blanket (WA) in preventing perioperative hypothermia in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA).

METHODS

A retrospective cohort study was performed in a teaching hospital and data were collected for all patients undergoing THA or TKA between January 1, 2015 and May 1, 2022. We used logistic and linear regressions to analyze hypothermia occurrence and important complications. Results were adjusted for confounders and time, and was present in all subgroups and after imputation of missing data.

RESULTS

In total, 4,683 of 5,497 patients had information on type of heating. We found more perioperative hypothermia in patients treated with an HM compared to a WA for both THA (odds ratio-adjusted 1.42 [1.0 to 1.6] P = .06) and TKA (odds ratio-adjusted 2.10 [1.5 to 3.0] P < .01). There was no difference in postoperative infections between groups (all between 0.5% and 1.3%). Patients who had an HM significantly stayed longer in the postoperative ward (a mean difference of 4 [TKA] to 6 [THA] minutes, P < .01), but there was no difference in hospital stay.

CONCLUSION

A WA is superior compared to an HM in preventing perioperative hypothermia, with no increased risk of complications. Patients who have an HM stayed longer at the postoperative ward, potentially because of higher hypothermia rates. Therefore, it is suggested to use a WA instead of an HM.

The Effect of Using a Normothermia Checklist on Awakening Time From Anesthesia and Coagulation Disorder: A Randomized Controlled Trial

BACKGROUND

Inadvertent perioperative hypothermia (IPH) is a common issue in surgical patients. To avoid this issue, the patient should be monitored continuously throughout the perioperative process. Evidence-based practices in line with relevant guidelines are necessary to maintain normothermia.

PURPOSE

This study was developed to determine the effect of using a control list developed for preventing IPH on time of awakening from anesthesia and coagulation disorder in surgical patients.

METHODS

In this randomized controlled study, nursing interventions were applied to patients in accordance with the normothermia checklist (NC) developed by the researchers to prevent IPH.

RESULTS

In this study, 30 patients were respectively assigned to the experimental and control groups. Conducting nursing interventions in accordance with the control checklist was found to be effective in preventing IPH. Moreover, time of awakening from anesthesia was significantly shorter in the experimental group (3.77 ± 1.10 minutes) than the control group (11.03 ± 2.51 minutes; p < .05). Furthermore, tendency to bleed was higher in the control group than the experimental group, and a statistically significant between-group difference in coagulation disorders was found ( p < .05).

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The results of this evidence-based study indicate that implementing nursing interventions in line with the developed NC is effective in preventing IPH. Preventing IPH, which increases the risk of numerous complications in surgical patients, is an important responsibility of nurses. Nurses may employ the NC proposed in this study to better secure the safety and minimize the risk of complications in surgical patients.

Perioperative hypothermia prevention: development of simple principles and practice recommendations using a multidisciplinary consensus-based approach

OBJECTIVES

To develop a consensus on evidence-based principles and recommendations for perioperative hypothermia prevention in the Australian context.

DESIGN

This study was informed by CAN-IMPLEMENT using the ADAPTE process: (1) formation of a multidisciplinary development team; (2) systematic search process identifying existing guidance for perioperative hypothermia prevention; (3) appraisal using the AGREE II Rigor of Development domain; (4) extraction of recommendations from guidelines meeting a quality threshold using the AGREE-REX tool; (5) review of draft principles and recommendations by multidisciplinary clinicians nationally and (6) subsequent round of discussion, drafting, reflection and revision by the original panel member team.

SETTING

Australian perioperative departments.

PARTICIPANTS

Registered nurses, anaesthetists, surgeons and anaesthetic allied health practitioners.

RESULTS

A total of 23 papers (12 guidelines, 6 evidence summaries, 3 standards, 1 best practice sheet and 1 evidence-based bundle) formed the evidence base. After evidence synthesis and development of draft recommendations, 219 perioperative clinicians provided feedback. Following refinement, three simple principles for perioperative hypothermia prevention were developed with supporting practice recommendations: (1) actively monitor core temperature for all patients at all times; (2) warm actively to keep body temperature above 36°C and patients comfortable and (3) minimise exposure to cold at all stages of perioperative care.

CONCLUSION

This consensus process has generated principles and practice recommendations for hypothermia prevention that are ready for implementation with local adaptation. Further evaluation will be undertaken in a large-scale implementation trial across Australian hospitals.

Nurse anesthetists' perceptions of heat conservation measures in connection with surgery - a phenomenographic study

BACKGROUND

To minimize the risk of perioperative hypothermia, it is recommended that healthcare professionals be familiar with heat conservation measures and use passive and active warming methods, in line with international guidelines. However, there is a low level of adherence perioperatively to the use of heat conservation measures. To understand why, there is a need to capture the nurse anesthetists' perspective. The aim is to describe nurse anesthetists' perceptions of heat conservation measures in connection with surgery.

METHODS

An inductive descriptive design with a phenomenographic approach was chosen. A total of 19 nurse anesthetists participated and were interviewed. Data were analyzed according to Larsson and Holmström's phenomenographic seven-step model.

RESULTS

Six ways of understanding the phenomenon heat conservation measures in connection with surgery were found: the preventive, the useable, the untenable, the caring, the adaptive, and the routine care approach. These approaches were related to each other in a flexible way, allowing for several to co-exist at the same time, depending on the situation.

CONCLUSIONS

Nurse anesthetists want to prevent the patients' heat loss and maintain normothermia, regardless of the type of surgery. This willingness, motivation, and intention enable the use of heat conservation measures. However, there are perceptions that have an impact, such as doubts and uncertainty, access, time and financial constraints, preconditions, routines or habits, and lack of availability of education/training. These barriers will require support from an organizational level to promote lifelong education and guidelines. As well as offer education at the nurse anesthetists' program.

Predicting Intraoperative Hypothermia Burden during Non-Cardiac Surgery: A Retrospective Study Comparing Regression to Six Machine Learning Algorithms

BACKGROUND

Inadvertent intraoperative hypothermia is a common complication that affects patient comfort and morbidity. As the development of hypothermia is a complex phenomenon, predicting it using machine learning (ML) algorithms may be superior to logistic regression.

METHODS

We performed a single-center retrospective study and assembled a feature set comprised of 71 variables. The primary outcome was hypothermia burden, defined as the area under the intraoperative temperature curve below 37 °C over time. We built seven prediction models (logistic regression, extreme gradient boosting (XGBoost), random forest (RF), multi-layer perceptron neural network (MLP), linear discriminant analysis (LDA), k-nearest neighbor (KNN), and Gaussian naïve Bayes (GNB)) to predict whether patients would not develop hypothermia or would develop mild, moderate, or severe hypothermia. For each model, we assessed discrimination (F1 score, area under the receiver operating curve, precision, recall) and calibration (calibration-in-the-large, calibration intercept, calibration slope).

RESULTS

We included data from 87,116 anesthesia cases. Predicting the hypothermia burden group using logistic regression yielded a weighted F1 score of 0.397. Ranked from highest to lowest weighted F1 score, the ML algorithms performed as follows: XGBoost (0.44), RF (0.418), LDA (0.406), LDA (0.4), KNN (0.362), and GNB (0.32).

CONCLUSIONS

ML is suitable for predicting intraoperative hypothermia and could be applied in clinical practice.

Perioperative temperature management: a survey of 6 Asia-Pacific countries

BACKGROUND

Anesthesia leads to impairments in central and peripheral thermoregulatory responses. Inadvertent perioperative hypothermia is hence a common perioperative complication, and is associated with coagulopathy, increased surgical site infection, delayed drug metabolism, prolonged recovery, and shivering. However, surveys across the world have shown poor compliance to perioperative temperature management guidelines. Therefore, we evaluated the prevalent practices and attitudes to perioperative temperature management in the Asia-Pacific region, and determined the individual and institutional factors that lead to noncompliance.

METHODS

A 40-question anonymous online questionnaire was distributed to anesthesiologists and anesthesia trainees in six countries in the Asia-Pacific (Singapore, Malaysia, Philippines, Thailand, India and South Korea). Participants were polled about their current practices in patient warming and temperature measurement across the preoperative, intraoperative and postoperative periods. Questions were also asked regarding various individual and environmental barriers to compliance.

RESULTS

In total, 1154 valid survey responses were obtained and analyzed. 279 (24.2%) of respondents prewarm, 508 (44.0%) perform intraoperative active warming, and 486 (42.1%) perform postoperative active warming in the majority of patients. Additionally, 531 (46.0%) measure temperature preoperatively, 767 (67.5%) measure temperature intraoperatively during general anesthesia, and 953 (82.6%) measure temperature postoperatively in the majority of patients. The availability of active warming devices in the operating room (p < 0.001, OR 10.040), absence of financial restriction (p < 0.001, OR 2.817), presence of hospital training courses (p = 0.011, OR 1.428), and presence of a hospital SOP (p < 0.001, OR 1.926) were significantly associated with compliance to intraoperative active warming.

CONCLUSIONS

Compliance to international perioperative temperature management guidelines in Asia-Pacific remains poor, especially in small hospitals. Barriers to compliance were limited temperature management equipment, lack of locally-relevant standard operating procedures and training. This may inform international guideline committees on the needs of developing countries, or spur local anesthesiology societies to publish their own national guidelines.

Protocol Implementation for Normothermia in Surgery Settings in Italy: Budget-Impact Analysis

Introduction

Hypothermia is a well-known risk of the perioperative period and considered a preventable effect of anesthesia care. Nevertheless, it is not fully controlled, causing a number of adverse outcomes following surgical operations and thus increasing length of stay in hospital and treatment costs. The aim of this study was to assess the budget impact (BI) of the implementation of proactive strategies to prevent inadvertent perioperative hypothermia (IPH) in surgical patients in Italy, as recommended by international guidelines and by a good clinical practice (GCP) guideline of the Italian Society of Anesthesia, Analgesia, Reanimation, and Intensive Care.

Methods

BI was calculated over a 3-year period from the perspective of the Italian National Health Service (NHS). Model inputs were extracted from national literature when available and otherwise from international sources. The reference analytic model was based on the cost-effectiveness analysis of the National Institute for Health and Care Excellence clinical guidance 65. Estimates were based on assessments made about current malpractice in Italy and on a hypothesis of how future practice might change by implementing the GCP. Model output included overall BI results, variations in the number of warmed patients, medical-device average costs and use of mix.

Results

The base-case estimate quantified a decrease of 35% in extra days of hospital stay due to IPH and a net BI of –€60.92 million.

Conclusion

Increasing protocol adoption for preventing IPH would lead to both clinical advantages and significant savings for the NHS. Its large diffusion in Italian hospitals is thus desirable.