PE R IOPE RAT IVE PRACT ICE
that they should create a risk assessment tool based on the NICE guidance.2
This they
have called the Inadvertent Perioperative Hypothermia Risk Assessment Tool (Table 1) and is based on NICE Guidance and the OneTogether Assessment Toolkit to measure the standards.
In order to collate all the elements, Nur-in Mohammed undertook a PDSA cycle which aimed to ensure that all patients are risk assessed according to the guidelines. PDSA cycles have proved to be a useful tool to use when working through an issue and wanting to ensure that it is a sound initiative providing clarity for what the change might deliver.
The model for improvement provides a framework for developing, testing and implementing changes leading to improvement.3
The model helps to
ensure that the aims and objects of the improvement are clear, how the change will be measured and what the measures of success are going to be. The four stages of the model are: l Plan: the change to be tested or implemented
l Do: carry out the test or change l Study: based on the measurable outcomes agreed before starting out, collect data before and after the change and reflect on the impact of the change and what was learned
l Act: plan the next change cycle or full implementation.
In order to ensure that all staff were fully informed and engaged with the project, a study session was held for those staff working in the Day Surgery Unit so that they were able to use the Risk Assessment tool in Table 1.
It also included what staff actions should be, once they had assessed the risk and had a score for each patient. The intervention guidelines devised for staff to follow were based on clinical evidence from NICE recommendations and the OneTogether framework.
Equipment challenges To keep the project cost neutral, it was known that there were insufficient warming machines to pre-warm all the patients that might need them, so the working group team
ASA1
ASA2 ASA3 ASA4 ASA5
Risk Factors for Inadvertent Perioperative Hypothermia ASA Grade 2 and above
Undergoing combined general and regional anaesthesia Undergoing major or intermediate surgery Age more than 75 years Low BMI – less than 20
1 or below – LOW RISK 2 or above 0 HIGH RISK
Risk Assessment Tool – Table 1 Low risk
l Measure and document baseline score body temperature, retake an hour before transfer to theatre
l Provide two blankets
l Advise patient to keep warm and inform nurses/ HCAs when feeling cold
Perioperative Hypothermia.
Tick
High Risk
l Measure and document baseline core body temperature, retake an hour before transfer to theatre.
l Start active warming using Forced Air Warming Equipment 30 minutes before transfer to theatre
Intervention Guidelines – Table 2 Note: If patient’s body temperature is below 36°C, start active warming IMMEDIATELY, regardless of risk for Inadvertent
decided that they would use blankets instead and progress the procurement issue later in the project.
Therefore, the lack of equipment would not prevent the project taking place, but they would use the resources that they had. In addition to fewer Forced Air Warming machines than necessary, they were using tympanic thermometers which are not recommended for their ability to measure core temperature accurately.4
The latter are known to be less accurate than direct measurement using pulmonary artery catheters; distal oesophageal and urinary bladder are considered the most accurate methods and sites for direct core temperature measurement or direct estimation of core temperature.5
Documentation challenges In addition to the equipment difficulties, the teams were finding challenges in the documentation from surgical pre-assessment clinics who were failing to document the patient’s ASA grading.
An essential element of the identification and management of the individual patient is determined by their ASA grading. A review
A normal healthy patient, (that is, without any clinically important comorbidity and without a clinically significant past/present medical history
A patient with mild systemic disease A patient with severe systemic disease
A patient with severe systemic disease that is a constant threat to life A moribund patient who is not expected to survive without the operation
ASA Grading – Table 36 16 l
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of their pre-assessment documentation identified that only 65% of all patients were being ASA graded and, therefore, the next PDSA cycle focused on improvement of the patient’s ASA grading documentation. The solution to this aspect of care and of the quality improvement initiative was to run a study session with the pre-assessment team. ASA grading is not only important to the warming of patients but to their general risk assessment prior to surgery, as it highlights co-existing diseases and functional capacity. In addition to the pre-assessment documentation issue, it was noted that documentation of intraoperative temperatures was not all that it could be, especially for short procedures.
The theatre team were the next group to have a training session led by Nur-in to establish better processes for charting patient temperatures throughout their surgery. NICE recommends a measurement is taken every 30 minutes, and is documented.7
Quality improvement outcomes As an ongoing project, the outcomes from the first three months were very positive, showing compliance to the NICE guidance improved significantly. The incidence of perioperative hypothermia dropped by 20%. Documentation of intraoperative temperature increased from 43% to 95% and, while the ASA grading documentation still leaves a bit to be desired, the overall improvement is significant. The challenge will be to ensure that the changes are embedded and sustainable.
Plans for additional changes include a further training session for all ward staff on
MARCH 2021
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