1/10/2012. Objectives. Normothermia as a SSI Reduction Tool. Disclosure. Darin Prescott, MSN, MBA, RN,BC, CNOR, CASC

Transcription

1 Normothermia as a SSI Reduction Tool Darin Prescott, MSN, MBA, RN,BC, CNOR, CASC Disclosure Arizant Healthcare Inc., a 3M company Objectives Describe the impact of hypothermia on perioperative patient outcomes, including SSIs Determine effectiveness of perioperative patient warming measures Explain the relatedness of preoperative warming to the incidence of hypothermia Using an evidence-based practice model, identify the effectiveness of a forced-air warming gown to decrease rate of hypothermia 1

2 Surgical Care Improvement Project (SCIP) The Surgical Care Improvement Project (SCIP) is a national quality partnership of organizations focused on improving surgical care by significantly reducing surgical complications. It is a unique partnership that is proving to be a transformational undertaking in health care. The SCIP goal is to reduce the incidence of surgical complications nationally by 25 percent by the year (Qualitynet.org) SCIP Steering Committee American College of Surgeons (ACS) American Hospital Association (AHA) American Society of Anesthesiologists (ASA) Association of peri- Operative Registered Nurses (AORN) Agency for Healthcare Research and Quality (AHRQ) Centers for Medicare & Medicaid Services (CMS) Centers for Disease Control and Prevention (CDC) Department of Veteran s Affairs Institute for Healthcare Improvement (IHI) Joint Commission (JC) Current SCIP Initiatives Beta-blocker administration Venous thromboembolism prevention Antibiotics Administration within one hour before incision Use of antimicrobial recommended in guideline Discontinuation within 24 hours of surgery end Glucose control in cardiac surgery patients Proper hair removal Normothermia 2

3 Best Practices for Preventing SSIs Clipping Remove hair appropriately Antibiotics Use prophylactic antibiotics appropriately Temperature Maintain normothermia Sugar Maintain glucose control Why Normothermia? Research indicates a correlation between unplanned perioperative hypothermia and: impaired wound healing, adverse cardiac events, altered drug metabolism, coagulopathies, surgical site infection, delayed wound closure, prolonged hospital stay, increased blood products administration, myocardial infarction, and mechanical ventilation Normothermia is defined as a core body temperature of 96.8 o o F (36 o - 38 o C) Forced-Air Warming: Clinical Evidence Nearly 170 studies published on the safety and effectiveness Including >60 randomized controlled trials Forced-air warming is the only patient warming modality with peer-reviewed clinical outcomes data proving effectiveness in maintaining normothermia resulting in a reduction of SSIs 3

4 Surgical Wound Infections Hypothermic colorectal surgical patients with mild hypothermia have: 20% 15% 10% 5% 0% Infection Rate Hypothermic Normothermic Adapted from: Kurz et al., New Engl J Med, 1996 Days Length of Hospital Stay Patients with Patients without wound infections wound infections Adapted from: Kurz et al., New Engl J Med, 1996 Normothermia and SSI Reduction There is no longer a question whether maintenance of normal core body temperature is important for decreasing the incidence of SSI; the answer is unequivocally yes. Barie, PS. Surgical Site Infections: Epidemiology and Prevention. Surgical Infections. Vol 3, Supplement 2002; S-9 S-21. AORN Recommended Practices Assess for the risk of unplanned hypothermia Age BMI Skin integrity Length of surgery Develop a plan of care including necessary supplies and equipment Temperature monitoring Core temperature measurement Tympanic, distal esophagus, nasopharynx and pulmonary artery Interventions to prevent unplanned hypothermia Forced-air warming for 15 minutes pre-op Circulating- water garments and table pads 4

5 AORN Recommended Practices, cont. Warming devices are used safely Irrigation fluids 98.6 F IV Fluids follow manufacturer instructions Competency Documentation PNDS: Potential diagnoses Risk for imbalanced body temperature Ineffective thermoregulation Hypothermia Policies and procedures Quality ASPAN Standards & Practice Recommendations All patients should receive: Limit skin exposure to lower ambient environment temperatures Initiate passive warming interventions (e.g. blankets, drapes and reflective composites) Maintain ambient room temperature at degrees C Patients with anesthesia time anticipated to be more than 30 minutes, at risk for hypothermia or increased risk of complications should receive: Forced-air warming Initial Interventions to Promote Normothermia in Colorectal Patients Education of General Surgeon groups Maintain OR temperatures at 68 o F Increased use of the current forced-air warming blanket preoperatively Assured just-in-time warm fluids are used for irrigation Applying warm cotton blanket at end of case Re-applying forced-air warming blanket immediately after dressings applied Discovered forced-air warming on the gel pad Considered forced-air warming gown in conjunction with or without a forced-air warming blanket 5

6 Initial Practice Interventions Normothermia Task Force Initiated Representation included: Perioperative Registered Nurses (intra-op), Perianesthesia Registered Nurses (pre & post-op), Clinical i l Materials Management Specialist, Anesthesiologist, and Advanced Practice Registered Nurses (CNS & CRNA) Task was to assure to assess the process of maintaining normothermia of colo-rectal patients SCIP-Infection-10: Change in October 2009 Proportion of patients undergoing any operation (any age) who have anesthesia for more than one hour, who have active warming devices used or achieve normothermia within 30 minutes immediately before or 15 minutes immediately after the end of anesthesia. Excludes patients with intentional hypothermia (Bratzler, 2008) CMS SCIP-Infection-10 Perioperative Temperature Management Measure Numerator Active warming used intraoperatively OR At least one temp 36.0 C within 30 minutes immediately before or 15 minutes immediately after anesthesia end time Denominator All patients undergoing surgical procedures under general or neuraxial anesthesia of 60 minutes or longer 6

7 Evidence Based Practice Not the same as Research or Performance Improvement Utilizes clinical research Utilizes clinical expertise Puts research into practice Utilizes multidisciplinary approach Evidence Based Practice Project Iowa Model of Evidence-Based Practice Triggers problem focused and/or knowledge focused Evaluate priority of topic for organization Team formation Research, literature and other evidence gathering and evaluation Pilot the change in practice Determine implementation Monitor Triggers Problem Focused Process Improvement Data Internal/External Benchmarking Data 7

8 Achievement of Desired Standard Continued to Fluctuate Triggers Knowledge Focused Research and Literature National standards and guidelines New products Priority for the Facility Effects of hypothermia on patients National standards and regulations 8

9 Assemble a Team Core Charge Nurse from Pre-op Admission Area Clinical Value Analysis Nurse Perioperative Educator Forming a team purpose Purpose Review the literature Get input from stakeholders Determine process of pilot Relevant Research and Related Literature Effects of Hypothermia Infection rates of surgical patients Prevention of Hypothermia Intraoperatively Use of warm cotton blankets U f f d i bl k t Use of forced air blankets or gowns Effectiveness of Prewarming 9

10 Effects of Hypothermia Kurz, Andrea, Sessler, Daniel I., et al, Postoperative Hemodynamic and Thermoregulatory Consequences of Intraoperative Core Hypothermia, Journal of Clinical Anesthesia, August, 1995, pp patients randomly assigned to routine or upper body forced air blanket Temps significantly less post Time required for full recovery 4 hours to reach normothermia Effects of Hypothermia Frank, Steven M., Unintentional Hypothermia is Associated with Postoperative Myocardial Ischemia, Anesthesiology, March, 1993, pp patients lower extremity vascular reconstruction 36% incidence in non-warmed patients 16% incidence in warmed patients Effects of Hypothermia Schmied, Harald and Kurz, Andrea, Mild Hypothermia Increases Blood Loss and Transfusion Requirements During Total Hip Arthroplasty, Lancet, 2/3/96, pp patients primary unilateral total hip arthroplasties 8 units required in 7 of the 30 hypothermic patients 1 unit in 1 normothermic 10

11 Effects of Hypothermia SSI Melling, Andrew C, et al, Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial, The Lancet, September 15, 2001, pp patients breast, varicose vein, or hernia surgery SSIs 14% non-warmed (19/139) 5% warmed (13/277) More postoperative antibiotics in non-warmed group Effects of Hypothermia - SSI Kurz, Andrea, Sessler, Daniel I., et al, Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of wound infection and temperature group, The New England Journal of Medicine, May 9, 1996, pp patients undergoing g colorectal surgery randomly assigned hypothermia group or normothermia group SSIs 19% non-warmed (18/96) 6% warmed (6/104) Hypothermic patients had sutures removed one day later and average stay increased by 2.6 days (+20%) Effects of Hypothermia Additional studies including a meta-analysis of 18 studies on the negative effects of hypothermia. Delayed time to extubation Development of neck seromas and flap dehiscence Increased shivering and oxygen consumption Delayed wound healing Decreased drug metabolism Increased hospital stay Decreased thermal comfort for patient 11

12 Prewarming Effectiveness Reviewed studies of prewarming with forced-air blankets Decreased amount of temperature drop Decreased number of patients with hypothermia More effective than cotton blankets Level of Evidence A Evidence from well-designed metaanalysis B Evidence from well designed controlled trials, both randomized and nonrandomized, with results that consistently support a specific action, intervention or treatment Evaluation of Research Base Research supported Negative effects on surgical patient when they experienced hypothermia during their perioperative experience Forced-air warming during the intraoperative period did decrease hypothermia Prewarming with forced-air product also decreased the incidence of hypothermia 12

13 Evidence Based Project Purpose Determine if the use of forced air gowns would decrease the percentage of patients experiencing hypothermia during the perioperative period Determine if patient comfort would increase SCIP criteria although we looked at the entire perioperative period Evaluate financial impact Costs Linen usage Develop a PICO statement Reason to define our project P = patient population or problem to be evaluated I = intervention to be considered and evaluated C = comparison intervention that is currently being done O = outcomes that are anticipated will be accomplished EBP Project: Forced Air Warming with Gown Patient population Surgical patients receiving spinal or general anesthesia Intervention Prewarming with forced-air warming gowns Comparison i Use of cotton blankets/current t interventions Outcome desired Decrease number of surgical patients with hypothermia as defined by a temp of less than 36 degrees C during their perioperative experience 13

14 EBP Project: Forced-air Warming with Gown Purpose: Goal was to decrease the incidence of patients experiencing hypothermia during their perioperative experience, increase patient satisfaction and be cost effective Process Group representing Center for Surgical Care, PACU and Surgery Data collection for approximately 200 patients using current methods of warm cotton blankets Data collection for approximately 200 patients t using forced air gowns Education of the device for the above departments and the post-op inpatient units Survey of nurses following the trial Evaluation Forms: Prior to trial Areas involved: Center for Surgical Care Operating Room Post Anesthesia Care Unit Data collected: Temperature Warming used Lowest temperature in surgery Cotton blankets used 14

15 Evaluation Form During trial Areas involved: Center for Surgical Care Operating Room Post Anesthesia Care Unit Data collected: Temperature Warming used Lowest temperature in surgery Cotton blankets used Use for IV starts Evaluation Form After trial staff survey Ease of use Effectiveness Patient response Blanket reduction Number of patients being cold Support purchase Evaluation After trial staff survey Units Surveyed Center for Surgical Care Pre-Op Holding PACU Surgical Unit (4 th ) Surgical Unit (4 th ) Ortho Unit (6 th ) 15

16 Facility Project Pilot 189 patients in the group prior to using forced-air warming gowns 239 in the group that trialed the forced-air warming gowns Results Related to Hypothermia Reduction in patients being cold Reduction in patients shivering Reduction in number of outpatients experiencing hypothermia Reduction in number of outpatient admissions experiencing hypothermia All Patients Hypothermia Rate Hypothermia rate for all patients at some point during surgery: 19% reduction 16

17 Outpatients Hypothermia Rate Hypothermia rate for outpatients at some point during surgery: 14% reduction Outpatient Admissions Hypothermia Rate Hypothermia rate for outpatient admissions: 26.5% reduction Evaluation After trial staff survey Effectiveness for IV Starts Blanket reduction Patient Response Number of patients being cold Ease of use Support implementation 17

18 Staff Evaluation Surveys It was indicated on 55 patients that the gown was tried for IV starts It was successful 54 times. Staff Evaluation Surveys Linen Usage Blanket Usage Decrease of approx. 2 blankets in CSC, 1 in Pre-op Holding and 2 in PACU Also decrease of approx. 2 on the unit Gown Usage Eliminated the need for linen gown usage during the first day Warming gown was reused for some patients after admission during the days following surgery Linen Usage Blankets Per Patient Decrease 18

19 Patient Feedback Positive feedback submitted directly to the product manufacturer Autonomy in the ability to control temperature of the device Patient t requests Ease of use Support implementation Staff response on survey Supported implementation Next Steps Determined for Implementation Education of best period of time to have on patient according to the evidence believe this will decrease rate of hypothermia further Education regarding use for IV starts Education on units for complete implementation ti throughout hospital Implemented July,

20 Achievement of Desired Standard Tracked on Quarterly PI Reporting Surgical Site Infections Compared quarter July September, 2008 with July September, 2009 Percentage reduction translated to decrease of 8 infections Reviewed literature t and information for average cost of SSI Savings for the hospital but also improved care for the patient PI Information regarding PACU Stays Decrease in number of extended stays in PACU related to hypothermia 20

21 Importance of Evidence-Based Practice Project and Implementation Impact on patient Improve patient outcomes Improve patient comfort Increase patient autonomy Sharing of Information Presentation at the SCH Research and Evidence- Based Practice Conference in 2009 Facility EBP Group presentations in May, 2010 Presentation at the Association of peri-operative Registered Nurses Congress in 2011 Poster Abstract Presentations Summer Institute on Evidence-Based Practice, San Antonio, TX American Association of Ambulatory Surgery Centers Conference 2010, Anaheim, CA Questions? Contact Information: 21

22 References Kurz A, Sessler DI, et al. Perioperative Normothermia to Reduce the Incidence of Surgical-Wound Infection and Shorten Hospitalization. New Engl J Med. 1996;334: Barie, PS. Surgical Site Infections: Epidemiology and Prevention. Surgical Infections. Vol 3, Supplement 2002; S-9 S-21. Bratzler, D.W. (2008, June). The surgical care improvement project: An update. Presentation at annual meeting Association of Practitioners in Infection Control and Epidemiology, Denver, CO. Specifications Manual for National Hospital Inpatient Quality Measures Discharges (4Q09) through (1Q10). Centers for Medicare and Medicaid Services (n.d.). Surgical Care Improvement Project. Retrieved March 13, 2009 from, QualityNet Web site: Siew-Fong, N., Chen-Sim, O., Khiam-Hong, L., Poh-Yan, L., Yiong-Hauk, C., & Biauw-Chi, O. (2003). A comparative study of three warming interventions to determine the most effective in maintaining perioperative normothermia. Anesthesia & Analgesia, 96, Sessler, Daniel I., Complications and Treatment of Mild Hypothermia, Anesthesiology, August, 2001, pp Mahoney, Christine and Odom, Jan, Maintaining intraoperative normothermia: A meta-analysis of outcomes with costs, AANA Journal, April, 1999, pp McAnally, Heth B., et al, Hypothermia as a Risk Factor for Pediatric Cardiothoracic Surgical Site Infection, The Pediatric Infectious Disease Journal, April, 2001, pp Leslie, Kate, Sessler, Daniel I., Mild Hypothermia Alters Propofol Pharmacokinetics and Increase the Duration of Action of Atracurium, Anesthesia Analgesia, 1995, pp Kurz, Andrea, Sessler, Daniel I., Perioperative Normothermia to Reduce the Incidence of Surgical Wound Infection and Shorten Hospitalization, The New England Journal of Medicine, May 9, 1996, pp Agrawal, Nishant, et al, Hypothermia During Head and Neck Surgery, The Laryngoscope, August, 2003, pp Bush, Harry L., et al, Hypothermia during elective abdominal aortic aneurysm repair: The high price of avoidable morbidity, Journal of Vascular Surgery, March, 1995, pp Frank, Steven M., Perioperative Maintenance of Normothermia Reduces the Incidence of Morbid Cardiac Events: A Randomized Clinical Trial, JAMA, April 9, 1997, pp References Just, Bernard, et al, Prevention of Intraoperative Hypothermia by Preoperative Skin Surface Warming, Anesthesiology, August, 1993, pp Kim, Ji Young, et al, The effect of skin surface warming during anesthesia preparation on preventing redistribution hypothermia in the early operative period of off-pump coronary artery bypass surgery, European Journal of Cardio-Thoracic Surgery, 2006, pp Sessler, Daniel I. and Schroeder, Marc, Heat Loss in Humans Covered with Cotton Hospital Blankets, Anesthesia Analgesia, pp Camus, Yvon, et al, Pre-Induction Skin Surface Warming Minimizes Intraoperative Core Hypothermia, Journal of Clinical Anesthesia, pp Vanni, Simone Maria D Angelo Angelo, et al, Preoperative Combined with Intraoperative Skin Surface Warming Avoids Hypothermia Caused by General Anesthesia and Surgery, Journal of Clinical Anesthesia, 2003, pp Sessler, Daniel I., et al, Optimal Duration and Temperature of Prewarming, Anesthesiology, March, 1995, pp Andrzejowski, Jl, et al, Effect of prewarming on post-induction core temperature and the incidence of inadvertent perioperative hypothermia in patients undergoing general anaesthesia, British Journal of Anaesthesia, November, 2008, pp Kurz, A et al, Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization, The New England Journal of Medicine, May, 1996, pp