Dr Richard Hughes
Dr Shahood Ali
Kevin Robinson, 3M Ltd
Cardiff and Vale University Health Board
Inadvertent peri-operative hypothermia is a constant problem in surgery. Virtually all patients experience this to some extent following the administration of an anaesthetic. So much so that NICE published guidance in April 2008 (CG65) on avoidance of this situation.
Core elements of this advice are widely adopted throughout Wales, but patients often still finish surgery hypothermic. One particular element which is poorly followed is in the measurement and recording of patient temperature regularly over the course of a surgical procedure. The reason for this is the lack of a reliable non-invasive patient temperature measure for use in the clinical environment.
Following years of clinical anaesthesia practice, it was evident that the area requiring study was in the peri-operative temperature management of trauma patients. It was perceived that some of our elderly patients with medical co-morbidities are those most at risk of developing peri-operative hypothermia. Although presumed to be currently without problem, no previously published patient temperature audit had been undertaken with such a population, largely because of the lack of an appropriate thermometer.
3M launched the SpotOn Temperature monitoring system a few years ago. This has been validated against significantly more invasive methods and has been shown to be in agreement with them. The major advantage of the system is that it is non-invasive and records a core patient temperature through innovative zero-heat flux technology. Although commercially available, it has not been adopted widely within the NHS.
Analysis & Approach
The intention of the study was to evaluate the ease of use of the 3M SpotOn system for patient temperature monitoring and to study current temperature management practice. The intention was to complete a full audit cycle with implementation of remedial remedies.
Goals & Targets
The aim of the project was to evaluate the SpotOn technology for ease of use but largely to identify if and where we had a problem in the peri-operative temperature management of trauma patients. The aim was to recruit 200 patients into the study to facilitate sub-group analysis of specific target patient groups.
The project documented patient temperature data on 156 patients who underwent trauma surgery at the University Hospital of Wales. The results of our project clearly demonstrate areas where current peri-operative practice deviates from NICE recommendation. Although only 4% of our patients start hypothermic, over 20% of all patients arrive in the recovery room clinically cold (<36 oC). Invariably, active patient warming is initiated intra-operatively, but for various reasons this may be ineffective or inadequate. Warming of intravenous fluids administered happened in only 3 of the patients studied, whereas NICE advises all patients should receive warmed hydration.
Focusing on a sub-group of patients receiving surgical treatment for a hip fracture, a third of them were clinically hypothermic upon arrival to the recovery room. The hip fracture patients also amounted to over 70% of the patients who stayed a significantly long time in the recovery room due to temperature issues.
Ultimate patient outcome correlation with peri-operative hypothermia is impossible as eventual patient progress is multi-factorial and it is extremely difficult to tease out one element.
Interventions & Actions
Although efforts must be made to comply with NICE guidance to reduce the overall 20% post-operative hypothermia rate, particular attention must be applied to addressing the unacceptably high peri-operative hypothermia rate in patients who undergo surgical fixation of femoral fractures. It is in this latter cohort where invariably a regional anaesthetic is utilised and in whom invasive temperature measurement is impossible.
The intention of the project was to complete a full audit cycle following implementation of corrective measures but lack of initial data and the timescale concerned restricted completion.
The plan is to link with trauma nursing staff to highlight the importance of achieving patient normothermia pre-operatively in high-risk populations. There is certainly a place for the targeted peri-operative implementation of the SpotOn core temperature measurement system in the trauma management of femoral fracture patients. This supports the principles of Prudent practice by focusing on specific patients in who benefit can result from the intervention.
We have demonstrated that the use of the 3M SpotOn technology can easily and accurately monitor the core temperature of a patient throughout the course of a surgical procedure. The SpotOn Temperature Monitoring system is easy to use, well tolerated by patients, provides dynamic non-invasive temperature measurement and can be used to accurately direct peri-operative patient thermal care.
NICE published guidance over 7 years ago on optimal patient management to minimise potential peri-operative hypothermia. This audit project has identified significant variance from this guidance and deficiencies in the care afforded to our patients. Most notably, the process has highlighted particular areas of concern when considering patients with hip fracture, and these require future multi-disciplinary attention. Adoption of specific targeted use of the SpotOn technology can help direct healthcare personnel to deliver optimal evidence-based care for vulnerable high-risk patients and to direct patient improvement interventions.
Fit with Prudent Healthcare
The SpotOn technology is clearly innovative and acts to provide the clinician with accurate patient data to act upon. This project has demonstrated the effectiveness of the technology and illustrated both where clinicians can improve globally and more specifically apply this technology in a targeted high-risk patient group. In this trauma-related project, a sub-group has been identified where there is perceived patient benefit through adoption of this technology.
Part of Cohort Bevan Exemplars 2015-16