Mercury Rising: Temperature Management Roundtable
This article appears in the April print issue of Surgical Products.
Experts from four companies that provide temperature management products discuss the technology that allows clinicians to keep themselves and their patients safe and comfortable.
SP: What are some of the potential consequences of overlooking patient temperature management?
Karen Moore, Marketing Director, Ecolab Healthcare: Maintaining core body temperature is critical to improving outcomes for surgical patients. Clinical research shows that even mild hypothermia leads to adverse effects including increased blood loss, delayed wound healing, potential adverse cardiac outcomes, lengthened recovery and hospital stays and increased risk of surgical site infections. Inadvertent hypothermia jeopardizes patient health and is costly to the facility. Actively managing the patient’s temperature throughout the perioperative continuum reduces risk to the patient and unnecessary cost to the facility. It is important to recognize the opportunities before, during and after surgery to maintain patient normothermia.
Kelley Terrell, Senior Marketing Manager, Techstyles Nonwovens at Encompass Group, LLC: Clinical evidence demonstrates that mild hypothermia increases the incidence of serious adverse consequences including surgical site infections and adverse cardiac events including ventricular tachycardia.
Brent Augustine, President, Augustine Temperature Management: According to Mahoney in Economics of Patient Warming (Outpatient Surgery Magazine 2005), each hypothermic patient could incur as much as $2,500-7,000 in additional costs. Warming literally saves lives and is one of the least expensive things a hospital can do to improve surgical outcomes.
SP: Generally speaking, do most facilities do an adequate job of addressing patient temperature management? Why or why not?
Terrell: Most facilities have implemented patient temperature management protocols for the intraoperative and postoperative environments. However, the benefits of effective prewarming are still frequently overlooked and the impact remains significant. In a 2012 study, the data reflected that despite more aggressive measures, over 32% of patients arrive in the postoperative area hypothermic. We are beginning to consider the solution may be more complex than simply applying active measures intraoperatively for longer duration procedures. The most effective warming strategies focus on the patient's needs and maximizing skin surface coverage to prevent cutaneous heat loss. Shorter duration procedures (typically 90 minutes or less) can typically be effectively addressed by passive warming products such as reflective warming gowns or blankets. However, patients undergoing longer duration procedures benefit from combining active and passive warming measures. This combination provides maximum coverage as well as a supplemental heat source.
Augustine: Even facilities that follow SCIP guidelines may not be doing as well as they think. A recent study by Leijtens in the Journal of Arthoplasty showed that forced-air warming failed 28% of the time, a rate the physician authors called “disturbingly high.” Other studies have corroborated the low success rate, and since many facilities still use forced-air warming systems, the overall failure rate is high.
SP: What are some of the products out there that are designed to deal with patient temperature management?
Augustine: Some technologies dating to the 1980s—like forced-air warming and circulating-water systems—are being challenged by less expensive, environmentally friendly, reusable electric warming systems. Among electric warming systems, for example, there are older-style carbon-fiber heaters and the newer conductive-polymer blankets and mattresses.
Moore: Technologies available include methods to warm irrigation fluid, warm IV fluids and warm the surface of the patient. Systems that allow for active irrigation fluid warming within the sterile field are replacing the use of cabinet warmers in many facilities.
Terrell: Forced air is one of the most common active warming measures used intraoperatively. The efficacy of these products is well documented. However, according to recent studies, they can take up to 30 minutes to have a measurable impact. This can present a challenge in shorter duration procedures where there may not be time to rewarm the patient before transport to PACU. Reflective warming technology products combine the function of traditional linen with intrinsic warming and insulating properties. They use the body’s radiant heat as a generator and minimize cutaneous heat loss. They are ultra-lightweight and move with the patient throughout the perioperative journey to maintain normothermia.
SP: What are the most important characteristics your customers look for in temperature management products?
Terrell: The primary focus of today's healthcare market is quality, outcomes, and cost. They are focused on providing the best care for their patients. They are seeking continuous improvement through solutions that are safe, simple and effective. Since the majority of surgical procedures are now performed on an outpatient basis and last 50 minutes or less, products must be proactive in nature. Effective prewarming is crucial since there may not be time in the OR to warm the patient with active warming measures.
Moore: When evaluating temperature management products, buyers should look for devices that improve patient outcomes, drive O.R. efficiency, and decrease risk to the patient and the facility. Solutions should be portable, easy-to-use, and help facilities to meet clinical and quality guidelines. For instance, current protocols may require nursing staff to make multiple trips to and from a warming cabinet to retrieve warm fluids. These fluids may be too hot to use immediately without risk of burning the patient, but will then cool so quickly in the O.R. that they have a cooling rather than warming effect on the patient. Having a warmer that continuously warms fluid available in the O.R. provides a solution to these challenges.
Augustine: Safety, effectiveness, cost, and ease of use are the most important characteristics customers look for in temperature management products. Safety means thermal safety as well as avoiding any unintended negative consequences. Forced-air warming systems have been linked to higher peri-prosthetic joint infection rates compared to air-free warming. Forced-air systems also produce waste heat that carries floor-level particles to the surgical site. Air-free systems do not. Effectiveness is important because patient normothermia is surprisingly difficult to consistently achieve and most systems are ineffective. Cost reduction is a critical mission for the entire healthcare system. Lastly, ease of use for the clinician is imperative.
SP: How do you expect these products to evolve in the future?
Augustine: Air-free warming is the future. It’s inconceivable to continue using forced-air technologies that knowingly increase infection risks in orthopedic implant surgery. Safety, effectiveness, cost, and ease of use are imperative and air-free conductive fabric warming is the only technology positioned to meet those needs.
Moore: Existing technologies could provide increased value to facilities by adding functionality, improving ease of use and providing connectivity to databases and patient records.
Terrell: I am confident as we continue to strive toward better solutions and improved outcomes we will discover new applications incorporating today's more technical nonwoven materials. I am excited to be a part of an industry with so much opportunity.
SP: What are some of the potential consequences of overlooking the need to keep surgeons and staff cool in the OR?
Bill Graessle, President, Polar Products: Surgeons and hospital staff in the OR work under intense pressure in an environment that requires extraordinary mental clarity, dexterity, and eye-hand coordination. They must often wear gowns, lead aprons, and other gear. Add to that the intense activity in the OR and AORN guidelines for OR room temperature and there is a very real danger of overheating of the OR staff. Overheating can cause a variety of problems in any work environment, and it is a well understood phenomenon. According to OSHA, if the body cannot get rid of excess heat, it will store it. When this happens, the body's core temperature rises and the person begins to lose concentration and has difficulty focusing on a task. These problems can be particularly dangerous in the OR. Keeping personnel cool helps to mitigate the risk of overheating and resulting fatigue, loss of focus and concentration.
SP: What are some of the products out there that are designed to deal keep OR staff cool?
Graessle: Personal cooling systems fall into two main categories:
• Active systems that circulate cooling liquid through a series of tubes built into a vest. These systems require power and a source for the cooling liquid.
• Passive systems that incorporate cooling components into the garment. These often take the form of phase change cooling packs. No power or outside cooling source is required.
SP: What are the most important characteristics your customers look for in cooling products?
Graessle: Of course the primary requirement is effectively delivering a comfortable cooling temperature and garment for an extended period of time. Key to delivering this includes:
• Ease of mobility
• Easy to use
• Adjustable cooling
• Light weight
• Easily maintained
How these various components are delivered and the relative importance and trade-offs can often be a function of personal preference. For instance look at three choices commonly used by OR personnel:
1. An active system vest may weigh just one pound and will last for six-plus hours on a single reservoir charge. This choice requires power, a cooling liquid reservoir and connecting tubes. Many OR doctors find this to be the best option.
2. A passive cooling vest provides total mobility with no cords of tubes. These vests can weigh four pounds and may require cooling inserts to be replaced every three hours. Many OR personnel find this a good choice.
3. Additional OR personnel may find a simple passive cooling neck band is all that is required for their own personal cooling needs.
SP: Do the products out there on the market today meet the needs and wants of customers and potential customers? How do you expect these products to evolve in the future?
Graessle: The products do an excellent job and with continued investment in research and development the ever increasing demand for lighter weight, increased portability, ease of use, and lower cost will be met.
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