SSI-Normothermia

I found the following information on the Opana Website and was wondering what you thought? SDS has been doing a great job capturing all the patients that require pre-op warming (laparotomy patients). Patients are warmed with the Bair Hugger blankets and we will find out in the coming months whether the SSI (surgical site infection) rate is down.
My question for the PACU nurses is the following: currently our discharge criteria from PACU is 35.5 degrees C. OPANA and Safer Healthcare Now indicates tha Best Practice is that normothermia is 36-38 degrees C. Do you think that we should change our discharge criteria to 36 degrees C to support Best Practice?

OPANA recommends the following guidelines to maintain normothermia in the perioperative area. Please remember that your institution's policies and the recommendations of your anesthesia departments may not concur with the following guidelines and must supersede these standards. All information given below is referenced and is based on evidence found in the literature written on this subject.

Background:
In 2002, researchers conducted a point prevelance survey of nosocomial infections among 6,745 patients in 29 Canadian acute care hospitals across nine provinces. Canadian surgical site infection rates were found to account for 21% of five types of infections surveyed, ranking third most common in nosocomial infections. (1)
Surgical Site Infections can increase mortality, readmission rate, length of stay and cost for patients who incur them. While rate of surgical site infection ranges between 2-3% for clean cases, an estimated 40-60% of these infections are preventable. (2)
The Canadian Patient Safety Institution was developed to look into these and other risks to patients in hospitals. Subcommittees were organized to focus on specific areas of the healthcare environment where patients may be at risk of injury or nosocomial insult. The campaign to deal with Surgical Site Infections and other potential risks to patients in hospital, was the "Safer Healthcare Now!" campaign. It focussed on 10 areas of healthcare with high rates of negative outcomes which were occurring predominantly in Intensive Care Units, Surgical Suites, geriatric and medical inpatient units. (3)
One of the topics that Safer Healthcare Now! focussed on, that is most relevant to the perianesthesia nursing group, was "Surgical Site Infection", based on the above findings from the research.

Goal of the Safer Healthcare Now! Intiative for Surgical Site Infections:
"Prevent Surgical Site Infections (SSI) and deaths by reliably implementing ideal perioperative care for all surgical patients." (3)
After investigation and searching the literature into studies in this field, the contributing factors for negative outcomes related to surgical site infections were determined and were categorized into just 4 main groupings. Interventions for consideration and implementation, based on evidence in the research that was related to these infection rates, were then recommended.
Interventions for the Prevention of Surgical Site Infections:
1. Appropriate use of prophylactic antibiotics (including appropriate selection, timing and discontinuation)
2. Appropriate hair removal at the surgical site: minimally, and if necessary, clipping of hair rather than shaving
3. Maintaining post-operative glucose control for major cardiac surgery patients cared for in an ICU
4. Perioperative normothermia for all open abdominal surgery patients
**Note: Normothermia: Medical literature suggests that patients have a decreased risk of surgical site infection if they are not allowed to become hypothermic at any time during the perioperative period. Although temperature control may benefit other surgical patients, such as intentional therapeutic hypothermia for hypothermic cardioplegia, for the SHN campaign this measure only applies to the colorectal or open abdominal surgical population for the purposes of national measurement. Open abdominal surgery includes all open urology, nephrectomies, prostatectomies, hysterectomies, excluding vaginal hysterectomies, thoracic, pneumonectomies and pulmonary thoracic surgeries.(2)

Contributing Factors for Hypothermia:
Extremes of age
Females
BMI
Length and type of surgical procedure
Cold irrigants and wet skin preparations
Fluid shifts
Room temperature
Comorbidites (the presence of large open wounds, endocrine diseases, pregnancy, burns, peripheral vascular disease)
Type of anesthesia used (general, regional)
Anxiety
Negative Outcomes from Hypothermia:
Surgical site infection (impaired wound healing)
Patient discomfort (shivering)
Increased need for blood products (impaired platelet function, reduced coagulation)
Altered drug metabolism
Unexpected, negative cardiac events
Increased need for mechanical ventilation
Reducing the Risk of Hypothermia in the Perioperative Visit:

The prevention of Surgical Site Infections from hypothermia in the open abdominal surgery, and in any surgical group, can be accomplished or reduced by maintaining a normal temperature (36º - 38º C) through all stages of the perioperative course:

a) Preoperative warming of patients: warm flannel blankets from electric blanket warming cabinets, forced-air convection "housecoats", clothing to cover patients' extremeties and heads, preoperative monitoring of patient temperature, observation of overt indicators of hypothermia (regardless of core temperature): shivering, peripheral vasoconstriction, piloerection
b) Intraoperative warming of patients: warm fluids such as intravenous and irrigants, blood warmers, continuous monitoring of patient temperature (core preferable, tympanic) throughout the procedure, humidified and warm gases, warming blanket under patient on the operative table
c) Postoperative warming of patients: warm flannel blankets from electric blanket warming cabinets, forced-air convection blankets, circulating water mattresses, warm IV fluids, immediate and frequent monitoring of patient temperature until normalized (core preferable, tympanic), observation of overt indicators of hypothermia (regardless of core temperature): shivering, peripheral vasoconstriction, piloerection

Outcome Indicator: The postoperative surgical patient will have a normal temperature between 36.0º - 38.0º C in the PostAnesthesia Care Unit. (2)

Data collection for the SSI Campaign for Normothermia, Inclusion/Exclusion Criteria:

1. Total number of patients during this month who had an inpatient surgical procedure of this type (colorectal surgery). If more than one surgical procedure was performed during a single index hospitalization, include data only from the first surgical procedure.
2. Exclude patients whose age is less than 18 yrs on admission to hospital.
3. Exclude patients whose principal diagnosis code or admission diagnosis is suggestive of a preoperative infectious disease
4. Exclude patients who were admitted for treatment of burns or for organ transplantation (3)

Goal Rate:
95% patients who have undergone open abdominal surgery, or colorectal surgery specifically, will have documented postoperative temperatures in the range of 36.0º - 38.0º C. (3)

PeriAnesthesia Nursing Interventions:

1. Preoperatively: PreAdmission Units can instruct patients to bring their own warm housecoats, slippers, pyjama bottoms and headwear to the hospital for the day of surgery.
On the day of surgery, a preoperative temperature should be taken. Monitoring patients for obvious signs of hypothermia is necessary (shivering, peripheral vasoconstriction, piloerection). Patients should wear their own housecoats, socks, pyjama bottoms and headwear until entering the Operating Room. Only after induction of anesthesia should the clothing be removed (it may be necessary to have the patient remove his own outer "housecoat" prior to general anesthesia) and only the clothing that is necessary to remove in order to access the surgical site.
Any signs of infection (fever, rigor) should be reported to a healthcare professional on the morning of surgery and prior to entering the Operating Room.
2. Postoperatively: Post Anesthetic Care Units and Day Surgery Units should monitor postoperative temperatures IMMEDIATELY upon admission from the Operating Room and document these on the postoperative document (paper or online). Temperatures outside of the range of 36º - 38º C should be treated at once (warming measures should begin at once if temperature less than 36º C; report temperatures greater than 38º C to the surgical team for immediate treatment).
Once measures for treatment have been taken, postoperative temperatures should be taken every 30 minutes until the patient's temperature is within normal range. Once normothermia has been reached, frequent postoperative temperature tracking is no longer necessary in the PACU/DSU environment until just prior to transfer or discharge, unless other signs of hypothermia appear: shivering, peripheral vasoconstriction, piloerection. Complete documentation on the patient's chart of all temperatures should be recorded.

Written by Paula Ferguson

References:
1. Brennan. N Engl J Med. 1991; 324: 370-376.
2. CIHI Healthcare Canada, 2004. Unpublished data from D. Gravel, the Point Prevelance Working Group, the Canadian Nosocomial Infection Surveillance System, the Canadian Hospital Epidemiology Committee, "Point Prevalence Survey of Nosocomial Infections Within Seleced Health Care Insitutions" (2004).
3.www.saferhealthcarenow.ca