Introduction
Body temperature is one of the classical vital signs defined as measure of how adeptly the body eliminate heat. Perturbation is both an indicator and a cause of which is relevant in making medical decisions. It is common for patients to have complications such as infectious fever or hypothermia during surgery. Hypothermia is a core temperature of less than 36.50C for children below five years and 360C for older ones (Nemeth and Bräuer, 2021). The chances of death from malignant hyperthermia are 30% when there is no monitoring (Munday et al., 2022). The implication is that perioperative monitoring of body temperature helps identify any swift changes and manage them before they become fatal. It is recommended that hospitals follow the National Institute for Health and Care Excellence (NICE) guidelines to achieve normothermia before, during and after a surgical operation. Although there are guidelines for the best practice of continuously monitoring body temperature, most hospitals still fail to adhere by them hence, risking their patients’ lives.
Contextual Issue and Best Practice
As an anaesthetic trainee, the issue in my area of practice is non-compliance with the guidelines for measuring temperature. Specifically, anaesthetists tend to ignore the requirements for monitoring temperature for patients whose surgeries last for a short duration of about 30 to 90 minutes. The rationale for such negligence is that they feel it is just a simple procedure or not long enough to record temperatures. Noteworthy, I have worked in recovery before and saw many patients coming out of surgery with hypothermia and some shivering. Yet, trying to get those patients to a normothermic state is challenging, due to insufficient warming devices, resulting in prolonged recovery. Therefore, looking at the issue of normothermia is critical in preoperative practice as it may improve the quality of patient care in the hospitals.
Core body temperature monitoring is vital for most anesthetics as it helps to quantify any externalities which may be an indication of disease or physiological problem. All general anesthetics have a profound impairment on thermoregulatory control by reducing the threshold for cold defenses (Sessler, 2021). One study showed that the prevalence of hypothermia is 56.7% and higher when patients experience perioperative chills, the body temperature on arriving at the operating room, general anesthesia, and diabetes (Mendonça et al., 2021). Additionally, the surgical exposure and cold operating room environment cause most surgical patients to be hypothermic. Therefore, any surgery that lasts for at least thirty minutes requires continuous monitoring (Klein et al., 2021).
Best Practice as Described in Literature
The NICE guidelines provide strategies for achieving normal preoperative temperature, during the surgery, and post-operation. Perioperative temperature management can be done through thermal manipulation of various cooling and warming devices to achieve normothermia (Bindu et al., 2017). For instance, if the room is cold, a heater can be used to provide the necessary warmth to the patient so that by the time they are undergoing surgery, their body temperature is normal. If the patient is coming from home, they should be advised to keep warm, given that the human body has a tendency to adapt to the environmental temperature (Klein et al., 2021). Since my issue is patients are being taken temperature at the beginning of surgery and not continuously monitored or every 30 minutes as stipulated on NICE, I feel NICE guidelines should be referenced (NICE, 2019).
During the perioperative stage, most of the thermal regulation is through behavioral responses. Particularly, the patient should be asked to wear warm clothes, have slippers on the feet and possibly carry a blanket to keep warm (NICE, 2019). It may help to ask the patient or family members if they have any medical problems that affect their temperature or whether they tend to get cold quickly (NICE, 2019). More caution should then be taken in handling such patients that are already exposed to ensure extra warmth.
It is vital to use the correct equipment for measuring the temperature of patients. According to Sessler (2021), there are only four thermometers available for preoperative use, including the infrared, zero heat flux, thermistors, and thermocouples. The person measuring the temperature should be competent in reading and correctly interpreting the readings. According to the NICE (2019) guidelines, the professional should be trained in their use and be able to maintain the equipment as directed by the manufacturer. The implication is that thermometers should only be purchased from licensed and credible brands.
Furthermore, it is important to select the correct monitoring thermometer to avoid wrong measurements and estimations. When making estimations, the surgeon or nurse should not exceed ±0.5°C for the true core temperature (Sessler, 2021). The core temperature can be evaluated from regions that are well perfused with the core blood vessels, including the nasopharynx, pulmonary artery, distal esophagus, tympanic membrane, deep forehead, sublingual, rectum, axilla, and urinary bladder (NICE, 2019). The rationale is that the nurse selects site for monitoring based on the type of thermometer and convenience. It is important that the doctor does not assume or make indirect estimates for adults before their surgery. Moreover, there should be compliance with the local policies for infection control.
Comparison to Workplace Practice
We have NICE guidelines which the hospital has adopted which have been laminated and put on each anaesthetic room. The guidelines indicate the consequences of perioperative hypothermia, ways of monitoring the temperature and patients at high risk of developing low temperature before operation. In my workplace, there are no written or oral policies that help provide guidance to professionals on how to manage patients’ temperature before operation. The implication is that the attending surgeon is legally and ethically obliged to check the temperature (NICE, 2019). The other disadvantage is that such practice causes a lack of uniformity in practice as there is no standardization. A few patients get optimal care while others do not. Nonetheless, the trust requires that surgeons and their teams follow the NICE guidelines which are good if there is absolute adherence.
There is no policy which means there is no updating unless the NICE guidelines are updated. Then, the trust expects professionals to know the changes. Most anaesthetists do not adhere to the NICE guidelines, especially when it is a short operation lasting 30 to 60 minutes. They assume that temperature changes in such interventions are negligible. Regarding the use of evidence-based practice, there are no formal requirements to integrate new research findings in temperature management. However, if the surgeon chooses to use findings from a practice and provide evidence for its effectiveness, then it is allowed.
The circumstances between our trust and the guidelines for best practices offered in the literature are mostly similar. For instance, Cobbold (2019) states that hypothermia is more common for individuals undergoing surgery compared to hyperthermia. Similarly, from the observation at the hospital, the patients are likely to have low temperatures. The other similarity with the literature is that some individual characteristics, such as age, illness, and body weight, can influence the temperature outcome. The only different circumstance recorded in the literature is the use of different types of thermometers, given that in our hospital, we only use zero heat flux. (Hale et al., 2021). Therefore, given that the conditions of the patients, description of best practices, and types of patients are similar, the literature findings can help in shaping practice.
Implication for Failure to Follow Best Practice
Perioperative hypothermia prevention is important and ignoring it can be costly to the patient, the organization, staff, and relatives. In some cases, the disadvantages are indirect but recurrent. The trust is likely to incur some extra expenses and a bad reputation when a high number of their surgical patients suffer from perioperative hypothermia (Rauch et al., 2021). People will lose confidence in the organization because of the errors. Moreover, given that it is an era of social media, they may choose to air their grievances online, where everyone can see the negative reviews. The firm may end up losing some of its clients, making sustainability hard if it operates for profit. Furthermore, there is a risk of court suing and legal battles with the patient or their relative.
Staff, especially the surgical team, may have their license revoked if they persistently make errors that risk the life of the patient. Ignoring the perioperative temperature and then proceeding with the operation increases the time used doing surgery (Kameda, 2022). The delay means that the schedule of the doctor has to be adjusted, leading to a backlog of work. However, the complications due to hypothermia can surprise the surgical team, causing some panic in the operating room. The surgeon can be sued by the family or the client for negligence and suffer from a negative reputation.
The patient can suffer multiple negative consequences from the periodic hypothermia. According to Simgen et al. (2021), perioperative hypothermia can cause head injury, nervous system dysfunction, and cardiac dysfunction. The patient will then be exposed to long hours in the operating room. Moreover, their healing process will be slower because of the complications other adverse effects include Surgical Site Infections-how long periods of recovery, coagulopathy leading to increased risk of blood transfusion (NICE, 2019). Thus, such patients stay longer in the hospital and may accrue a huge bill. Moreover, they will need to spend more money on treatment for every complication. Nevertheless, because of the prolonged ill health, they delay getting back to work or doing business and may even suffer losses. The indirect economic effect can be adverse and even lead to depression and anxiety, which weakens the already suppressed immune system of the patient (Simgen et al, 2021)
Relatives of patients suffer emotional turmoil when their loved one is going through surgery. Any extra complication affects their psychological stability as they empathize with their patient. If, due to hypothermia, the client has to stay longer in the hospital, family members have to budget for additional expenses. Particularly, they have to consider buying drugs, paying the extra hospital bill, transport to visit their patient, among others (Rauch et al., 2021). Moreover, they are the non-professional caregivers and may have to forsake some of their duties to continue helping the sick. The implication is that they lose time that could be used to engage in work activities (Singh, et al., 2022)
Action Plan for Improvement of Practice
The laxity I observation of best practice guidelines, lack of policy, high incidence of perioperative hypothermia, and the related effects are a course for concern. It is prudent to devise an action plan that will promote quality of care for the patients and improve the reputation of the task. The anaesthetic team together with theatre staff should work together to achieve that goal. As stated by Boet et al. (2018), audit and feedback effectively enhance the professional practice of medical practitioners. In addition, once the negative effects have been identified, it is vital to research and provide evidence-based solutions. Moreover, there should be an evaluation strategy alongside to help see if there is a positive impact from the changes.
In medical issues, the auditing is done by using relevant models and guidelines as the reference point. Some of the validated approaches comprising adverse events tools include “adverse event trigger tools, the model for improvement, root cause analysis, systematic reviews, failure mode, and effects analysis risk assessment tools” (Tanner et al., 2021, p. 1). In addition, criteria tools like checklists, morbidity and mortality meetings, and the Appraisal of Guidelines for Research and Evaluation (AGREE II) can help to diagnose the problem correctly and rectify it. The NICE inadvertent perioperative hypothermia guideline provides steps that can be used in auditing and evaluation.
It is vital to carry out an audit of the trust to establish the nature of the problem. Noteworthy, my observation while working with the organization indicates that there is an obvious problem with perioperative monitoring of body temperature. However, having a formal auditing report will provide a better perspective on the extent of the problem, reasons, persons implicated, and areas for change. Therefore, there are several aspects of the operation room that I am going to audit. First, I will start with the medical employees to see if there are sufficient number of professional workers against the ratio of patients that visits the trust for surgery. Next, I will conduct an audit on the available thermometers and ensure that all are fit for their functions. The internal auditing model will include all the medical reports in the department to determine the number of incidences reported and if the information is up-to-date (Tanner et al., 2021).
The auditing practice will start by informing the administrative management of the objectives and reasons. Regarding the number of staff-to-patient ratios, a simple mathematic analysis will help in establishing the findings (DeLaet, 2020). There will be physical counting of all the thermometers and heaters available in the Surgery department. The audit of the medical reports will include descriptive statistics to know the percentages, means, and mode of the errors. In addition, I will do a root cause analysis (RCA), which involves identifying factors that cause performance variations (Singh et al., 2022). Noteworthy, the RCA will help identify systematic factors that lead to ignorance of perioperative temperature monitoring. The management may have a problem with setting and enforcement of policies which contributes to the problem.
I have an idea of what the auditing process entails, but I will need guidance and support. There are various processes involved, and I do not have the skills and experience needed. For instance, I will need assistance in doing the statistical analysis. Moreover, I will need to have support from the administrators and the entire surgical team. The support from the store and record-keeping departments is important for getting the right data. Working with a research team and benchmarking with hospitals that show excellence in the practice may be important depending on the resources available for the research.
I will need information on practice improvement within the context of monitoring perioperative temperature. The first place of getting the information is through relevant library databases and journals that provide peer-reviewed papers on medical subjects. In addition, some information will be sourced from interviews with the surgical team to establish what they understand and practice on temperature monitoring. The trust has no policy for perioperative temperature monitoring, so there is nothing to review. Nonetheless, I will research on the effectiveness of rules and regulations of practice that other healthcare institutions have as a benchmark and decide on the best way to personalize to our trust.
Several changes are needed in the surgical department to promote adherence to the best practice guidelines. First, the institution will have to draft a policy to guide the roles of patients and the surgical team during the perioperative period. A possible rule is making it mandatory for the surgeon or the assistant to inform the patient and their relatives to keep warm as they await a scheduled surgery (Singh, 2019). The other change is establishing a policy for monitoring the temperature of all patients before their operation, regardless of the duration of the surgery will take. The management and administrators must enforce the rules by constantly reviewing the surgeons. If necessary, there should be some punishment for the staff who consistently ignore the rules.
Any form of institutional change will always suffer from resistance because humans love maintaining the status quo and avoiding uncertainties. It is expected that the staff will not immediately want the new transformation as it is demanding. To effectively devolve the proposal, they will be part of the project from the start as indicated in Lewis model of change (Brown and Edwards, 2019). I will have to explain the need for the change, ask for their ideas, and make them on the agenda. In addition, the employees will receive training to understand the new competencies and to boost their confidence. Possible area of training includes the NICE guidelines and policies on the best practices.
Guidance and support from the administration and staff are crucial for the success of the project. For instance, implementation may need financial resources for research and training, which I expect the finance department to cater to. Cooperation and teamwork are crucial in policy development which may need a series of meetings and discussions. The other support involves the evaluation of the success of the project to determine if there are continuous positive changes. More information will be needed on strategies, types, and techniques for assessing the result of best practice implementation (Pereira et al., 2022).
Conclusion
Monitoring of perioperative temperature is crucial for early detection of readings that are higher or lower than normothermia. Research findings show that hypothermia is more common than hyperthermia and has many negative implications. From my work experience in our trust, I noticed that the surgeons tend to neglect perioperative temperature observation for patients scheduled to under short surgical procedures. However, such individuals are still at risk of developing low temperatures, which prolongs the treatment process and causes other complications. The first step in improving adherence to best practices for monitoring temperature is conducting a literature search and establishing the guidelines. An audit of current practice to compare with the literature is then done to identify gaps and set up an action plan.
Reference List
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