A study of cost and time in healthcare setting as effected by the implementation of hypothermia guidelines in an adult outpatient surgery setting

1. Cost and Time Effectiveness of the
ASPAN* Hypothermia Guidelines in an
Adult Outpatient Surgery Setting
*American Society of PeriAnesthesia Nurses

2. Perioperative Hypothermia: The Problem
Hypothermia, as defined by ASPAN, is a core
temperature below 36°C (96.8°F)
Hypothermia during the perioperative period can
negatively effect patient outcome by causing:
•impaired wound healing,
•altered drug metabolism,
•impaired platelet function,
•untoward cardiac events,
•patient discomfort from shivering.
Hypothermia averaging 1.5°C (2.7°F) below normal
can significantly add to hospitalization costs.

3. Perioperative Hypothermia: Sycamore Outpatient
Surgery
The current discharge criteria for outpatient surgery
at Sycamore Hospital specifies that the patient’s
temperature must be 35°C (95°F) or higher.
A recent pilot study demonstrated that 36% of
patients discharged from Sycamore PACU were being
discharged with temperatures below 36°C (96.8°F)
Patients are not meeting the ASPAN standard of
normothermia, 36°-38°C (96.8°-100.4°F), and
therefore are at increased risk for adverse
outcomes and increased costs of care.


4. Research Question: Is the ASPAN Hypothermia
Protocol Effective and Efficient?
Because patients were not meeting the recommended
normothermia guidelines set forth by ASPAN, it was
decided that consideration should be given to
implementing the ASPAN Hypothermia Protocol (see
Form 1 below) at Sycamore outpatient surgery.
No data supporting the effectiveness and efficiency
of the Hypothermia Protocol are available, however.
Therefore, the Sycamore outpatient surgery unit
undertook a study to test the cost and time
effectiveness of the Hypothermia Protocol.


5. Study Hypotheses
The following hypotheses are being tested in
this study:
A. Implementation of the ASPAN Hypothermia
Guidelines will achieve a discharge temperature
of 36° C (96.8° F) in equal or less time than
current “treatment as usual” achieves the
present discharge temperature goal of 95.0°F.
B. Implementation of the ASPAN Hypothermia
Guidelines will achieve a discharge temperature
of 36° C (96.8° F) for equal or less cost than
current “treatment as usual” achieves the
present discharge temperature goal of 95.0° F.

6. Study Stage 1: Pre-intervention Data Collection
Between the dates of April 1 and April 30, 2005
temperatures at seven time points were collected
(see Form 2) from all outpatient surgeries that met
study criteria. The amount of time between each
stage of the outpatient surgery process was also
recorded. This data established a baseline for the
current patterns of temperature change across time.
surgeryT2T1 T4T3 T5 T6 T7
admission
leaving
discharge
15 minutes
after arrival
to discharge
arrival to
discharge
leaving
recovery
prior to
entering OR
arrival to
recovery

7. Study Stage 2: Post-intervention Data Collection
Between the dates of May 1 and May 31, 2005,
temperatures and times were collected in exactly the
same manner as in Stage 1. In Stage 2, however, the
ASPAN Hypothermia Protocol was implemented.
Interventions in this protocol include (see Form 3):
warm blankets,
socks, head covering
frequent temp monitoring
and observing for s/s of
hypothermia
forced air warming
system
warm IV
fluid

8. Data Analysis: What Can this Information Tell Us?
Data collected from Stage 1 was compared with data
from stage 2 to answer questions about:
1. Differences in time that patients remain in each
phase of the outpatient surgery process, and
2. Differences in cost of caring for each patient
during the outpatient surgery process.

9. Results: A General Description of the Data (1)
Sample Characteristics
334 162 17251 16 35134 64 70
0
50
100
150
200
250
300
350
400
Full Sample Stage 1 Stage 2
Sample Size Over 65 Female
Being over the age of 65
or female places a patient
at  risk for perioperative
hypothermia. This risk
should be equally
represented in both
groups when a
comparison is made
between the groups so
that we are comparing
The 65 or over group was significantly larger
in Stage 1. Statistically, however, this did not
effect the findings of the study.
to

10. Results: A General Description of the Data (2)
Surgeries by Stage
23
20
6
49
34
14
5
1
20
7
15
4
0
3
0
3
13
12
9
39
8
56
31
18
10
0
28
3
21
1
1
3
1
5
6
9
0
10
20
30
40
50
60
Arthroscopy
(1)
Arthroscopy
with
m
enisctom
y
(2)
Arthroscopy
with
ACL
(3)
Allarthroscopy
Allshoulder(4)
Cystoscopy
(5)
Cystoscopy
with
stent(6)
Cystoscopy
with
sling
(7)
Allcystoscopy
Laproscopic
cholysysectom
y
(8)
Hernia
repair(9)
Breastbiopsy
(10)
CornealTransplant(11)
Upper&
lowerextrem
ity
repair(12)
Bunyanectom
y
(13)
Hand
surgery
(14)
O
rthopedic
m
isc.(15)
M
iscellaneous
(16)
Stage 1 Stage 2
Overall, Stage 1 patients and Stage 2
patients experienced similar types of
surgeries.
1. Took 2,338
temperature
readings;
2. completed data
collection forms on
334 patients totaling
7064 data entries;
3. changed practice
habits around
hypothermia
management;
4. and, systematically
improved patient care
& outcomes.
To complete this
study, PACU nurses
at Sycamore:

11. Results: Did it take more time? (Hypothesis 1)
Hypothesis 1
Implementation of the ASPAN Hypothermia Guidelines will achieve a
discharge temperature of 36° C (96.8° F) in equal or less time than
current “treatment as usual” achieves the present discharge
temperature goal of 95.0°F.
Average Time in Hospital
1:49 4:251:53 4:311:45 4:20
0:00
0:28
0:57
1:26
1:55
2:24
2:52
3:21
3:50
4:19
4:48
Post Operative to Discharge Time Admission to Discharge Time in Hospital
Full Sample Stage 1 Stage 2
There was no difference*
between Stage 1 and
Stage 2 in the average
time patients spent in
the hospital.
Implementation of the
ASPAN Hypothermia
Guidelines did not lead
to an increase in length
of patient stay.
ALL CASES (T3-T7) No significant effect for Stage, F(1, 310)=3.49, p=.063, partial eta squared=.011. No
significant effect for the covariate surgery, F(1, 310)=.558, p=.456, partial eta squared=.002
ALL CASES (T1-T7) Significant effect for Stage F(1, 311)=5.35, p=.021, partial eta squared=.017. No
significant effect for the covariate surgery, F(1, 311)=2.08, p=.15, partial eta squared=.007. Although a
statistically significant effect was found in T1-T7, effect size and clinical significance are negligible.
*

12. Results: Did it Cost More Money? (Hypothesis 2)
Hypothesis 2
Implementation of the ASPAN Hypothermia Guidelines will achieve a
discharge temperature of 36° C (96.8° F) for equal or less cost than
current “treatment as usual” achieves the present discharge
temperature goal of 95.0° F.
There was no
difference* between
Stage 1 and Stage 2 in
the average cost per
patient for PACU stay.
Implementation of the
ASPAN Hypothermia
Guidelines did not lead
to an increase in cost
per patient stay.
PACU COST No significant effect for Stage, F(1, 319)=.45, p=.503, partial eta squared=.001.
POST PACU COST A significant difference was found between the cost of Stage 1 and Stage 2 cost during the post PACU stay (Stage 1 M=$141.36 ,
SD=$42.19; Stage 2 M=$131.77, SD=$36.34 ), however, effect size is very small (F(1, 312)=4.38, p=.037, partial eta squared=.014).
TOTAL POST SURGERY COST No significant effect for Stage, F(1, 306)=.101, p=.751, partial eta squared=.000.
*
Average Cost1253.5
1390.76
1239.86
1383.96
1397.14
136.05
140.82
1266.57
131.57
0
200
400
600
800
1000
1200
1400
1600
PACU Post PACU Total Post Surgery Cost
Dollars
Full Sample
Stage 1
Stage 2

13. Results: Other Information that Caught our
Attention
Temperature Trends Across Time
96.00
96.20
96.40
96.60
96.80
97.00
97.20
97.40
97.60
97.80
T1 T2 T3 T4 T5 T6 T7
Full Sample
Stage 1
Stage 2
Patients’ body temperatures drop during surgery and do not
recover admission levels before being discharged. More
efforts may be needed to maintain body temperature during
the intraoperative period.
Temperature Changes
-0.84
0.43
-0.86
0.32
-0.82
0.54
-1
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
Inter-operative Temperature Change Post Operative to Dischare Temperature
Change
Full Sample Stage 1 Stage 2
operativeperiod

14. Results: Other Information that Caught our
Attention
The number of patients
being discharged below
the recommended ASPAN
level decreased by 86%.
The changes in
hypothermia protocol
represent a significant
improvement in patient
care without increasing
the use of time and fiscal
resources.
% Discharged Below ASPAN Standard (96.8 F)
39.2
5.4
0
5
10
15
20
25
30
35
40
45
Stage 1 Stage 2

15. Results: Other Information that Caught our
Attention
Although the use of active warming measures increased from
Stage 1 to Stage 2, the forced air warming system was used in
only 39% of the cases for which it was indicated. This finding
indicates some barrier to use for nurses working in perioperative
settings. Further investigation should be done to determine
reasons for the high failure rate.

16. Conclusions: What We Now Know & How it
Changed Our Practice (1)
1. ASPAN Hypothermia guidelines can be implemented at
Sycamore Perioperative services in a timely and cost
effective manner. The hypothermia guidelines will increase
the likelihood of positive patient outcomes. Therefore, the
guidelines have been adopted into unit practice.
2. Intraoperative temperature drops are not recovered prior to
patient discharge. Confirmation of this long suspected fact
has heightened intraoperative and perioperative staff
awareness regarding the importance of intervening to
maintain normothermia.

17. Conclusions: What We Now Know & How it
Changed Our Practice (2)
3. Several practice changes are being implemented: (a)
Implementation of ASPAN hypothermia guidelines; and (b)
temperatures are now taken upon arrival to Phase 2
discharge as well as prior to discharge so that appropriate
warming interventions can be implemented prior to
discharge, ensuring acceptable discharge temperatures.
4. Explorative and educational interventions are needed to
understand the under use of forced air warming systems with
hypothermic patients. Presently, staff leaders are actively
encouraging staff to use passive and active warming
measures.