Intraoperative Electronic Alerts Improve Compliance With National Quality Program Measure for Perioperative Temperature Management

Perioperative temperature monitoring for patient safety: A period prevalence study of five hospitals

BACKGROUND

Monitoring body temperature is essential for safe perioperative care. Without patient monitoring during each surgical phase, alterations in core body temperature will not be recognised, prevented, or treated. Safe use of warming interventions also depends on monitoring. Yet there has been limited evaluation of temperature monitoring practices as the primary endpoint.

OBJECTIVE

To investigate temperature monitoring practices during all stages of perioperative care. We examined what patient characteristics are associated with the rate of temperature monitoring, along with clinical variables such as warming intervention or exposure to hypothermia.

DESIGN

An observational period-prevalence study over seven days across five Australian hospitals.

SETTINGS

Four metropolitan, tertiary hospitals and one regional hospital.

PARTICIPANTS

We selected all adult patients (N = 1690) undergoing any surgical procedure and any mode of anaesthesia during the study period.

METHODS

Patient characteristics, perioperative temperature data, warming interventions and exposure to hypothermia were retrospectively collected from patient charts. We describe the frequencies and distribution of temperature data at each perioperative stage, including adherence to minimum temperature monitoring based on clinical guidelines. To examine associations with clinical variables, we also modelled the rate of temperature monitoring using each patient's count of recorded temperature measurements within their calculated time interval from anaesthetic induction to postanaesthetic care unit discharge. All analyses adjusted 95% confidence intervals (CI) for patient clustering by hospital.

RESULTS

There were low levels of temperature monitoring, with most temperature data clustered around admission to postanaesthetic care. Over half of patients (51.8%) had two or less temperatures recorded during perioperative care and one-third (32.7%) had no temperature data at all prior to admission to postanaesthetic care. Of all patients that received active warming intervention during surgery, over two-thirds (68.5%) had no temperature monitoring recorded. In our adjusted model, associations between clinical variables and the rate of temperature monitoring often did not reflect clinical risk or need: rates were decreased for those with greatest operative risk (American Society of Anesthesiologists Classification IV: rate ratio (RR) 0.78, 95% CI 0.68-0.89; emergency surgery: RR 0.89, 0.80-0.98), and neither warming interventions (intraoperative warming: RR 1.01, 0.93-1.10; postanaesthetic care unit warming: RR 1.02, 0.98-1.07) nor hypothermia at postanaesthetic care unit admission (RR 1.12, 0.98-1.28) were associated with monitoring rate.

CONCLUSIONS

Our findings point to the need for systems-level change to enable proactive temperature monitoring over all phases of perioperative care to enhance patient safety outcomes.

REGISTRATION

Not a clinical trial.

Implementation of continuous temperature monitoring during perioperative care: a feasibility study

Background

Continuous body temperature monitoring during perioperative care is enabled by using a non-invasive “zero-heat-flux” (ZHF) device. However, rigorous evaluation of whether continuous monitoring capability improves process of care and patient outcomes is lacking. This study assessed the feasibility of a large-scale trial on the impact of continuous ZHF monitoring on perioperative temperature management practices and hypothermia prevention.

Methods

A feasibility study was conducted at a tertiary hospital. Participants included patients undergoing elective surgery under neuraxial or general anesthesia, and perioperative nurses and anesthetists caring for patient participants. Eighty-two patients pre and post introduction of the ZHF device were enrolled. Feasibility outcomes included recruitment and retention, protocol adherence, missing data or device failure, and staff evaluation of intervention feasibility and acceptability. Process of care outcomes included temperature monitoring practices, warming interventions and perioperative hypothermia.

Results

There were no adverse events related to the device and feasibility of recruitment was high (60%). Treatment adherence varied across the perioperative pathway (43 to 93%) and missing data due to electronic transfer issues were identified. Provision of ZHF monitoring had most impact on monitoring practices in the Post Anesthetic Care Unit; the impact on intraoperative monitoring practices was minimal.

Conclusions

Enhancements to the design of the ZHF device, particularly for improved data retention and transfer, would be beneficial prior to a large-scale evaluation of whether continuous temperature monitoring will improve patient outcomes. Implementation research designs are needed for future work to improve the complex area of temperature monitoring during surgery.

 Trial registration

Prospective registration prior to patient enrolment was obtained from the Australian and New Zealand Clinical Trials Registry (ANZCTR) on 16^th April 2021 (Registration number: ACTRN12621000438853).

A Century of Technology in Anesthesia & Analgesia

Technological innovation has been closely intertwined with the growth of modern anesthesiology as a medical and scientific discipline. Anesthesia & Analgesia, the longest-running physician anesthesiology journal in the world, has documented key technological developments in the specialty over the past 100 years. What began as a focus on the fundamental tools needed for effective anesthetic delivery has evolved over the century into an increasing emphasis on automation, portability, and machine intelligence to improve the quality, safety, and efficiency of patient care.

Using a Normothermia Bundle With Perioperative Prewarming to Reduce Patient Hypothermia

PURPOSE

To determine if implementing a normothermia bundle, which includes preoperative forced-air warming blankets, reduces incidence of inadvertent perioperative hypothermia (IPH).

DESIGN

Intervention study using retrospective chart review.

METHODS

Patients received a preoperative forced-air warming blanket and temperature management with the normothermia bundle. Temperature status data was collected from patient charts to evaluate the incidences of IPH and findings from this data analysis was used to measure improvement in perioperative temperature management.

FINDINGS

Of 200 patients, 63 (31.5%) remained normothermic, 37 (18.5%) had at least one documented hypothermic temperature, and 100 (50%) had no documented temperature during the intraoperative phase of care. Although compliance with intraoperative temperature monitoring decreased by 13% postintervention, the incidence of documented IPH in reviewed records was decreased by 3.6-fold.

CONCLUSION

Implementing a normothermia bundle that includes a preoperative forced-air warming blanket may lower the incidences of IPH, especially in surgical cases lasting over 120 minutes.

Anesthesia provider performance in the first two years of merit-based incentive payment system: Shifts in reporting and predictors of receiving bonus payments

STUDY OBJECTIVE

The Merit-Based Incentive Payment System (MIPS) program was intended to align CMS quality and incentive programs. To date, no reports have described anesthesia clinician performance in the first two years of the program.

DESIGN

Observational retrospective cohort study.

SETTING

Centers for Medicare and Medicaid Services public datasets for their Quality Payment Program.

PATIENTS

Anesthesia clinicians who participated in MIPS for 2017 and 2018 performance years.

INTERVENTIONS

Descriptive statistics compared anesthesia clinician characteristics, practice setting, and MIPS performance between the two years to determine associations with MIPS-based payment adjustments.

MEASUREMENTS

Logistic regression identified independent predictors of bonus payments for exceptional performance.

MAIN RESULTS

Compared with participants in 2017 (n = 25,604), participants in 2018 (n = 54,381) had a higher proportion of reporting through groups and alternative payment models (APMs) than as individuals (p < 0.001). The proportion of clinicians earning performance bonuses increased from 2017 to 2018 except for those MIPS participants reporting as individuals. Median total MIPS scores were higher in 2018 than 2017 (84.6 vs. 82.4, p < 0.001), although median total scores fell for participants reporting as individuals (40.9 vs 75.5, p < 0.001). Among clinicians with scores in both years (n = 20,490), 10,559 (51.3%) improved their total score between 2017 and 2018, and 347 (1.7%) changed reporting from individual to APM. Reporting as an individual compared with group reporting (OR: 0.75; 95% CI: 0.71 to 0.80; p < 0.001) was associated with lower rates of bonus payments, as was having a greater proportion of patients dual-eligible for Medicaid and Medicare. Reporting through an APM (OR: 149.6; 95% CI: 110 to 203.4; p < 0.001) and increasing practice group size were associated with higher likelihood of bonus payments.

CONCLUSIONS

Anesthesia clinician MIPS participation and performance were strong during 2017 and 2018 performance years. Providers who reported through groups or APMs have a higher likelihood of receiving bonus payments.