Improvement in the identification and management of inadvertent hypothermia in the critically ill: an audit cycle

Abstract

Introduction The purpose of this study was to assess our practice in identifying and managing inadvertent hypothermia and whether this could be improved by education and introduction of a protocol. Hypothermia is associated with multiple physiological abnormalities including reduced myocardial contractility, peripheral vasoconstriction, increased infection risk and impaired coagulation [1]. Inadvertent hypothermia may therefore be an avoidable risk factor in the critically ill. The UK National Institute of Clinical Excellence has issued guidance for avoidance of inadvertent hypothermia (temperature <36°C) during the perioperative period. We audited our practice against three standards from these guidelines: all patients should have at least 4-hourly temperature observations; no patient should become inadvertently hypothermic; and all inadvertently hypothermic patients should be rewarmed. Methods Data were collected prospectively. Body temperature was recorded routinely by nursing staffusing a tympanic thermometer. We noted any occasion where the body temperature dropped below 36°C along with any associated interventions - such as the use of additional bed sheets or a forced air warming device. After the first audit period a simple education programme was delivered. We also introduced a departmental protocol for the prevention and management of inadvertent hypothermia. Six months later we re-audited our practice. Results Data were collected from 130 patients (2,931 patient-hours) in the first audit period and from 87 patients (2,070 patient-hours) in the second audit period. In the first period 29% of patients had at least 4-hourly temperature measurements compared with 40% in the second period (P <0.01). The average number of overdue temperature observations per day was 1.4 in the first period and 0.9 in the second (P <0.01). Twenty-four per cent of patients became hypothermic in the first period compared with 22% in the second (P = 0.07); however, the time these patients remained hypothermic reduced from an average of 7.9 hours to 6.1 hours (P <0.01). An intervention was made and documented in 15% of cases in the first period and 46% in the second (P <0.001). Conclusion We saw some improvement following an education programme and introduction of a clinical protocol although there remains room for further improvement.