Welcome to the APSA Quality and Safety committee Perioperative Thermoregulation Toolkit. This page is intended to help anyone who is interested in Quality Improvement (QI) pertaining to the prevention of perioperative hypothermia.
Available toolkit projects are listed below. Many of the approaches described are evidence-based - some are not. These approaches have not been approved by APSA.
At Hasbro Children’s Hospital, a lack of standardization of temperature monitoring and warming of pediatric surgical patients was noted during the development of a colorectal bundle. Therefore, a QI initiative pertaining to preoperative warming was undertaken with the aim of establishing a standard assessment for monitoring patients and to implement measures to improve preoperative temperature maintenance. The project is in its launching phase, and baseline data is being collected.
- Meeting with perioperative nursing leadership to discuss the situation. Agreement of a 2-week period of documentation of preoperative admission and discharge temperatures in order to determine the magnitude of problem.
- Collaborative efforts with the nursing team to determine the most effective ways of warming individual pediatric patient groups, with the following agreements:
- Temperature in the preopative suite is set by engineering (no local control) to a pre-specified range
- Non-ambulatory patients are warmed with heat-conserving blankets and parental care, where appropriate
- Toddlers and children of play age are dressed in specially designed heat conserving jackets and pants
- Pre-teens and teens, who generally sit in chairs preoperatively to watch TV or play video games, are warmed with heat conserving blankets
- Implementation of warming measures
- Post-implementation 2-week monitoring cycle to determine compliance with new measures and effect of changes
Stakeholders: surgeons, anesthesiologists, preoperative nursing
Challenges and Solutions: Compliance with assessments
Links to published data (used to develop the protocol):
Submitted by: Elizabeth Renaud, MD
At Nemours/Alfred I. DuPont Hospital for Children, a multidisciplinary project was implemented to prevent perioperative hypothermia in NICU patients. During the project design and implementation phases, stakeholders convened and met on monthly basis for a year. A standardized postoperative handoff process was developed during this time.
- Nemours (DE) PPT - Hypothermia Prevention and Safe Handoff Protocols (Guidelines for heat loss prevention and temperature monitoring, workflow diagram describing the ideal communication between the OR and NICU to facilitate an effective patient handoff, structured postoperative handoff form)
Stakeholders: NICU nursing, OR nursing, surgery, anesthesia, neonatology
Challenges and Solutions:
Links to published data (used to develop the protocol): 
Submitted by: Loren Berman, MD
St. Joseph’s Children’s Hospital developed the "Thermoregulation Guidelines for the Care of the Pediatric Patient" with the purpose of preventing and reducing the number of pediatric patients that experience inadvertent or unintended hypothermia.
- Multidisciplinary team meetings with anesthesiologists/CRNAs, pediatric preoperative/PACU personnel, OR staff, ER, radiology, floor nursing and ICU representation to address concerns and solutions
- Development of the "Thermoregulation Guidelines for the Care of the Pediatric Patient" based on current evidence-based literature and feedback from the staff
- Dissemination of the guidelines to multiple bodies (OR Directors Collaborative, Surgical Professional Practice Council, SJCH Quality Council, Medical Executive Council and Medical Staff Advisory Council) for approval
- Departmental guideline distribution for staff education
- Audits to evaluate the effectiveness of guidelines
- Medical Director of Pediatric Anesthesia, Dr. Thomas Moroney
- Medical Director of Pediatric Surgery, Dr. Grant Geissler
- Director of Surgical Services, Mary Robinson, RN
- Director of Patient Services, Babette Bailey, RN
- Manager Pediatric PreOp/PACU, Gabrielle Carriles, RN
- Manager Imaging Services, Rita Carracela RT
- Manager of Emergency Services, Felicia Glover, RN
- Pediatric Surgical Program Coordinator, Kirsten Yancy, RN
Challenges and Solutions:
- Coordination of multidisciplinary meetings
- Buy-in from all staff on the importance of preventing inadvertent hypothermia
- Rollout and education of the guidelines
- Worked with executive assistants, secretaries and stakeholders to set meetings and provide coverage to ensure participation of key stakeholders and bedside teams
- Presentation on current rates of hypothermia, evidence-based literature on adverse effects of hypothermia, hospital costs related to hypothermia, and proposed recommendations. Support from senior leadership.
- Worked with educators for each department to present guidelines to staff. Worked with the medical director of anesthesia to provide education for CRNAs and anesthesiologists. Presented at the Pediatric Surgical Process Improvement and Patient Safety Committee.
Submitted by: Grant Geissler, MD
Additonal Implementers: Kirsten Yancy, RN, BSN, CPN
- Guidash JC, Berman L, Panagos PG, et al. Engaging Frontline Providers Prevents Hypothermia and Improves Communication in the Postoperative Neonate. Adv Neonatal Care. 2021;21(5):379-386. [PMID:33538496]
- AST Guideline Statement for the Maintenance of Normothermia in the Perioperative Patient. (2015, April 10). Retrieved April 1, 2018 from http://www.ast.org/uploadedFiles/Main_Site/Content/About_Us/SOP_For_Normothermia.pdf
- Beedle SE, Phillips A, Wiggins S, et al. Preventing Unplanned Perioperative Hypothermia in Children. AORN Journal, 2017;105(2), 170–183. https://doi.org/10.1016/j.aorn.2016.12.002
- Nakayama DK, Lester SS, Rich DR, et al. Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients. J Pediatr Surg. 2012;47(1):112-8. [PMID:22244402]
- Kim P, Taghon T, Fetzer M, et al. Perioperative hypothermia in the pediatric population: a quality improvement project. Am J Med Qual. 2013;28(5):400-6. [PMID:23354871]
- Engorn BM, Kahntroff SL, Frank KM, et al. Perioperative hypothermia in neonatal intensive care unit patients: effectiveness of a thermoregulation intervention and associated risk factors. Paediatr Anaesth. 2017;27(2):196-204. [PMID:27917566]
- Brozanski BS, Piazza AJ, Chuo J, et al. STEPP IN: Working Together to Keep Infants Warm in the Perioperative Period. Pediatrics. 2020;145(4). [PMID:32193210]
- Bajwa SJS, Swati MD. Perioperative hypothermia in pediatric patients: diagnosis, prevention and management. Anaesth Pain & Intensive Care. 2014;18(1):97-100
- Bobo S. The Effects of Active versus Passive Prewarming of Pediatric Surgical Patients during the Pre-operative Period. J Child Adolesc Behav 3:258. doi:10.4172/2375-4494.1000258
- Burns SM, Wojnakowski M, Piotrowski K, et al. Unintentional hypothermia: implications for perianesthesia nurses. J Perianesth Nurs. 2009;24(3):167-73; quiz 174-6. [PMID:19500750]
- Eyelade OR, Orimadegun AE, Akinyemi OA, et al. Esophageal, tympanic, rectal, and skin temperatures in children undergoing surgery with general anesthesia. J Perianesth Nurs. 2011;26(3):151-9. [PMID:21641530]
- Haberman, D. (2014, March 31). Temperature Management in Children. Retrieved March, 2018 from https://www.wfsahq.org/components/com_virtual_library/media/0977d4d0eb723039ec431112d9b2fe5f-40839906db923e34c0d5069cdcb06ef8-305-Temperature-management-in-children.pdf
- Hooper VD. An introduction to the ASPAN evidence-based clinical practice guideline for the promotion of perioperative normothermia. J Perianesth Nurs. 2009;24(5):269-70. [PMID:19853809]
- Hooper VD, Chard R, Clifford T, et al. ASPAN's evidence-based clinical practice guideline for the promotion of perioperative normothermia: second edition. J Perianesth Nurs. 2010;25(6):346-65. [PMID:21126665]
- Sessler DI. Temperature monitoring and perioperative thermoregulation. Anesthesiology. 2008;109(2):318-38. [PMID:18648241]
- Sohn VY, Steele SR. Temperature control and the role of supplemental oxygen. Clin Colon Rectal Surg. 2009;22(1):21-7. [PMID:20119552]
- Torossian A, Bräuer A, Höcker J, et al. Preventing inadvertent perioperative hypothermia. Dtsch Arztebl Int. 2015;112(10):166-72. [PMID:25837741]
- Çam R, Yönem H, Özsoy H. Core Body Temperature Changes During Surgery and Nursing Management. Clinical Medicine Research. Special Issue: Fever: Incidence, Clinical Assessment, Management Choices & Outcomes. 2016; 5(2-1):1-5. doi: 10.11648/j.cmr.s.2016050201.11