IN 2013, THE CENTERS for Medicare and Medicaid Services reduced diagnosis-related group payments to hospitals and reallocated the money toward incentives based on patient satisfaction.1 While 70% of the incentives are still based on clinical quality measures, including patient outcomes and clinical processes, the other 30% are based directly on patient satisfaction.1 At the authors' institution, a 115-bed major medical center and Level III trauma center in the Southwest US, a survey was utilized as a data collection tool to assess overall patient experience on the day of surgery. Results revealed that more than 33% of patients were dissatisfied with their thermal comfort. This article details an initiative to improve surgical patient satisfaction with thermal comfort using reflective blankets at the authors' institution.
Thermal comfort is defined as “the individual person's perception of comfort, lacking distress from feelings of being too cool or too warm.”2 It helps patients maintain normothermia, decreases preoperative anxiety, and increases patients' sense of well-being.3
In addition to patient dissatisfaction, hypothermia is associated with anxiety and physical discomfort, potentially leading to pathophysiologic sequela that may continue postoperatively, including hypertension, an increased perception of pain, and dysrhythmias such as tachycardia.2,4 Thermal discomfort can be so pronounced that many patients recall it as one of the most negative aspects of their surgical experience.5
The importance of patient warming in the maintenance of thermal comfort is well supported. Multiple studies have reported an increase in patient satisfaction and perception of thermal comfort and a decrease in patient anxiety when warming methods are utilized in the pre- and postoperative period.3,6-8 One increasingly popular method of patient warming in the hospital setting is the use of reflective blankets.
Reflective blankets, sometimes called space blankets, were introduced in the 1960s and initially used for survival purposes.9 They function by reflecting heat radiating from the body.9 An early study found that reflective blankets reflect 80% of radiated body heat and may reduce radiant heat loss from 100 to 40 kcal per hour.10
A 2017 study looked at the effect of reflective blankets compared with forced-air warming in maintaining patient normothermia during hip and knee arthroplasties. After adequate prewarming, no significant differences in patient temperature were demonstrated between the reflective blanket group and the active warming group.11
Another study compared three interventions to prevent heat loss in trauma patients: three warmed cotton blankets, a reflective blanket with one prewarmed cotton blanket, and a forced-air warming blanket. All three methods were equivalent in preventing hypothermia.12
Forced-air warming is a common and effective approach to achieving normothermia and patient satisfaction. This method could be potentially cost-prohibitive, however, due to the expense of purchasing the equipment, the corresponding costs and infrastructure involved in maintaining it, and the cost of each single-use warming blanket.
For instance, a common warming model frequently found in ORs is a fixed pricing model for federal purchase listed at $1804.02 per unit, with corresponding one-time use warming gowns at $10.00 each.13 In some healthcare institutions, forced-air warming units may be provided by companies at no cost as an incentive to use their products and purchase their $10.00 one-time use gowns. While this decreases the cost of forced-air warming to some extent, the cost of reflective blankets is minimal, with one-time use costs ranging from $0.75 to $1.40 per blanket.14
The purpose of this project was to determine if utilization of reflective blankets throughout the pre- and postop periods increased patient satisfaction scores regarding thermal comfort compared with current practices at the authors' institution. The authors did not include patients' actual recorded body temperatures as part of the project, as it focused on thermal comfort and patient perceptions of warmth.
The authors' institution is a 115-bed major medical center and Level III trauma center serving over 100,000 enrolled beneficiaries from all age groups. Its surgical volume is approximately 800 surgeries per month.15
Surgical patients typically arrive at the same-day surgery unit a minimum of 2 hours before their scheduled start time. They are provided a room with a reclining chair, a surgical gown, and one unwarmed cotton blanket and wait until it nears time for their surgery. From there, they are moved to the preoperative holding area just outside the OR. Here, they wait again until the previous surgery is completed, and the OR is cleaned and set up. In the OR, anesthesia providers use forced-air warmers and forced-air warming blankets while patients are under anesthesia. After surgery, patients are transported to the postanesthesia care unit (PACU). This process leaves multiple opportunities for patients to feel cold during their surgical experience.
Planning the intervention
Because the project was strictly a quality improvement initiative, a “not research” determination was approved through the institution's Human Research Protections Department. As such, this initiative was granted exemption from attaining institutional review board approval. No protected health information was logged for the project, and no collected data included information that would allow for patient identification. All data were retrieved from the data collection tool and patient electronic medical records on the day after surgery and recorded for analysis. The dataset was saved on a secure server in a password-protected folder.
The improvement initiative was planned in three phases. Phase 1 consisted of recruiting key influential individuals from the anesthesia team, the same-day surgery unit, the transport unit, and the PACU. Problems regarding patient dissatisfaction with thermal comfort, its impact on the organization, and the possible interventions were described in two seminars to the identified unit leaders. Each individual provided departmental input and professional expertise on interventions and barriers, and these were worked into the implementation plan.
Phase 2 culminated in the dissemination of information about the patient warming problem, the supporting evidence for the intervention, and the implementation plan to all involved staff.
Finally, the intervention was implemented in Phase 3.
The intervention involved the application of a reflective blanket against the patient's gown or skin by the preoperative nurse, who instructed the patient on how to utilize it throughout the surgical experience. The reflective blanket remained with the patient as he or she was transported from one location to another and reapplied once the transportation was complete. One room-temperature cotton blanket was applied on top of the reflective blanket.
Warming strategies in the OR were left up to the anesthesia and surgical team, so the intraoperative management of temperature remained unchanged. The anesthesia providers utilized forced-air units and blankets while the patient was anesthetized, and the reflective blankets were used pre- and postop. At the first opportunity after the patient lost consciousness, the reflective blanket was removed and placed on the stretcher. It was reapplied following the completion of the surgery and subsequent emergence from anesthesia. In the PACU, the reflective blanket remained on the patient, and, upon discharge, he or she could take it home.
To ensure fidelity and strict adherence to the protocol, as well as availability for consultation, one of the authors was present in the same-day surgery unit at all times for the first 2 weeks of implementation.
The project consisted of a pre- and postintervention design utilizing a previously instituted patient satisfaction data collection tool. This survey was already a part of a periodic quality process at the institution to evaluate overall patient experience on the day of surgery. It is comprised of 15 items to assess multiple measures of patient satisfaction on the day of surgery, not just thermal comfort. Patients are asked to respond to specific statements about their perioperative patient experience by making a selection on a Likert scale of 1 (strongly agree) to 5 (strongly disagree). They are also provided an area to write in comments related to their answers.
During the intervention, patient satisfaction regarding thermal comfort was assessed using the five-point Likert scale on the patient satisfaction data collection tool. Patients were presented with the statement “I was too cold” and asked to rate their level of agreement on the Likert scale. Patients were considered satisfied with their thermal comfort if they selected options 4 (disagree) or 5 (strongly disagree).
Data were collected throughout April 2018 and compared with previously collected data from November 2017. The department's quality process is not continuous, but periodic. Assessments were completed using the normal departmental quality process data collection.
The preintervention cohort consisted of 134 patients and was compared with 188 respondents in the postintervention cohort. Results were collected in a spreadsheet and analyzed using statistical software. The collected demographic information consisted only of age and gender data. There were no significant differences in demographic characteristics between the pre- and postintervention cohorts, which were similar in both mean age (P = .12) and distribution of gender (P = .32).
Data consisted of responses to the statement “I was too cold” on the five-point Likert scale. The preintervention cohort had a mean score of 3.9, with a margin of error standard deviation (SD) of 1.1; the postintervention cohort demonstrated a mean score of 4.2, with a margin of error SD of 1.0. Utilizing Pearson's chi-squared test to determine the role of chance and with a statistical significance of 0.05, the postintervention cohort demonstrated a significant increase in the mean patient satisfaction (P = .01).16,17
Approximately 66% (88 of 134 respondents) of those in the preintervention cohort and 80% (150 of 188 respondents) of those in the postintervention cohort were satisfied with their thermal comfort level (see Satisfaction data). Using a Pearson's chi-squared test and with a statistical significance of 0.05, respondents demonstrated a statistically significant 14% increase in thermal comfort satisfaction (P = .004).
Additionally, patients had the option to leave comments on the survey, which included:
- “I am basically a cold person but loved the space blankets. This has been the only time I've had surgery where I can say I was actually warm in the recovery room.”
- “The silver cover blankets kept me warm. They can be a little noisy when you move.”
- “Silver blankets are great. Keep using them.”
The intervention results demonstrated success in the quality improvement initiative to increase patient thermal comfort satisfaction with reflective blankets. Although the measured outcomes were slightly different, the effectiveness of the reflective blankets was consistent with previous literature.9-12
The success of the initiative was multifactorial. Staff involvement was incredibly high, and, anecdotally, the authors believe this was due to the unique intervention. Many staff members were aware of reflective blankets but had never considered using them in a hospital setting.
The staff also verbalized that a key reason for success was educating patients on the use of the reflective blanket, as well as reinforcing and encouraging personal autonomy in managing their own thermal comfort.
While patient education was a huge component of our warming protocol, staff education also played an important role. The authors strictly adhered to the intervention by personally educating staff from all areas of perioperative care on thermal comfort, including the same-day surgery unit, pre-op holding, the OR, and the PACU, and by ensuring the distribution of a reflective blanket to each patient.
Variables that could possibly interfere with the long-term sustainability of the intervention may include staff resistance, apathy, or lack of interest, as well as the need for continued staff education given the frequent staff turnover on the unit. Patient temperature was intentionally not recorded, as the patient's perception of temperature was the focus of this study. Another limitation was that the number of cotton blankets used per patient was not recorded. While the authors believe the reflective blankets visibly appeared to reduce the number of blankets used per patient, this cannot be confirmed.
Costing practices can be highly variable and complex in healthcare facilities. Although the improvement project was successful in its intended goals, future initiatives should include an economic analysis. This analysis should include reductions in facility linen costs, cost savings related to reduced staff time spent restocking and distributing multiple blankets, increased reimbursement secondary to patient satisfaction, and comparisons with other warming modalities such as forced air.
While this intervention may be instituted at any hospital across the US, it may be of special utility in healthcare settings where resources and capital expenditures are limited, such as rural communities, outpatient clinics, long-term-care facilities, austere environments, and developing countries, as the use of reflective blankets is an inexpensive and effective way to increase thermal comfort and maintain normothermia.
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