The first PDSA cycle involved introducing the QI project and sharing the aims of the project at a department grand rounds in the latter part of October 2018. Enrollment to participate in the project was open to all anesthesiologists in the division, and participants could earn up to 20 hours of MOCA Part 4 credits. A spreadsheet was developed and maintained to track each anesthesiologist’s monthly percentage of hypothermic patients. The de-identified patient data were shared with the division via monthly emails. In addition, individual providers with a hypothermic patient in the recovery room received a notification email.
The anesthesiologists participated in the QI project by reviewing their personal percentage of hypothermic patients on an ongoing basis to earn the credit. There was no explicit requirement to decrease their own rate of patients with body temperature less than 36 °C or expectation to achieve a predetermined goal, so the participants could not “fail.”
Because of the large interest in this project, a hypothermia committee was formed that consisted of 36 anesthesiologists. This group reviewed the data and exchanged ideas for improvement in November 2018 as part of the first PDSA cycle. The committee met monthly and was responsible for actively engaging other members of the department and perioperative staff to help in this multidisciplinary effort of combating hypothermia in our surgical pediatric population.
PDSA cycle 2 involved several major initiatives, including direct incorporation of the rest of the perioperative team. The perioperative nursing team was educated on the risks of hypothermia and engaged to take an active role by maintaining the operating suite temperature at 21.1 °C and turning on the Bair Hugger (3M) blanket to 43 °C on the OR bed prior to patient arrival to the OR. Additionally, anesthesia technicians (ATs) were tasked with ensuring an adequate supply of Bair Hugger drapes for all cases of the day. The facility’s engineering team was engaged to move the preoperative room temperature controls away from families (who frequently made the rooms cold) and instead set it at a consistent temperature of 23.9 °C. ATs were also asked to place axillary and nasal temperature probes on the anesthesia workstations as a visual reminder to facilitate temperature monitoring closer to the start of anesthesia (instead of the anesthesia provider having to remember to retrieve a temperature probe out of a drawer and place it on the patient). Furthermore, anesthesiologists were instructed via the aforementioned monthly emails and at monthly department meetings to place the temperature probes as early as possible in order to recognize and respond to intraoperative hypothermia in a timelier manner. Finally, supply chain leaders were informed of our expected increase in the use of the blankets and probes and proportionally increased ordering of these supplies to make sure availability would not present an obstacle.
In PDSA cycle 3, trainees (anesthesia assistant students, anesthesia residents and fellows) and advanced practice providers (APPs) (certified registered nurse-anesthetists [CRNAs] and certified anesthesia assistants [C-AAs]) were informed of the QI project. This initiative was guided toward improving vigilance for hypothermia in the rest of the anesthesia team members. The trainees and APPs usually set up the anesthesia area prior to patient arrival, so their recruitment in support of this effort would ensure appropriate OR temperature, active warming device deployment, and the availability and early placement of the correct temperature probe for the case. To facilitate personal accountability, the trainees and APPs were also emailed their own patients’ rate of hypothermia.