There are several limitations to our QI project. The first involves the measuring of postoperative temperature in the recovery units. The temperatures were obtained using the same medical-grade infrared thermometer for all the patients, but other variables, such as timing and techniques, were not standardized. Secondly, overall surgical outcomes related to hypothermia were not tracked because we were unable to control for other confounding variables in our large cohort of patients, so we cannot say if the drop in the hypothermia rate had a clinically significant outcome. Thirdly, we propose that SDT offers a compellingly fitting explanation of the psychology of motivation in our efforts, but it may be possible that other theories may offer equally fitting explanations. The ability to measure the degree of motivation is lacking, and we did not explicitly ask participants what their specific source of motivation was. Aside from SDT, the reduction in hypothermia rate could also be attributed to the ease and availability of warming equipment that was made in each OR. This QI project was successfully applied to only 1 institution, so its ability to be widely applicable remains uncertain. In addition, data collection continued during the COVID-19 pandemic when case volumes decreased. However, by June 2020, the number of surgical cases at our institution had largely returned to prepandemic levels. Additional data collection beyond April 2021 would be helpful to determine if the reduction in hypothermia rates is truly sustained.
Conclusion
Overall, the importance of maintaining perioperative normothermia was well disseminated and agreed upon by all departments involved. Despite the limitations of the project, there was a significant reduction in rates of hypothermia, and sustainability of outcomes was consistently demonstrated in the poststudy period.
Using 3 cycles of the PDSA method, we successfully decreased the median rate of postoperative hypothermia in our pediatric surgical population from a preintervention value of 6.9% to 1.3%—a reduction of more than 81.2%. We provided motivation for members of our anesthesiology staff to participate by offering MOCA 2.0 Part 4 credits, but the lower rate of hypothermic patients was maintained for 15 months after the credits were distributed. Over the course of the project, there was a shift in culture, and extra vigilance was given to temperature monitoring and assessment. We attribute this sustained cultural change to the deliberate incorporation of the principles of competency, autonomy, and relatedness central to SDT to the structure of the interventions, avoiding rigid guidelines and pathways in favor of affective engagement to establish intrinsic motivation.
Acknowledgements: The authors thank Joan Reisch, PhD, for her assistance with the statistical analysis.
Corresponding author: Edgar Erold Kiss, MD, 1935 Medical District Dr, Dallas, TX 75235; edgar.kiss@UTSouthwestern.edu.
Financial disclosures: None.