INNOVATIONS AND 1.

5
OPERATIONS ANCC
of Surgeons Committee on Trauma, Simon, & Hunt, 2014; An interdisciplinary team formed that was charged Contactwith
Hours
Improving Thermoregulation for Trauma
Keane, 2016; van der Ploeg et al., 2010). Large multicenter developing and implementing EBP change. Relevant
studies have identified hypothermia as a significant andpublications were gathered and evaluated for reliability,
independent predictor of mortality (Balvers et al., 2016;validity, and bias. The team found sufficient research
Patients in the Emergency Department:
Ireland et al., 2011), making patient temperature an im-with consistent findings to warrant a practice change.
portant modifiable risk factor in the ED for mortality The changes were piloted for a 3-month period to assess
An Evidence-Based Practice Project
among trauma patients. For example, one study found for feasibility and any improvement in outcomes.
that hypothermic trauma patients who had further tem- The clinical nurse specialist (CNS) conducted a system-
perature drop in the ED MSN,
Ada Saqe-Rockoff, had aRN, 50%AG-CNS,
mortalityCEN versus 29.9%
■ Finn atic search on MPH
D. Schubert, PubMed for articles
■ Amanda pertaining
Ciardiello, RN,to BSN,
tempera-
CEN
mortality among Douglas,
■ Elizabeth those whoRN, didBSN,
not haveCCRN further tempera- ture assessment, incidence, and implications of hypother-
ture drop (Ireland et al., 2011). mia on trauma patients, rewarming methods, and prior
Fortunately, hypothermia is arguably the easiest factor EBP projects on thermoregulation for trauma patients.
of the triad of death to address (Keane, 2016). Various Evidence-based practice interventions were derived from
modalities are available for temperature assessment and the best available clinical evidence with a focus on clini-
ABSTRACT knowledge was then applied to clinical practice through
detection of hypothermia, such as oral, tympanic, rectal, cal expertise and patient values and expectations (Melnyk
staff education and training, equipment availability,
and bladder thermometers (van der Ploeg et al., 2010).&and
Extensive evidence exists on the association between Fineout-Overholt, 2014).
environmental adjustments. More patients with
hypothermia
There exist aand increasedofmorbidity
multitude rewarming andmethods
mortality in
with vary-hypothermia
Block et al. and (2012) developed
hyperthermia andidentified
were implemented
in 2017,a as
trauma
ing patients.
degrees Gaps in practice
of efficacy, including related to temperature
warmed intravenous nurse-led,
compared evidence-based
with 2016. There wasprotocol to improve
a significant tempera-
increase in
assessment
fluids, warmedhaveblankets,
been identified in literature,
forced-air warming along with
blankets, ture
corecontrol in hypothermic
temperature assessmenttrauma
from 4%patients.
in 2016 to The
23% team
in
limited personnel knowledge regarding management of
bladder irrigation, gastric irrigation, and arteriovenous by- sought
2017 (p to<expand on its use
.001). Blanket project and conductpatients
in normothermic a literature
patients with accidental hypothermia. An interdisciplinary increased in 2017 (p
pass
team (Paal et al.,
identified gaps2016; van der
in practice Ploeg
in our et al., 2010).
institution regardingTrauma
review to address all=aspects
.002). This project is
including an example
incidence of hy-
nurses should be encouraged to take ownership of vital of how nurses
pothermia, can utilizeand
associated an evidence-based
contributing practicepreven-
factors,
temperature assessment and documentation of rewarming model to translateand
research into clinical practice. Best
sign assessment,
and initiated including early
an evidence-based temperature
practice project to evaluation
change tion, recognition, treatment. The evidence-based
practice interventions regarding temperature assessment
(Keane,
practice at2016), and initiate
our institution. Theappropriate
goals were tosteps for rewarm-
decrease time knowledge was then applied to clinical practice through
and rewarming measures for trauma patients can be
ing. Gaps in practice
to temperature related
assessment, to temperature
increase assessment
core temperature staff education
successfully and training,
implemented withequipment availability,
negligible cost. Further and
assessment,
have and increase
been identified implementation
in the literature, alongof appropriate
with limitedenvironmental
research should be dedicated to examine barriers towere to
adjustments. The project’s goals
rewarming methods.
personnel knowledge This project used
regarding the Iowa Model
management of patients decrease time toand
implementation temperature
adherence to assessment,
evidence-based increase core
practice
of Evidence-Based
with Practice to provide
accidental hypothermia (van der a framework
Ploeg et for
al., 2010).temperature
interventions.assessment, and increase implementation of
execution and evaluation. We conducted a literature
At our own institution, an interdisciplinary team identified
review to address all aspects of hypothermia, including
appropriate rewarming methods.
gaps in practice regarding temperature assessment
incidence, associated and contributing factors, prevention, and
documentation of rewarming
recognition, and treatment. and initiated an evidence-
This evidence-based
based practice (EBP) project to change practice.

Key Words
Hypothermia, CHANGES
PRACTICE Nursing, Thermoregulation, Trauma

Warmed Blankets

U
METHODS
nintentional injuries are the fourth highest cause of Prevention
Cameron, Fitzgerald, & Paul,
of hypothermia or2011; Keane,
further 2016;
heat loss in Langhelle,
trauma
death for Americans and lead to an estimated 28.1 Lockey, patientsHarris, & Davies,
is a primary 2010;Impaired
concern. Simmons, Pittet, & Pierce,
homeostasis, pre-
million
Context visits to emergency departments (EDs) yearly 2014; van
hospital der Ploeg,
exposure, andGoslings, Walpoth,
resuscitation &
efforts Bierens, 2010;
can all lead
(Heron, 2016). Many trauma patients are hypother- to Zafren & Mechem,
hypothermia 2017). Along
in trauma with
patients metabolic
(Keane, 2016).acidosis
Trauma
NYU Langone Hospital—Brooklyn (formerly NYU
mic, defined as body temperature of less than 36°C patients and coagulopathy, hypothermia
are also fully exposed inisthe a factor
early in the “triad
stages of as-of
Lutheran Medical Center) is a 450-bed teaching facility
(96.8°F; Block, Lilienthal, Cullen, & White, 2012). Hypo- sessment death,” a cycle
as partthat can primary
of the decreasesurvey
the success of resuscita-
(Emergency Nurses
located in southwest Brooklyn, New York City. It is a
thermia has been reported in as many as two-thirds of allAssociation, tion efforts (Keane, 2016; Simmons
2014). Warmed blankets etare
al.,not
2014). Hypo-
adequately
Level I trauma center with more than 75,000 annual ED
trauma patients, of this, 9% present with body tempera- utilized thermia during
leads to peripheral
trauma vasoconstriction,
evaluation as the teamfollowed by
needs access
visits. In 2016, 2,383 trauma cases were evaluated at NYU
tures of 33°C (91.4°F) or lower (Farkash et al., 2002). lactate
to buildupfor
the patient and acidosisintravenous
acquiring (Keane, 2016). In addition,
access, perform-
Langone Hospital—Brooklyn (NYU Langone Medical
Extensive evidence exists on the association between ing hypothermia
a Focusedleads to a decrease
Assessment in thrombininproduction,
with Sonography Trauma,
Center, 2016). The year 2016 marked several milestones
hypothermia and increased morbidity and mortality for and inhibition
other of fibrinogen synthesis,
assessments and impaired
and interventions. plate-en-
The team
for NYU Langone Hospital—Brooklyn, including its first
trauma patients (Balvers et al., 2016; Ireland, Endacott, couraged let aggregation
the useand
of adhesion.
warm blanketsThesefor deleterious
all patientseffects
when
year as part of the NYU Langone Health System, and the
are seen starting
exposure was notat body temperatures
necessary for medicalof 36°C (96.8°F)
interventions.
launch of a new electronic medical record (EMR).
and progressively worsen with further temperature drops
(Martini, 2009; Mitrophanov, Rosendaal, & Reifman, 2013;
Wolberg, Meng, Monroe, & Hoffman, 2004). Hypother-
Approach
Author Affiliations: Departments of Nursing (Mss Saqe-Rockoff, mia
Ciardiello, increases
Trauma Bayrisk for arrhythmias, which are frequently
Temperature
and Douglas) and Clinical Research (Mr Schubert), NYU Langone
Our project utilized theNew
Iowa unresponsive to cardioactive
Model of Evidence-Based In preparation for the EBP changes, drugs, the
electrical pacing, and
CNS discussed with
Hospital – Brooklyn, Brooklyn, York. defibrillation (Soar et al., 2010). Other associated complica-
AllPractice to provide
of the authors a framework
have nothing to declare. for execution and evalu- leadership from point of care, pharmacy, and central pro-
ation (Brown, 2014). Thermoregulation in trauma pa- tions include
cessing whethermultiorgan failure, pulmonary
a room temperature of 80°F edema,
would hypo-
nega-
Correspondence: Finn D. Schubert, MPH, Clinical Research Office, glycemia, hyperkalemia,
tients was a problem-focused trigger. It was determinedtively impact equipment and supplies located in the and infection (American College
trau-
NYU Langone Hospital – Brooklyn, 150 55th St, Brooklyn, NY 11220
that the trigger is of high priority to the ED and trauma ma
(finn.schubert@nyumc.org).
bay. It was determined that temperature change would
program, which facilitated organizational engagement. not disrupt normal storage and function of equipment.
DOI: 10.1097/JTN.0000000000000336

14
JOURNAL OF TRAUMA
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NURSING
Copyright
Copyright©©2018
2018Society
SocietyofofTrauma
TraumaNurses.
Nurses.Unauthorized
Unauthorizedreproduction
reproductionofofthis
thisarticle
articleisisprohibited.
prohibited.
 With collaboration from the engineering department, Appropriate Escalation of Rewarming Measures
the trauma bay ambient temperature was set to the rec- Rewarming measures available and a clear pathway of
ommended 80°F (Block et al., 2012; Zafren & Mechem, escalation based on the patient’s temperature were out-
2017). Staff were educated about the importance of keep- lined. Nursing staff competencies for use of the rapid
ing the trauma bay doors closed at all times to maintain infuser with automatic fluid warming are maintained
the temperature. In order for the trauma doors to remainthrough yearly competency training. More invasive core
closed at all times, extensive reinforcement was requiredrewarming measures, such as warm irrigation of the blad-
with staff of all disciplines, including nursing, nursing as- der, stomach, or pleural space, are to be implemented by
sistants, physicians, and environmental services. Educa- physicians in rare scenarios of severe hypothermia that
tion on the importance of hypothermia prevention for require aggressive rewarming (van der Ploeg et al., 2010;
the exposed, critical patient was conducted frequently Zafren & Mechem, 2017). The importance of follow-up
through huddles. Regular reminders were provided to thetemperature assessment was also stressed, because trau-
staff to ensure that the trauma bay doors remained closed. ma patients have been shown to have further tempera-
ture drop during resuscitation (Block et al., 2012; van der
Ploeg et al., 2010).

Temperature Assessment
Prior studies have shown a pervasive lack of temperature
assessment in trauma patients (Block et al., 2012; Ireland Educational Interventions
et al., 2006; Langhelle et al., 2010). The use of peripheralA thermoregulation checklist was adapted from a previ-
thermometers to expedite temperature assessment has ous work (Block et al., 2012) in collaboration with ED
been promoted in some works (Block et al., 2012; Keane,management, ED nurse educator, and the manager of the
2016). However, a systematic review and meta-analysis surgical intensive care unit (Figure 1). Final feedback and
found that peripheral thermometers lack clinically accept- adjustments were provided by staff nurses. Huddles were
able accuracy. Their use is discouraged when accurate conducted by the CNS multiple times per day for 1 week
body temperature measurement will influence clinical before launching the checklist. All ED nurses received a
decision, such as in postoperative, injured, or critically illmass e-mail outlining the EBP project and checklist. Af-
patients (Niven et al., 2015). Huddles were held to raise ter go-live, weekly huddles were conducted with staff of
awareness about the significance of accidental hypother-all shifts. During huddles, the checklist was disseminated
mia on trauma patients. The need for patient temperature with education and rationale for each field. Experienced
assessment on arrival was reinforced, with an emphasis and motivated staff nurses were approached to serve
on core temperature evaluation. as champions. The champions were asked to promote

Figure 1. Hypothermia checklist for all level 1 and level 2 trauma activations. Adapted from “Evidence-Based Thermoregulation
for Adult Trauma Patients,” by J. Block, M. Lilienthal, L. Cullen, and A.White, 2012, Critical Care Nursing Quarterly, 35(1), pp. 50–63.
doi:10.1097/cnq.0b013e31823d3e9b. Reprinted with permission from the authors.

16 WWW.JOURNALOFTRAUMANURSING.COM Volume 25 | Number 1 | January-February 2018

Copyright © 2018 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited.
the checklist and thermoregulation interventions to their
peers, as well as periodically checking implementation
of rewarming measures. Random trauma charts were au-
dited by the CNS with verbal or e-mail feedback pro-
vided to the staff. The thermoregulation checklist outlined
expectations for assessment and interventions of trauma
patients.

Evaluation
The impact of the interventions was assessed by review
of all charts for Level 1 and Level 2 trauma activations
from January to March 2017. Trauma activations from
January to March of 2016 were also reviewed and entered
in REDCap, a secure data collection portal (Harris et al.,Figure 2. Changes in trauma bay ambient temperature over
time. Error bars represent standard deviation.
2009), to serve as a comparison group in understanding
the impact of the intervention. The CNS verified every
20th record against the EMR to ensure the accuracy of col-Another goal of this project was to increase compliance
lected data. All completed checklists were collected andwith temperature assessment during trauma evaluations.
reviewed. Compliance with temperature assessment and While the number of temperatures taken within 9 min-
documentation, rewarming methods implemented, and utes of activation dropped between 2016 and 2017, the
trauma bay temperature were reviewed. Findings postin- overall number of temperatures taken within 19 or fewer
tervention were compared with trauma patients from the minutes increased slightly from 81.4% to 83.9% (Table 2).
same time period in 2016. Of note, the previous EMR made it easier to backdate all
trauma documentation, which may have made the times
Data analysis included descriptive statistics for all vari-
ables and assessment of differences between the pre- and to first temperature in 2016 appear shorter than they were
in practice. Core temperature assessment increased from
postintervention time frames using the χ2 test, Fisher exact
test, and Student t test as appropriate. All data analysis4.9
was% in 2016 to 24.4% in 2017 (p < .001) (Table 1).
completed in R version 3.3.3 (R Core Team, 2016) using Over the two 3-month periods reviewed for this pro-
RStudio version 1.0.136 (RStudio Team, 2015). Analysisject, there were a total of 10 hypothermic patients. Indoor
also included assessment of certain variables collected exposure
only was the most common mechanism associated
in the postintervention time period, such as trauma baywith hypothermia and was a factor in all three cases of
temperature and adherence to the new protocols. Informal severe hypothermia. All hypothermic patients were iden-
feedback was collected from the staff during the project. tified from rectal temperatures. Alcohol ingestion was
identified in 40% of hypothermic patients (Table 3).

RESULTS DISCUSSION
During the period of January–March 2017, there were 193 Various sources provide a range of temperature cutoffs for
trauma activations. Of these activations, 82 (41%) had hypothermia
a (Block et al., 2012; Keane, 2016; Langhelle
completed checklist; however, we were able to analyze et al., 2010; Niven et al., 2015; van der Ploeg et al., 2010).
data for all trauma activations using data from the chart.
To create a process with standardized interventions, the
More patients with hypothermia and hyperthermia wereteam set the hypothermia cutoff at 96.8°F (Langhelle
identified in 2017 than those in 2016. There was a signifi-
et al., 2010; Niven et al., 2015). While this cutoff is higher
cant increase in core temperature assessment from 4%than in some found in the literature, hypothermia has been
2016 to 23% in 2017 (p < .001). Blanket use in normo- associated with progressively worsening coagulopathy
thermic patients increased in 2017 (p = .002) (Table 1).starting at 96.8°F (Mitrophanov et al., 2013; van der Ploeg
Our institution did not have continuous temperature et al., 2010; Zafren & Mechem, 2017).
monitoring of the trauma bay preintervention. On the dayOne project goal was to improve time to first tempera-
that trauma bay temperature was adjusted (January 2017),ture. Previous articles have recommended use of periph-
the thermostat setting and thermometer reading were 70°F.
eral thermometers because of the ease of obtaining a tem-
After the intervention, trauma bay ambient temperatureperature reading (Block et al., 2012; Keane, 2016). Oral
was monitored and recorded in the checklist during trau-thermometers are accurate in confirming normothermia
ma activations. The CNS monitored and trended the baybut lack accuracy in hypothermic patients and are sub-
temperature over the course of 3 months of the projectject to interference from head and face temperature (Paal
(Figure 2). Over the period of 3 months, there was a steady
et al., 2016). A systematic review and meta-analysis found
increase in the average temperature of the trauma bay.that peripheral thermometers lack clinically acceptable

JOURNAL OF TRAUMA WWW.JOURNALOFTRAUMANURSING.COM 17

NURSING
Copyright © 2018 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited.
 TABLEPatient
1 Characteristics and Main Results
2016 2017
n = 271 n = 202 p
Characteristics
Age in years (median, IQR) 52.4 (28.2, 74.9) 68.6 (45.1, 81.8) <.001

Sex .278
Male 163 (60.1) 110 (54.7)
Female 108 (39.9) 91 (45.3)
Temperature category .006
Hyperthermia 6 (2.2) 13 (6.4)
Normothermia 261 (96.3) 179 (88.6)
Mild hypothermia 0 (0) 4 (2.0)
Moderate-severe hypothermia 2 (0.7) 4 (2.0)
Missing 2 (0.7) 2 (1.0)
Temperature source <.001

Oral 174 (64.2) 142 (70.3)

Rectal 7 (2.6) 43 (21.3)
Tympanic 2 (0.7) 1 (0.5)
Axillary 9 (3.3) 4 (2.0)
Missing 70 (29.2) 12 (5.9)
Warming measures
Normothermia n = 261 n = 179

Blankets 208 (79.7) 163 (91.1) .002

Mild hypothermia No patients n=4 N/A

Blankets 4 (100)
Warm IV fluids 0 (0)
Moderate-severe hypothermia n=2 n=4

Blankets 1 (50) 2 (50) 1.0

Bair hugger 2 (100) 3 (75) 1.0
Warm IV fluids 1 (50) 3 (75) 1.0
Checklist completed – 82 (40%)
Note. IQR = interquartile range; IV = intravenous.

accuracy. Their use was discouraged in critical or injured Increasing the ambient temperature was met with the
patients and any scenario where accurate body tempera-most staff resistance. Block et al. (2012) reported similar
ture would influence decisions (Niven et al., 2015). Of difficulties in implementing warming of the environment,
note, all cases of hypothermia were detected with core although they did not include data on their progress.
temperature readings. One patient in 2016 had an ini- Frequent reminders to the staff and adjustments to the
tial oral temperature of 97.0°F and a rectal temperature trauma bay thermostat and closing of the doors were re-
of 87.9°F. Increased use of rectal thermometers in 2017 quired. Although there was a steady increase in trauma
may have contributed to the increased identification of bay temperature in January through March 2017, com-
hypothermia, allowing earlier implementation of rewarm-pliance with maintaining the 80°F temperature remained
ing modalities and prevention of further heat loss for inconsistent, and in May 2017, after the evaluation pe-
these trauma patients (Table 2). riod presented in this article, a lockbox was placed over

18 WWW.JOURNALOFTRAUMANURSING.COM Volume 25 | Number 1 | January-February 2018

Copyright © 2018 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited.
Acknowledgments Limitations
Keane, M. (2016). Triad of death: The importance of temperature
TABLE Time to First Temperature, by Year
2 the NYU Langone Hospital—Brooklyn This monitoring in trauma patients. Emergency Nurse, 24(5), 19–23.
The authors thank was a single-center EBP project in an urban Level 1
doi:10.7748/en.2016.e1569
ED nurses for their hard work2016 and dedication2017 to improv- traumaLanghelle,center. Because
A., Lockey, D., Harris,of the
T., &small
Davies, number
G. (2010). of Body
hypother-
ing patient care and Kathy Peterson, n (%) RN, MSN, n (%)CEN, and mic patients,
temperature our
of project
trauma was
patients unable
on to
admission determine
to hospital: chang-
A
Time to Temperature
Staci Mandola, RN, BSN, for their leadership and support.escomparison in patientofoutcomes anaesthetised from andour interventions (Table
non-anaesthetised patients.3).
0-9 min 188 (69.9) 116 (60.1) Emergencythis
Although Medicine Journal, used
evaluation 29(3), a 239–242.
comparison doi:10.1136/
group
emj.2009.086967
10-19 min 31 (11.5) 46 (23.8) comprising the same months of patient admissions, en-
Martini, W. Z. (2009). Coagulopathy by hypothermia and acidosis:
abling
Mechanismscontrol
us to of thrombinfor obvious
generation seasonal
and fibrinogeneffects related
availability.
KEY POINTS
20-29 min 21 (7.8) 13 (6.7) to The
theJournal
incidence of hypothermia,
of Trauma: Injury, Infection, theandevaluation
Critical Care,may
• Hypothermia
30+ min is a high impact 29presentation
(10.7) that
18requires
(9.3) have
67(1),been vulnerable
202–209. to secular effects related to other
doi:10.1097/ta.0b013e3181a602a7
vigilance. Melnyk,
hospitalB.initiatives
M., & Fineout-Overholt,
or broaderE.changes (2014). Evidence-based
in the health care
• Critical and trauma patients should have core temperature landscape practice in nursing & healthcare: A guide to best practice (3rd
between the pre- and postintervention data.
ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
assessment to ensure optimal detection of abnormal One important hospital-wide
the thermostat to ensure consistency. For the following Melnyk, B. M., Fineout-Overholt, E.,effect was the L.,
Gallagher-Ford, launch of a
& Kaplan,
temperatures. new EMR system inofAugust 2016, which changed many
L. (2012). The state evidence-based practice in US nurses.
•2 Extensive
weeks, daily checks
education of the trauma
is required bay temperatures
to successfully implement workflows JONA: Theand Journalmade it more
of Nursing difficult to backdate
Administration, 42(9), 410–417.tem-
revealed
evidence-based a consistent temperature
interventions and achieve of 80°F.
practice change. doi:10.1097/nna.0b013e3182664e0a
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Nurses often identify lack of education, access to Mitrophanov, A. Y., Rosendaal, F. R., & Reifman, J. (2013).
time to temperature comparison.
information, and time for implementing EBP as bar- Computational analysis of the effects of reduced temperature
riers to implementing change (Melnyk, Fineout-Over- on thrombin generation. Anesthesia & Analgesia, 117(3), 565–
holt, Gallagher-Ford, & Kaplan, 2012). Compliance 574. doi:10.1213/ane.0b013e31829c3b22
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