Aha moment leads to new burn protocol
Temp management cuts mortality in burned kids
It happened a lot: A burn patient with areas of 30% or more burned would go into surgery for debridement and come back to recovery with an extremely low body temperature. There, Debbie Laws, RN, would spend an entire 12-hour shift trying to make sure the patient did not die. While doing an evidence-based practice course and looking for a quality improvement project, Laws had four such patients. It got her thinking: What do low temperatures do to the body? And is there anything that can be done to make these patients more stable?
Her quality project seemed to find her.
Laws said most of the research into patients with burns over 30% or more of their bodies comes out of the military. Because the skin is gone, there is nothing to keep the heat from escaping, and the core temperature can drop by as much as 20% without warming assistance. That makes the body hemodynamically unstable. It is exacerbated in operating rooms, which are kept cold, and by blood and IV products, which are usually kept refrigerated and delivered cold to the patient.
So patients who are already at risk for chilling are sent to a cold environment, unwrapped for surgery, and given cold fluids, Laws says. It was not a recipe for making them well. "It would take us a whole shift to stabilize them after a surgery," she says.
Some of the solution was easy: Use blood warmers. The hospital has them, but was not using them. The other parts of her protocol also made a lot of logical sense, but simply hadn't been put together in a package:
- Get the patient's core temperature up before surgery so that he or she is toasty before heading into a cold environment.
- Use hats and socks to keep whatever body parts you can warm.
- Break surgeries into parts if they cover a large body area or if there are surgeries on multiple parts of the body.
- Uncover as little of the body as possible at a time in the operating room.
- Use bed warmers when possible.
- Teach ABC + T to the community.
The last part relates to stabilizing patients before they come to the burn center. First responders usually concern themselves with ABC — airway, breath, circulation. But for large-area burns, temperature is key, Laws says. She notes that the inclination is to pour cold water on a burn. But for a large burn, that risks putting the body into shock and reducing the core temperature of the victim to the point that you put the patient at risk of harm or death by doing so. Laws is publicizing ABC + T for Temp to hospitals, emergency medical personnel, air ambulance services, and the wider community.
She is asking stakeholders how to help them to remember the importance of keeping burn victims warm, especially in air transport situations: It can be cold in a helicopter.
Before the project started in December 2012, patients were routinely coming back from surgery with body temperatures at 90 degrees F before Laws implemented her program. The data she collected show the number declined by 60% to about 20% of the total returning with temperatures below the goal of 97.7F. "And it's been a long time since there was someone whose temp was all the way down to 90," she says.
Compliance with the protocol is at 95% on her unit, and just about all patients are making it back from dressing changes with their temperatures stable at the goal point.
Laws has presented her findings at conferences and fielded calls from other hospitals who are interested in her research and the protocol she developed.
For more information on this topic, contact Debbie Laws, RN, Arkansas Children's Hospital, Little Rock, AR. Telephone: (501) 364-1100.