Pediatric quality & safety · 2026
Preventing Perioperative Hypothermia in Neonatal Surgical Patients: A Phased Quality Improvement Initiative within the Wake Up Safe Collaborative.
СтатьяНазвание и аннотация: Перевод в очереди
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Patak Lance S, Tjia Imelda M, Shaw Thomas L, Bedre Lynne
Аннотация
BACKGROUND: Neonates are at high risk for perioperative hypothermia, which is associated with increased morbidity and mortality. A serious safety event involving profound postoperative hypothermia prompted a quality improvement initiative to prevent perioperative hypothermia in neonatal intensive care unit surgical patients.
PROBLEM: A review of prior cases at our institution demonstrated that only 50% of neonates returned from surgery normothermic.
METHODS: A three-phase intervention was implemented: (1) a multidisciplinary hypothermia prevention checklist with standardized warming and transport processes; (2) assignment of a dedicated intraoperative "temperature guardian" responsible for continuous monitoring and team communication; and (3) implementation of dual-source intraoperative temperature monitoring. We collected perioperative temperature data across 39 consecutive surgical events.
INTERVENTIONS: Focused on standardizing preparation, clarifying team roles, enhancing intraoperative vigilance, and improving temperature measurement accuracy.
RESULTS: Implementation of phased interventions was associated with a reduction in hypothermia from 50% at baseline to 0% in subsequent phases, with elimination of hypothermia events and low rates of mild hyperthermia (≤20%), with 2 outlier events: 1 hypothermia emergency bedside procedure and 1 hyperthermia event with a falsely low core temperature reading during bowel irrigation. Checklist compliance improved to 92%. Intraoperative temperature monitoring compliance reached 100%.
CONCLUSIONS: A structured, phased quality improvement approach emphasizing team accountability, standardized workflows, and validated monitoring reliably maintained perioperative normothermia in high-risk neonatal patients and offers a reproducible model for improving neonatal surgical safety.
PROBLEM: A review of prior cases at our institution demonstrated that only 50% of neonates returned from surgery normothermic.
METHODS: A three-phase intervention was implemented: (1) a multidisciplinary hypothermia prevention checklist with standardized warming and transport processes; (2) assignment of a dedicated intraoperative "temperature guardian" responsible for continuous monitoring and team communication; and (3) implementation of dual-source intraoperative temperature monitoring. We collected perioperative temperature data across 39 consecutive surgical events.
INTERVENTIONS: Focused on standardizing preparation, clarifying team roles, enhancing intraoperative vigilance, and improving temperature measurement accuracy.
RESULTS: Implementation of phased interventions was associated with a reduction in hypothermia from 50% at baseline to 0% in subsequent phases, with elimination of hypothermia events and low rates of mild hyperthermia (≤20%), with 2 outlier events: 1 hypothermia emergency bedside procedure and 1 hyperthermia event with a falsely low core temperature reading during bowel irrigation. Checklist compliance improved to 92%. Intraoperative temperature monitoring compliance reached 100%.
CONCLUSIONS: A structured, phased quality improvement approach emphasizing team accountability, standardized workflows, and validated monitoring reliably maintained perioperative normothermia in high-risk neonatal patients and offers a reproducible model for improving neonatal surgical safety.