62 - Reducing Postoperative Neonatal Hypothermia at a High-Volume Children's Hospital

Description: Infants and neonates are at high risk for hypothermia, which is defined by the WHO as temperatures less than 36.0 degrees Celsius and has been associated with increased mortality and severe forms of intraventricular hemorrhage. Hypothermia has been shown to occur in infants and neonates undergoing surgical procedures because of their exposure to colder temperatures and increased heat loss in the operating room combined with the impaired ability for heat retaining mechanisms that are altered during administration of anesthesia. As a result, numerous governing bodies, including the U.S News & World Report, support recommendations to reduce post op hypothermia.

The SMARTIE aim of this initiative was to improve rates of euthermia (temperature of 36.0 to 37.5 degrees Celsius) for all patients returning to the NICU from non-cardiac procedures from a baseline of 67.9% to 100% by December 2025.

A workgroup was formed, and our target population was narrowed to include all infants admitted to the NICU who underwent non-cardiac surgical procedures. Infants who underwent cardiac surgical procedures were excluded given that they are often actively cooled while on bypass. A key driver diagram was completed and stratified our interventions into pre-operative, intra-operative and postoperative drivers. Secondary key drivers included opportunities for improved documentation, equipment, standardization, and additional IT support and interventions were developed to target each of these drivers. The primary outcome measure was the percentage of euthermic infants (temperature of 36.0 to 37.5 degrees Celsius) within 30 minutes of return to the NICU after a noncardiac surgical procedure. Secondary outcome measures included mild hypothermia (defined as 36 to 36.4 degrees Celsius), adverse respiratory outcomes, and bleeding events. Our balancing measure was the number of cases of post-operative hyperthermia (defined as a temperature of greater than or equal to 37.6 degrees Celsius).

From February 2020 to February 2025, there were a total of 365 non-cardiac surgical procedures performed on infants admitted to the NICU. Between February 2020 and July 2022, 162 non-cardiac surgical procedures were performed and 67.9% of these patients were euthermic within 30 minutes of return to the NICU. After implementation of multiple interventions from December 2022 through March 2024, special cause variation was observed from April 2024 to November 2024 and our baseline rate of euthermia increased to 96.1%. Our interventions during this period spanned multiple levels of reliability and included temperature documentation enhancements, new equipment including warmer battery packs and transport shuttles, standardizing use of a hypothermia bundle including neonatal hats, temperature monitoring supplies, and transwarmer mattresses, warming the operating rooms, and improved data reporting to stakeholders via monthly EPIC reports and quarterly multidisciplinary workgroup meetings. During and after this intervention period, 5 of 171 (2.9%) patients returned to the NICU hyperthermic (range: 37.6 to 38.2 degrees C).
Since formation of the post-operative neonatal hypothermia workgroup and subsequent interventions, we were able to improve the rates of post-operative euthermia from a baseline of 67.9% to 96.1%. We hope to apply these findings to infants undergoing other procedures including cardiac catheterization and cardiothoracic surgery.