Reports From the Field

Practical Application of Self-Determination Theory to Achieve a Reduction in Postoperative Hypothermia Rate: A Quality Improvement Project

Journal of Clinical Outcomes Management. 2021 July;28(4):180-188 | 10.12788/jcom.0056

Author(s):

Hadi Sakhai, MD

Ashley Bocanegra, MD

Neethu Chandran, MD

Stephen Kimatian, MD

Joan S. Reisch, PhD

Edgar Erold Kiss, MD

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References

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From Children’s Health System of Texas, Division of Pediatric Anesthesiology, Dallas, TX (Drs. Sakhai, Bocanegra, Chandran, Kimatian, and Kiss), UT Southwestern Medical Center, Department of Anesthesiology and Pain Management, Dallas, TX (Drs. Bocanegra, Chandran, Kimatian, and Kiss), and UT Southwestern Medical Center, Department of Population and Data Sciences, Dallas, TX (Dr. Reisch).

Objective: Policy-driven changes in medical practice have long been the norm. Seldom are changes in clinical practice sought to be brought about by a person’s tendency toward growth or self‐actualization. Many hospitals have instituted hypothermia bundles to help reduce the incidence of unanticipated postoperative hypothermia. Although successful in the short-term, sustained changes are difficult to maintain. We implemented a quality-improvement project focused on addressing the affective components of self-determination theory (SDT) to create sustainable behavioral change while satisfying providers’ basic psychological needs for autonomy, competence, and relatedness.

Methods: A total of 3 Plan-Do-Study-Act (PDSA) cycles were enacted over the span of 14 months at a major tertiary care pediatric hospital to recruit and motivate anesthesia providers and perioperative team members to reduce the percentage of hypothermic postsurgical patients by 50%. As an optional initial incentive for participation, anesthesiologists would qualify for American Board of Anesthesiology Maintenance of Certification in Anesthesiology (MOCA) Part 4 Quality Improvement credits for monitoring their own temperature data and participating in project-related meetings. Providers were given autonomy to develop a personal plan for achieving the desired goals.

Results: The median rate of hypothermia was reduced from 6.9% to 1.6% in July 2019 and was reduced again in July 2020 to 1.3%, an 81% reduction overall. A low hypothermia rate was successfully maintained for at least 21 subsequent months after participants received their MOCA credits in July 2019.

Conclusions: Using an approach that focused on the elements of competency, autonomy, and relatedness central to the principles of SDT, we observed the development of a new culture of vigilance for prevention of hypothermia that successfully endured beyond the project end date.

Keywords: postoperative hypothermia; self-determination theory; motivation; quality improvement.

Perioperative hypothermia, generally accepted as a core temperature less than 36 °C in clinical practice, is a common complication in the pediatric surgical population and is associated with poor postoperative outcomes.¹ Hypothermic patients may develop respiratory depression, hypoglycemia, and metabolic acidosis that may lead to decreased oxygen delivery and end organ tissue hypoxia.^2-4 Other potential detrimental effects of failing to maintain normal body temperature are impaired clotting factor enzyme function and platelet dysfunction, increasing the risk for postoperative bleeding.^5,6 In addition, there are financial implications when hypothermic patients require care and resources postoperatively because of delayed emergence or shivering.⁷