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

References

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The American Society of Anesthesiologists recommends intraoperative temperature monitoring for procedures when clinically significant changes in body temperature are anticipated.⁸ Maintenance of normothermia in the pediatric population is especially challenging owing to a larger skin-surface area compared with body mass ratio and less subcutaneous fat content than in adults. Preventing postoperative hypothermia starts preoperatively with parental education and can be as simple as covering the child with a blanket and setting the preoperative room to an acceptably warm temperature.^9,10 Intraoperatively, maintaining operating room (OR) temperatures at or above 21.1 °C and using active warming devices and radiant warmers when appropriate are important techniques to preserve the child’s body temperature.^11,12

Despite the knowledge of these risks and vigilant avoidance of hypothermia, unplanned perioperative hypothermia can occur in up to 70% of surgical patients.¹ Beyond the clinical benefits, as health care marches toward a value-based payment methodology, quality indicators such as avoiding hypothermia may be linked directly to payment.

Self-determination theory (SDT) was first developed in 1980 by Deci and Ryan.¹³ The central premise of the theory states that people develop their full potential if circumstances allow them to satisfy their basic psychological needs: autonomy, competence, and relatedness. Under these conditions, people’s natural inclination toward growth can be realized, and they are more likely to internalize external goals. Under an extrinsic reward system, motivation can waver, as people may perceive rewards as controlling.

Many institutions have implemented hypothermia bundles to help decrease the rate of hypothermic patients, but while initially successful, the effectiveness of these interventions tends to fade over time as participants settle into old, comfortable routines.¹⁴ With SDT in mind, we designed our quality-improvement (QI) project with interventions to allow clinicians autonomy without instituting rigid guidelines or punitive actions. We aimed to directly address the affective components central to motivation and engagement so that we could bring about long-term meaningful changes in our practice.

Methods

Setting

The hypothermia QI intervention was instituted at a major tertiary care children’s hospital that performs more than 40 000 pediatric general anesthetics annually. Our division of pediatric anesthesiology consists of 66 fellowship-trained pediatric anesthesiologists, 15 or more rotating trainees per month, 13 anesthesiology assistants, 15 anesthesia technicians, and more than 50 perioperative nurses.