Clinical application of multidisciplinary team- and evidence-based practice project in gynecological patients with perioperative hypothermia

Table 1 Quality evaluation results of the included guidelines

Ref.	Percentage of standardization in various fields						Number of domains ≥ 60% (n)	Number of domains ≥ 30% (n)	Recommended level
	Scope and purpose	Stakeholder involvement	Rigor of development	Clarity of presentation	Applicability	Editorial independence
Torossian et al[13]	100	88.89	79.17	100	68.75	62.5	6	6	A
Hooper et al[14]	88.89	52.78	62.5	80.56	43.75	20.84	3	5	B

Table 2 Quality evaluation results of the included systematic reviews

Indicators	Galvão et al[17]	Moola and Lockwood[18]	Wang and Mao[16]
Was an “a priori” design provided?	Yes	Yes	Yes
Was there duplicate study selection and data extraction?	Yes	Yes	Yes
Was a comprehensive literature search performed?	Yes	Yes	Yes
Was the status of publication used as an inclusion criteria, such as grey literature?	No	Yes	No
Was a list of studies provided?	Yes	Yes	Yes
Were the characteristics of the included studies provided?	Yes	Yes	Yes
Was the scientific quality of the included studies assessed and documented?	Yes	Yes	Yes
Was the scientific quality of the included studies used appropriately in formulating conclusions?	Yes	Yes	Yes
Were the methods used to combine the findings of studies appropriate?	Yes	Yes	Yes
Was the likelihood of publication bias assessed?	No	No	Yes
Was the conflict of interest stated?	Yes	Yes	No

Table 3 Contents of the best evidence

Stage	Evidence
Preoperative ward	To educate patients on thermal insulation and matters needing attention before surgery
	To measure and record the patient’s axillary temperature before surgery
	To actively warm patients whose body temperature is below 36°C to 36°C and keep the patient warm during transfer
Preoperative preparation room	To assess the risk factors for hypothermia in patients
	To use a temperature monitoring equipment to measure and record the patient’s body temperature before anesthesia induction
	To preheat 10-30 min before anesthesia induction
	To use carbon fiber heating wire to actively and continuously warm patients with body temperature below 36°C to above 36°C
	To maintain the operating room temperature no less than 24°C, and to lower the temperature only when active heating is established
Intraoperative operating room	To adopt an effective comprehensive thermal insulation strategy after anesthesia and maintain the axillary temperature at least 36.5°C
	To expose the surgical area and cover the rest for thermal insulation
	The infusion pipeline is continuously heated to 37°C if the intravenous infusion volume is more than 500ml.
	To heat the washing solution with a thermostatic chamber to 38-40°C
	To perform continuous intraoperative monitoring and recording every 15 min
	To evaluate intraoperative risk factors and hypothermia symptoms and signs
Postanesthesia care unit	To measure the body temperature and record it every 15 min. Passive insulation is adopted if there is no hypothermia. Monitoring site: armpit
	To adjust the PACU ambient temperature to 24°C
	To evaluate the patient's thermal comfort level
	To actively warm patients whose body temperature is below 36°C to above 36°C
	To heat the intravenous fluids
	To provide heated and humidified oxygen therapy for patients
	To transfer the patient out of PACU only when her body temperature is ≥ 36°C
24-hour postoperative gynecological ward	To measure, monitor and record the body temperature every 4 h
	To cover to keep warm
	To educate family members thermal insulation methods: blankets, socks, clothes, raising the ambient temperature, hot water, etc.
	To continuously and actively warm patients below 36°C until they feel warm and comfortable, and to monitor and record every 30 min
	To evaluate the patient's thermal comfort level
	To pay close attention to patients' psychological changes, perceive their potential negative emotions such as anxiety and depression, and give timely relief and comfort
	To patiently answer any problems that may cause psychological distress to patients, and help them establish a positive attitude

PACU: Postanesthesia care unit.

Table 4 Relationship between evidence, practice protocol related documentation and examination indicators

Stage	Evidence suitable for clinical scenarios	Practice protocol related documentation	Examination indicators	Examination objectives and methods
Preoperative ward	To educate patients on thermal insulation and matters needing attention before surgery	Manuals and videos of perioperative health education (patient edition)	The operating room has propaganda materials on hypothermia prevention and management	Department: Document consultation
			Checking the preoperative follow-up sheet of gynecological surgery patients	Medical staff: Document consultation and observation
	To measure and record the patient’s axillary temperature before surgery	Surgical patient handover/transfer proforma	Checking the surgical patient handover/transfer proforma	Medical staff: Document consultation and observation
	To actively warm patients whose body temperature is below 36°C to 36°C and keep the patient warm during transfer	Hypothermia emergency procedures	The operating room has a hypothermia emergency process to ensure continuous heat preservation during patient transfer	Medical staff: Document consultation and observation
Preoperative operating room	To assess the risk factors for hypothermia in patients	Hypothermia risk factor evaluation sheet	The operating room has an evaluation sheet to evaluate the risk factors of hypothermia in patients	Operating Room: document consultation
	To use a temperature monitoring equipment to measure and record the patient’s body temperature before anesthesia induction	Procedure for the use of temperature monitoring equipment	Before anesthesia induction, a temperature monitoring equipment is used for patients with operation duration of 2h or longer	Medical staff: Observation and document consultation
	To actively warm patients whose body temperature is below 36°C to above 36°C	Active heat preservation methods for hypothermia patients	Effective warming strategies are taken for hypothermia patients	Medical staff: Observation and document consultation
	To preheat 10-30 min before anesthesia induction	Pre-heat preservation methods	10-30 min of pre-heat preservation is performed on gynecological patients before anesthesia induction	Medical staff: Observation
	To maintain the operating room temperature no less than 24°C, and to lower the temperature only when active heating is established	-	The operating room ambient temperature is adjusted to 24°C and above before surgery	Medical staff: Observation
Intraoperative operating room	To adopt an effective comprehensive thermal insulation strategy after anesthesia and maintain the axillary temperature at least 36.5°C	Intraoperative comprehensive thermal insulation strategies (active and passive thermal insulation, blood transfusion and infusion warming, continuous dynamic monitoring of body temperature, etc.)	According to the probability of hypothermia in gynecological patients during operation, a corresponding comprehensive heat preservation strategy is selected to maintain the axillary temperature of the patient at least 36.5°C	Medical staff: Observation, document consultation
	To expose the surgical area and cover the rest for thermal insulation	-	The surgical area is exposed and the rest is covered for thermal insulation	Medical staff: Observation
	To warm the intravenous fluid or blood transfusion with a warming device to 37°C if the amount was ≥ 500 mL	Procedure for the use of infusion pipeline heating instrument	The infusion pipeline was warmed for those with a intravenous fluid or blood transfusion volume ≥ 500 mL	Medical staff: Observation
	To heat the intraoperative washing solution with a thermostatic chamber to 38-40°C	-	The washing solution is used at 38-40°C	Medical staff: Observation
	To continuously monitor and record the patient’s body temperature once every 30 min intraoperatively, and to record it once every 15 min during recovery from anesthesia	-	The body temperature is continuously monitored and recorded on time intraoperatively	Medical staff: Observation, document consultation
	To evaluate hypothermia symptoms and signs during the operation	Evaluation methods of symptoms and signs of hypothermia in patients during operation	The patient is observed for symptoms and signs of hypothermia during the operation	Medical staff: Observation
PACU	To measure the body temperature and record it every 15 min. Passive thermal insulation is adopted for those without hypothermia, and active thermal insulation is taken to above 36°C for those below 36°C	Active insulation methods and temperature handover record for hypothermia patients	The patient’s temperature is measured and the hypothermia patients are warmed effectively, and the temperature handover record is established	Medical staff: Observation, document consultation
	To adjust the PACU ambient temperature to 24°C	-	The PACU temperature is adjusted to 24°C and above	Medical staff: Observation
	To send the patient back to the ward when the body temperature is not lower than 36°C	-	The patient is transferred out from the PACU only when the body temperature is ≥ 36℃	Medical staff: Observation, document consultation
24-hour postoperative gynecological ward	To monitor and record the patient's axillary temperature every 4 h	-	The patient's axillary temperature is measured and recorded every 4 h	Medical staff: Observation, document consultation
	To cover to keep warm	-	The patient is covered to keep warm	Medical staff: observation
	To teach the patient's family how to keep warm effectively	Health education handbook	The patient’s family members' are informed of effective thermal insulation methods	Medical staff: Observation and questioning
	To continuously and actively warm patients below 36°C until they feel warm and comfortable, and to monitor and record every 30 min	Active heat preservation methods for hypothermia patients	The hypothermia patients are continuously and actively warmed, with their body temperatures monitored and recorded every 30 min	Medical staff: Observation, document consultation
	To evaluate the patient's thermal comfort level	Thermal comfort rating scale	The patient's thermal comfort level is assessed	Medical staff: Document consultation

PACU: Postanesthesia care unit.

Table 5 Barriers and action strategies for prevention and management of hypothermia in patients

Serial number	Obstacle	Action strategy
1	Nurses lack relevant knowledge and awareness of perioperative hypothermia management of gynecological patients	To hold special training to explain relevant knowledge to nurses with PPT combined with nursing knowledge handbook, and to explain various procedures and nursing norms through on-site demonstration and watching operation videos. To ensure that nurses in the operating room, anesthesiology department and gynecology department receive knowledge training on hypothermia prevention at least once every six months, and to assess them for knowledge and practice at least once a year after training
2	The contents of health education on the day before surgery vary greatly and lacks gynecological expertise	To formulate a preoperative education manual of gynecology specialty, and to push the preoperative education video for gynecological patients by WeChat official account
3	The lithotomy position is mostly commonly used posture in gynecological surgery, resulting in inadequate ankle and foot warmth. In addition, there is a lack of special thermal insulation equipment for the lithotomy position	To purchase lithotomy position-dedicated strip-shaped inflatable heating blankets, wrap the patient’s legs with cotton pads, and use sterile leg covers to meet the warm-keeping requirements of patients undergoing surgery in the lithotomy position
4	There are communication barriers among multi-department nurses on the prevention and management of perioperative hypothermia in gynecological patients	To establish a perioperative hypothermia prevention and management group led by the head nurses who also play a key role in the practice reform, with operating room gynecological specialists, anesthesiology nurses, gynecological nurses as the team members and the head nurses of the three departments as the group leaders. To establish a WeChat exchange group to remind, supervise and control the quality in the preoperative ward, preoperative preparation room, intraoperative operating room and postoperative PACU. To listen to the feedback and suggestions of nurses and patients during field observation, and adjust and optimize the nursing process. The head nurse should report the practice changes to the evidence-based practice group every month, so as to discuss, analyze and solve the problems that arise
5	There is a lack of corresponding evaluation tools	To introduce the intraoperative hypothermia risk prediction model calculation software constructed by Professor Huang Yuguang to evaluate the hypothermia risk of patients, and to explain the checked contents. To self-develop a thermal comfort scale, and conduct unified training for medical staff

PACU: Postanesthesia care unit; PPT: Power point.

Table 6 Comparison of nurses' implementation of examination indicators before and after application of the evidence-based program

Examination indicators	Before evidence application (n = 30)			After evidence application (n = 30)			χ2	P value
	Implemented	Unimplemented	Implementation rate (%)	Implemented	Unimplemented	Implementation rate (%)
Indicator 1	16	14	53.33	28	2	93.33	12.273	< 0.001
Indicator 2	15	15	50.00	29	1	96.67	20	< 0.001
Indicator 3	12	18	40.00	28	2	93.33	19.2	< 0.001
Indicator 4	0	30	0.00	27	3	90.00	49.091	< 0.001
Indicator 5	7	23	23.33	20	10	66.67	11.38	0.001
Indicator 6	15	15	50.00	30	0	100.00	20	< 0.001
Indicator 7	12	18	40.00	30	0	100.00	25.714	< 0.001
Indicator 8	15	15	50.00	30	0	100.00	20	< 0.001
Indicator 9	11	19	36.67	30	0	100.00	27.805	< 0.001
Indicator 10	29	1	96.67	30	0	100.00	1.017	0.313
Indicator 11	6	24	20.00	27	3	90.00	29.697	< 0.001
Indicator 12	28	2	93.33	30	0	100.00	2.069	0.15
Indicator 13	7	23	23.33	20	10	66.67	11.38	0.001
Indicator 14	3	27	10.00	30	0	100.00	49.091	< 0.001
Indicator 15	4	26	13.33	28	2	93.33	38.571	< 0.001
Indicator 16	14	16	46.67	30	0	100.00	21.818	< 0.001
Indicator 17	11	19	36.67	30	0	100.00	27.805	< 0.001
Indicator 18	30	0	100.00	30	0	100.00	-	-
Indicator 19	21	9	70.00	29	1	96.67	32.308	< 0.001
Indicator 20	12	18	40.00	28	2	93.33	19.2	< 0.001
Indicator 21	10	20	33.33	30	0	100.00	30	< 0.001
Indicator 22	0	30	0.00	30	0	100.00	60	< 0.001