As she waited for back surgery at Cooper University Hospital last week, Betty Lindley got a nice surprise.
Instead of the flimsy gown patients have groused about for years, she was given a new type of gown Cooper has been using for the last six months. A machine blows warm air between layers of paper - actually a DuPont fabric made of wood fibers, polypropylene, and polyester - in the gown to keep patients toasty before, during, and after surgery. The look isn't slimming, but Lindley didn't mind. As anyone who has ever visited an operating room knows, surgeons like it a lot colder than their half-dressed patients.
Lindley, who has had surgery before, liked how she felt under the puffy, purple gown. "I've been freezing cold before," she said. "I am warm, and I love it."
The new gowns, which are made by Minnesota-based Arizant Inc. and cost about $15 each, not only make patients feel better - doctors say they also help them heal better.
Plus, there is money at stake. As Medicare expands efforts to tie medical pay to performance, the government is requiring hospitals to report on their efforts to maintain normal body temperatures during surgery, starting Friday. Two percent of pay is connected to reporting on this and other measures known to improve patient results.
About 1,700 facilities, including several in this region, are now using the gowns, known as Bair Paws, compared with about 1,300 a year ago, said Jami Collins, a senior product manager at Arizant. The company and several competitors also make forced-air blankets most hospitals use in their ORs.
"We've been contacted by a number of facilities who say 'We need this now.' . . . It's obviously a driver for our business," said Troy Bergstrom, marketing communications manager for Arizant.
Locally, Thomas Jefferson University Hospital and Main Line Health hospitals began using the gowns in the last year. Abington Memorial Hospital has been using them for three years, and Fox Chase Cancer Center for four. The design was recently modified so the gowns can be used during surgery.
Temperatures in operating rooms typically are in the low 60s to keep surgeons, who wear multiple layers of clothing, comfortable.
Daniel Sessler, an anesthesiologist who is chairman of the department of outcomes research at the Cleveland Clinic, said doctors once took it for granted that surgical patients would be cold.
"Patients," he said, "were not actively warmed because people didn't think it made a difference."
It does. Sessler began studying the effect of lowered body temperature in the mid '90s. Allowing a patient's temperature to fall by just two degrees - this can happen easily during surgery - triples the risk of heart problems and wound infections, increases blood loss, and prolongs time in the recovery room 40 percent and in the hospital 20 percent, Sessler said. He has done research on patient warming with and without financial support from Arizant.
This is partly because the rooms are cold, but mostly because anesthesia changes the body's ability to retain and generate heat. Anesthesia makes it impossible for people to shiver, said Michael Goldberg, chief of anesthesiology at Cooper. Shivering is how we warm ourselves up when we are cold. After surgery, shivering is bad, because it saps energy and oxygen that could be better spent on recovery.
A tiny fraction of heart and brain operations go better when the body is cool, Sessler said.
Over the last decade, anesthesiologists, who are responsible for monitoring patient temperatures, have paid increasing attention to this issue. Sessler said he thought all hospitals warmed some patients now, usually with a combination of heated cotton blankets, the warmed air covers, and heated intravenous fluids. But, "there are probably a lot of hospitals who warm only a fraction of the patients who should be warmed," he said.
The government is requiring reporting of temperature control in procedures that take an hour or more, but some hospitals now use some kind of active warming in shorter operations as well.
The advantage of the gowns, which are loaded with Velcro, is that they can go easily from waiting areas to the OR. During a procedure, they can be opened in various ways so surgeons have access to the parts they need to cut while others are covered.
Sessler said there was plenty of evidence that warming patients before surgery was helpful, but no studies that showed whether the gowns led to better patient outcomes than the forced-air blankets, which cost less. Cleveland Clinic does not use the gowns.
Richard Webster, vice president for perioperative services at Jefferson, remains somewhat skeptical about the gowns, although his hospital now uses them for most cases. He estimates they cost an extra $150,000 a year. "It's not insignificant at a time when we're not being reimbursed more," he said.
"I think the jury's still out on how effective this is or how important it is."
The Virtua health system studied the problem, said Carol Mullin, vice president of clinical outcomes and quality management. What the staff found is that patient temperatures were fine in presurgery holding areas, but they dropped rapidly after patients got to the OR. Virtua is now making a big effort to start warming with the blankets and head coverings quickly in the OR. It is not using the gowns.
Patrick Breen, an anesthesiologist at Abington Memorial, said he thought the gowns made temperature control easier. When he arrived at the hospital 31/2 years ago, he was struck by how many patients spent a long time in the recovery room warming up after surgery. The hospital had warming blankets in its ORs, but they were not being used until most of the presurgical prep was finished. That took about 20 minutes. By then, it was hard to catch up.
The advantage of the gowns, he said, is that patients go into the OR warm and the staff immediately hooks their gowns to another warming unit.
He estimates that the gowns cost $3 to $4 more per case than the warmed-air blankets, and he thinks they are worth it.
Doctors also said that warm patients were happier patients. Surgical patients with the gowns are less likely to fuss about being cold, always a big complaint.
"We want them to feel well and feel comfortable before they have this very stressful thing happen," Goldberg said.
Doctors said some patients, especially large ones, did not want extra warming, but many do.
"All the little old ladies coming in having their hips and knees done, they love these things," Breen said.
Patients often ask, "Can I get this at home?" The answer is "No."
"We're focusing on getting surgical patients warm first," Bergstrom said.