Articles

RSS

Something dangerous is happening in operating rooms across the country: hosing. The practice of "hosing" is placing surgical patients at an increased risk for serious burns.

What is hosing?
Hosing is the improper use of a forced-air warming system by not properly attaching a disposable blanket to the hose end. Forced-air warming systems are routinely used before, during and after surgery to keep patients warm and to prevent complications from hypothermia. When perioperative practitioners use the system without attaching the blanket, the higher temperature air flow is concentrated on one area of the patient's body. Hosing has led to 1st, 2nd and even 3rd degree burns. In one particular case, the thermal injury progressed to a muscle necrosis so severe that it resulted in an above-the-knee amputation.

Forced-air warming systems have been safely used in over 35 million surgical procedures in the US. Maintenance of normal body temperature or normothermia is a realistic goal for practitioners. Forced-air warming is the de facto standard of care for maintaining patient normothermia in the US.

Warnings about the risk of hosing are provided in the leading manufacturer's manuals and on labels on the actual device. Hosing burns have occurred frequently enough to warrant the issuance of an ECRI Hazard Report, and to provide the impetus for a newly proposed Recommended Practice to the Association of periOperative Registered Nurses (AORN). In spite of these warnings, however, hosing still occurs. At the 2001 AORN annual convention, 18 percent of respondents to an informal survey indicated that hosing occurs at their facility.

Since forced-air warming is the most effective way to prevent and treat hypothermia in surgical patients, it is essential that all members of the surgical team are aware of the clinical and legal risks associated with misuse of the system.

Exploration of why hosing occurs
There are several theories about why professionals in the operating room may hose. Perhaps practitioners believe forced-air warming systems are low-tech and, therefore, low-risk to the patient. Or, maybe they do not know hosing can cause burns. Lack of knowledge about hypothermia and warming systems may seem unreasonable, but it may be the dominant reason behind the practice of hosing.

The most often stated reason for hosing is that practitioners are trying to cut costs by eliminating the expense of a disposable accessory – the blanket. In reports to ECRI and to manufacturers, perioperative staff said they did not want to unwrap a forced-air warming blanket until they were sure they needed it. In some cases, as the surgery progressed, and it became obvious that the patient was in need of warming, the staff could not position the blanket, as it is not meant to go on top of sterile drapes. So, in order to maintain sterility, they placed the hose of the warming unit under the drapes – and unintentionally burned patients.

One recent malpractice claim illustrates another theory. This case was brought against an anesthesiologist, the anesthesia group and the hospital. During trauma surgery on a 37-year-old male to repair multiple injuries sustained in a motor vehicle accident, a warming blanket (connected appropriately to a warming device) was placed across the upper extremities of the patient, but the hose from another warming unit was also placed between his legs. The circulating nurse was not individually named in the claim, but when deposed she stated that she placed the hose between the patient's legs at the request of the anesthesiologist. The patient suffered 2nd and 3rd degree burns to the inside aspect of both legs. This case remains in litigation.

Clinical risks
The warming unit is designed for use with the blanket attached to a hose in order to distribute warm air safely and evenly across a large a portion of the patient's body. The blankets are designed to distribute heated air uniformly across the skin, minimizing temperature differences and, thereby, reducing risk of thermal injury. The blankets also lower the temperature of the heated air because some of the heat is dissipated when the air moves through the blanket. Blanket air temperature is typically 2.0° to 5.5°C (3.6° to 10.0°F) lower than the temperature of the air from the hose.ii Therefore, failure to use the warming blanket decreases the efficiency of the warming system while significantly increasing the probability of thermal injury due to: concentrated hot air in one spot; elevated air temperature at hose nozzle from no back pressure of blanket attachment and contact between skin and the hose surface.

Legal risks
Securing FDA clearance of a medical device before marketing requires that the manufacturer provide reasonable assurance that the device is safe and effective. Safety and effectiveness are assessed with specific reference to the uses for which the device is intended, and then set forth in the instructions and labeling of the device. The use of forced-air warming systems without a warming blanket is a practice contrary to the FDA clearance.

Liability under a professional negligence theory may exist for the practitioner who uses equipment incorrectly. Misuse of warming systems that lead to burn injuries, therefore, increase liability risks for healthcare practitioners and their respective institutions. Saving the cost of a blanket – $10 or less in most cases – is hardly worth the risk.

How to combat hosing in your institution
Identification of actual or potential hosing risks in your operating room is the first step to reduce, and even eliminate, unnecessary injury to surgical patients. Find out if hosing occurs. Assume leadership for patient safety by promoting clinical education and behavioral change in perioperative practitioners. To help integrate patient safety activities and stop hosing in your institution: measure the prevalence of hosing; educate perioperative staff about hosing risks and evaluate your progress.

Avoiding hypothermia is a necessary clinical goal and forced-air warming is the most effective way to prevent and treat hypothermia in surgical patients. However, the improper use of these warming systems can cause serious harm to patients as well as place legal liability on the practitioner and institution. Patients have a right to expect safe care and certainly not to be injured. Perioperative practitioners must learn about the benefits of warming and the risks of hosing and must promote safe patient care by properly using forced-air warming systems.