Naval Hospital Twentynine Palms nurse earns RADM Elizabeth S. Niemyer Award for advancing patient safety

Story by Christopher Jones

Naval Hospital Twentynine Palms

Lt. Cmdr. Joseph “Joey” Biddix, a perioperative nurse and Division Officer of the Sterile Processing Department at Naval Hospital Twentynine Palms (NHTP) from June 2022 to June 2023, has been honored with a 1st place finish in the Navy Nurse Corps’ RADM Elizabeth S. Niemyer Award for Evidence-Based Practice. His award-winning project, Tackling Intraoperative Hypothermia: Implementing a Prewarming Protocol at a Remote Military Treatment Facility, showcased the successful implementation of a prewarming protocol at NHTP, beginning in June 2023.

The RADM Elizabeth S. Niemyer Award celebrates Navy nurses who significantly enhance the nursing profession through evidence-based practice (EBP) projects. Winners are recognized for their dedication to improving clinical outcomes, advancing professional nursing practices, and prioritizing patient care. Biddix’s achievement exemplifies the impact of applying research to real-world challenges in military healthcare settings.

Intraoperative Hypothermia (IH), defined as a drop in core body temperature below 36°C during surgery, poses a significant risk to patient safety. It can lead to adverse outcomes such as increased bleeding, heightened risk of surgical site infections, and worsened postoperative pain. While standard warming measures like Bair Hugger devices and warmed intravenous fluids are commonly used in operating rooms, Biddix noticed these interventions were insufficient for many patients at NHTP.

“Maintaining normothermia during surgery is a collaborative effort of the whole perioperative team,” Biddix explained. “However, I observed that despite employing standard warming measures, many of our patients were still experiencing hypothermia during surgery.”

This observation prompted Biddix to investigate potential solutions, drawing inspiration from his previous experience at Walter Reed National Military Medical Center. There, he recalled a fellow nurse attempting to launch a prewarming initiative. Intrigued by the concept, Biddix conducted a thorough literature review to evaluate the feasibility of implementing a similar protocol at NHTP.

“Prewarming has been studied for many years and has consistently been shown to be a safe and effective intervention for preventing intraoperative hypothermia,” Biddix said. “However, it’s not yet common practice, partly because research often takes up to 17 years to transition into widespread clinical application.”

To ensure the success of the project, Biddix selected the Johns Hopkins Model for Evidence-Based Practice (EBP) to guide the initiative. This framework emphasizes the importance of a structured approach, including a comprehensive review of existing research, stakeholder engagement, and measurable outcomes.

One of the key steps in the project was conducting a stakeholder analysis to identify and engage all necessary team members. Biddix brought together perioperative nurses, anesthesia providers, and preoperative corpsmen, ensuring their voices were heard and their concerns addressed.

“Many quality improvement projects fail because leaders don’t engage the right people early on,” Biddix explained. “When I met with the corpsmen in pre-op, I explained what IH is and why it’s a problem. Once they understood the negative outcomes associated with IH, they were more engaged and motivated to be part of the solution.”

The team then developed a prewarming protocol that utilized existing equipment, such as forced-air warming blankets, avoiding additional costs. By incorporating the new protocol into the corpsmen’s existing workflows, Biddix ensured the intervention was efficient and minimally disruptive.

“We didn’t want to create a process that was burdensome or added too many steps to what they were already doing,” Biddix explained. “Simplicity and integration into existing workflows were critical to the project’s success.”

To monitor the project’s impact, the team established both process and outcome measures. Process measures included ensuring prewarming was provided to the appropriate patients for at least 30 minutes before surgery and documenting key details, such as start times and patient refusals. Outcome measures focused on tracking rates of IH, its duration, and patients’ temperature trends compared to historical data.

“The ability to measure progress is essential,” Biddix emphasized. “You can’t know if your project is working without clearly defined metrics.”

Within two weeks of launching the protocol, the team achieved 100% compliance. The results were remarkable: the rate of intraoperative hypothermia dropped by 42.8%, and patients who still experienced IH had shorter episodes and recovered to normothermia more quickly.

“Additionally, prewarmed patients had better temperatures upon arrival to the Post-Anesthesia Care Unit (PACU),” Biddix said. “This not only improved patient safety but also boosted the corpsmen’s confidence in their ability to make a meaningful difference in patient outcomes.”

As with any quality improvement initiative, the project faced initial challenges. One significant hurdle was ensuring staff consistently remembered to implement prewarming and document it properly. Biddix addressed this by being present at the start of each day to observe and provide real-time feedback.

NHTP’s small size and remote location also posed unique challenges. However, Biddix saw this as an opportunity rather than a limitation.

“The facility’s size allows for manageable, impactful projects,” Biddix explained.

The success of Biddix’s project earned him the RADM Elizabeth S. Niemyer Award, highlighting the impact of his efforts on patient care and clinical practice. The protocol has also attracted attention beyond NHTP; it was submitted to the Association of periOperative Registered Nurses (AORN) Journal, where it is currently under review for publication.

“If published, I hope other facilities implement our protocol,” Biddix said. “Disseminating quality improvement projects is vital for advancing nursing practice and sharing lessons learned across the healthcare community.”

Now stationed with Fleet Surgical Team Nine in San Diego, Biddix continues to champion evidence-based practice in perioperative nursing. Reflecting on his experience at NHTP, he encourages other Navy nurses to embrace the opportunities provided by smaller facilities to innovate and improve care.

“Even though NHTP is remote, it’s a great place to take on meaningful projects,” Biddix said. “If there’s a process you wish was smoother or a safety concern you want to address, take on the challenge. You might be surprised by the difference you can make.”

Biddix’s work serves as an example of how evidence-based practice can transform patient outcomes, even in resource-limited settings. His commitment to patient safety, innovation, and teamwork possibly helps set a standard of excellence for military healthcare providers.