Differences in Noninvasive Thermometer Measurements in the Adult Emergency Department Ryan P. Bodkin MD, MBA, Nicole M. Acquisto Pharm.D., Joshua M. Zwart MD, Sean P. Toussaint MD PII: DOI: Reference:
S0735-6757(14)00404-5 doi: 10.1016/j.ajem.2014.05.036 YAJEM 54319
To appear in:
American Journal of Emergency Medicine
Received date: Revised date: Accepted date:
5 March 2014 23 April 2014 24 May 2014
Please cite this article as: Bodkin Ryan P., Acquisto Nicole M., Zwart Joshua M., Toussaint Sean P., Differences in Noninvasive Thermometer Measurements in the Adult Emergency Department, American Journal of Emergency Medicine (2014), doi: 10.1016/j.ajem.2014.05.036
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT TITLE PAGE
T
Title:
RI P
Differences in Noninvasive Thermometer Measurements in the Adult Emergency Department
SC
Running Title:
NU
Noninvasive Temperature Measurements
MA
Authors: Ryan P. Bodkin, MD, MBA
ED
Assistant Professor, Department of Emergency Medicine
601 Elmwood Ave. Box 655
CE
Rochester, NY 14642
PT
University of Rochester Medical Center
AC
Nicole M. Acquisto, Pharm.D. (Corresponding Author)
Emergency Medicine Clinical Pharmacy Specialist, Department of Pharmacy Assistant Professor, Department of Emergency Medicine University of Rochester Medical Center 601 Elmwood Ave. Box 638 Rochester, NY 14642 Telephone: (585) 275-6147 Fax: (585) 756-5582 E-mail: [email protected] (e-mail address may be published)
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT
Joshua M. Zwart, MD
T
Instructor, Department of Emergency Medicine
RI P
University of Rochester Medical Center
SC
Sean P. Toussaint, MD Previous Affiliation:
NU
Department of Emergency Medicine
MA
University of Rochester Medical Center Current Affiliation:
Rutland Regional Medical Center
PT
Reprint requests:
ED
Attending Physician, Department of Emergency Medicine
Nicole M. Acquisto, Pharm.D.
CE
University of Rochester Medical Center
AC
601 Elmwood Ave. Box 638 Rochester, NY 14642
E-mail: [email protected] (e-mail address may be published)
Source of Support: None
Prior Presentations:
Society for Academic Emergency Medicine Annual Meeting. Oral Lightening Presentation. Atlanta, GA, May 2013.
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT
Society for Academic Emergency Medicine Annual Meeting. Gallery of Excellence Poster Session. Atlanta, GA, May 2013. NYS American College of Emergency Physicians Scientific Assembly. Bolton Landing, NY,
T
RI P
July 2013.
SC
Key Words:
AC
CE
PT
ED
MA
NU
Temperature, noninvasive thermometers, temporal artery thermometer, oral thermometer, fever
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT ABSTRACT
T
Purpose
RI P
Detection of accurate temperature in the emergency department (ED) is integral for assessment, treatment, and disposition. The primary objective was to compare temperature measurements
NU
the discrepancy between febrile and afebrile patients.
SC
from noninvasive temperature devices in the adult ED. The secondary objective was to evaluate
MA
Methods
This was a prospective, observational study of adult patients presenting to the ED. Patients that
ED
required a temperature measurement based on standard of care were included. Data collection
PT
included oral and temporal artery (TA) temperature measurement taken consecutively. Data
AC
Results
CE
were evaluated using the paired Student’s t-test.
One hundred patients were identified. Mean oral temperature was 37.51ºC (SD ± 1.25) and mean TA temperature was 37.03ºC (SD ± 0.94). The mean difference was 0.48ºC (SD ± 0.8), p < 0.0001. Overall, 49% of patients had a difference in temperature measurements ≥ 0.5ºC. There were 47 febrile patients; determined by a measurement > 38ºC on oral or TA thermometer. The mean temperature difference in these patients was 0.87ºC (SD ± 0.85) compared to a mean temperature difference of 0.12ºC (SD ± 0.55) in the afebrile patients, p < 0.0001. A total of 57% of fevers recorded by the oral thermometer were not recorded by the TA thermometer.
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT
Conclusions
T
There was a statistically significant difference in measured temperatures between oral and TA
RI P
thermometers and a clinically significant difference in 49% of patients. Febrile patients had a greater discrepancy and variability between noninvasive temperature measurements. Caution
AC
CE
PT
ED
MA
NU
SC
should be taken when evaluating temperature measurements with these noninvasive devices.
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT INTRODUCTION Detection of a patient’s accurate temperature in the emergency medicine setting is an integral
T
finding in the assessment, treatment and disposition of patients. In particular, temperature is one
RI P
of the four criteria used to establish a diagnosis of systemic inflammatory response syndrome (SIRS). Identifying patients that meet SIRS criteria is important since it can be an indicator for
SC
serious infection, end organ damage and ultimately severe sepsis or septic shock. The failure or
NU
delay in determining this diagnosis has been well documented to increase morbidity and
MA
mortality [1].
Based on human physiology, the most accurate temperature measurement is intracorporeal, most
ED
notably with a pulmonary artery thermometer in the intensive care unit or with a bladder
PT
thermometer in other in-patient hospital settings. Unfortunately, invasive monitoring is not always practical in the emergency department (ED) and especially during the initial triage and
CE
evaluation of the patient. There have been technological advancements in noninvasive
AC
temperature measuring devices that are routinely used in the ED to allow the nurses and providers to obtain a quick and easy temperature measurement during triage.
The two most common noninvasive temperature measurement devices in the ED at our institution are the oral and temporal artery (TA) thermometers. However, there was anecdotal concern by our providers in the accuracy of the temperature measurements obtained by these devices. We sought to compare oral and TA thermometer measurements to determine if there was a clinically significant discrepancy in the temperature measurements obtained by these devices in the adult ED.
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT METHODS Study Design
T
This was a prospective, observational study of adult patients presenting to triage in the ED. The
RI P
primary objective of the study was to compare temperature measurements from two, commonly used, noninvasive thermometer devices. These were the General Electric Dinamap ProCare 400
SC
Auscilatory monitor with oral temperature capabilities and the Exergen Infrared Temporal
NU
Scanner TAT-5000 TA temperature device [2,3]. Secondary objectives were to determine if there was a larger discrepancy between these devices in patients that were measured as febrile
PT
Study Setting and Population
ED
from the institutional review board.
MA
(defined as a temperature > 38oC) by one or both devices. Approval for this study was obtained
This study was conducted in the adult emergency department of an 800-bed university teaching
CE
hospital. A convenience sample of patients was captured at adult triage based on investigator
AC
availability. Patients were included if they required a temperature measurement by either device based on standard of care. Patients were excluded if routine use of the oral or TA thermometer devices was not possible due to their medical condition inhibiting proper use of the device.
Study Protocol Patients were screened and enrolled by three investigators at triage of the adult emergency department during clinical shifts. Demographic information including age and sex was included. Oral and TA temperature measurements were obtained consecutively (within 1 minute) by one investigator and recorded. Our goal was to collect 50 afebrile patients and 50 febrile patients to
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT evaluate a diverse range of temperatures. This would allow us to accurately access our secondary outcome as well. We were able to capture febrile patients specifically by having the
T
nurse contact one of the investigators during their clinical shift if a febrile reading occurred at
RI P
triage by a noninvasive temperature device. The investigator was then able to obtain the
SC
consecutive oral and TA temperatures.
NU
Data Analysis
A clinically significant temperature difference between devices was defined a priori as ≥ 0.5oC.
MA
This temperature difference was defined following discussion with the emergency medicine research group that consists of experienced emergency medicine physicians. We estimated that a
ED
sample of 100 patients would provide 90% power to detect a 0.5oC difference in temperature
PT
between the oral and TA thermometer devices with a 2-sided alpha level of 0.05.
CE
Demographic data are reported with descriptive statistics. The primary and secondary outcome
AC
measures are reported as a mean difference in temperature and evaluated using the paired Student’s t test [Microsoft. (2007). Microsoft Excel [computer software]. Redmond, Washington: Microsoft]. Statistical significance was defined a priori as a p value ≤ 0.05.
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT RESULTS A total of 100 patients were identified during the study. There were 55 males and 45 females
T
with a mean age of 49 years (SD 19). Mean oral temperature was 37.51ºC (SD ± 1.25) and
RI P
mean TA temperature was 37.03ºC (SD ± 0.94). The mean difference was 0.48ºC (SD ± 0.8), p < 0.0001. Overall, there were 49% of patients that were detected to have a clinically significant
NU
SC
temperature difference of ≥ 0.5ºC between the two devices.
Patients were separated into two groups, those that were febrile (n = 47) and those that were
MA
afebrile (n = 53). The mean temperature difference in the febrile group was 0.87ºC (SD ± 0.85) compared to a mean temperature difference of 0.12ºC (SD ± 0.55) in the afebrile patients, p
38oC)
CE
on at least one noninvasive device. These data caution providers to utilize all objective and
Limitations
AC
subjective information in conjunction with these measurements during patient evaluations.
These results are not without limitations. The main limitation is that we were not able to determine which noninvasive temperature device was the most accurate. It was not feasible in our setting to obtain a core temperature at triage. However, we felt that comparing these two devices, with a reported accuracy of ± 0.1oC, to each other, would provide useful information about anecdotal concerns from our providers that already existed in regards to these devices [2,3]. Another limitation is that three different investigators performed temperature
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT measurements, which could create variability in the technique of temperature measurement and could affect the results. We tried to limit the variability by having each investigator read the
T
instruction manual for both devices and also receive a demonstration from the ED clinical
AC
CE
PT
ED
MA
NU
SC
RI P
facilities administrator prior to the start of the study.
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT CONCLUSION There was a statistical difference in recorded temperatures between oral and TA thermometers
T
and a clinically significant difference in 49% of patients. Febrile patients had a greater
RI P
discrepancy, almost 1oC, between noninvasive temperature measurements compared to those that were afebrile. These data caution providers to utilize all objective and subjective information in
AC
CE
PT
ED
MA
NU
SC
conjunction with these measurements during patient evaluations.
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT REFERENCES 1. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of
RI P
T
severe sepsis and septic shock. N Engl J Med 2001;345:1368-1377.
2. Med-Electronics.com. Taylor-Med, Inc.
SC
http://www.medelectronics.com/GE_DINAMAP_ProCare_420_Monitor_p/1424.htm.
MA
3. Exergen.com. Exergen Corporation.
NU
Accessed February 7, 2012.
http://exergencorporation.web.officelive.com/Documents/Specifications%20TAT-
PT
ED
5000%20REV%203.pdf. Accessed February 7, 2012.
4. Fulbrook P: Core body temperature measurement: a comparison of axilla, tympanic
AC
272.
CE
membrane and pulmonary artery blood temperature. Int Crit Care Nurs 1997;13:266–
5. Teran CG, Torrez-Llanos J, Teran-Miranda TE, et al. Clinical accuracy of a non-contact infrared skin thermometer in paediatric practice. Child Care Health Development 2012;38:471-476.
6. Batra P, Goyal S. Comparison of rectal, axillary, tympanic, and temporal artery thermometry in the pediatric emergency room. Pediatr Emerg Care 2013;29:63-66.
Noninvasive Temperature Measurements
S0735-6757(14)00404-5 doi: 10.1016/j.ajem.2014.05.036 YAJEM 54319
To appear in:
American Journal of Emergency Medicine
Received date: Revised date: Accepted date:
5 March 2014 23 April 2014 24 May 2014
Please cite this article as: Bodkin Ryan P., Acquisto Nicole M., Zwart Joshua M., Toussaint Sean P., Differences in Noninvasive Thermometer Measurements in the Adult Emergency Department, American Journal of Emergency Medicine (2014), doi: 10.1016/j.ajem.2014.05.036
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT TITLE PAGE
T
Title:
RI P
Differences in Noninvasive Thermometer Measurements in the Adult Emergency Department
SC
Running Title:
NU
Noninvasive Temperature Measurements
MA
Authors: Ryan P. Bodkin, MD, MBA
ED
Assistant Professor, Department of Emergency Medicine
601 Elmwood Ave. Box 655
CE
Rochester, NY 14642
PT
University of Rochester Medical Center
AC
Nicole M. Acquisto, Pharm.D. (Corresponding Author)
Emergency Medicine Clinical Pharmacy Specialist, Department of Pharmacy Assistant Professor, Department of Emergency Medicine University of Rochester Medical Center 601 Elmwood Ave. Box 638 Rochester, NY 14642 Telephone: (585) 275-6147 Fax: (585) 756-5582 E-mail: [email protected] (e-mail address may be published)
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT
Joshua M. Zwart, MD
T
Instructor, Department of Emergency Medicine
RI P
University of Rochester Medical Center
SC
Sean P. Toussaint, MD Previous Affiliation:
NU
Department of Emergency Medicine
MA
University of Rochester Medical Center Current Affiliation:
Rutland Regional Medical Center
PT
Reprint requests:
ED
Attending Physician, Department of Emergency Medicine
Nicole M. Acquisto, Pharm.D.
CE
University of Rochester Medical Center
AC
601 Elmwood Ave. Box 638 Rochester, NY 14642
E-mail: [email protected] (e-mail address may be published)
Source of Support: None
Prior Presentations:
Society for Academic Emergency Medicine Annual Meeting. Oral Lightening Presentation. Atlanta, GA, May 2013.
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT
Society for Academic Emergency Medicine Annual Meeting. Gallery of Excellence Poster Session. Atlanta, GA, May 2013. NYS American College of Emergency Physicians Scientific Assembly. Bolton Landing, NY,
T
RI P
July 2013.
SC
Key Words:
AC
CE
PT
ED
MA
NU
Temperature, noninvasive thermometers, temporal artery thermometer, oral thermometer, fever
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT ABSTRACT
T
Purpose
RI P
Detection of accurate temperature in the emergency department (ED) is integral for assessment, treatment, and disposition. The primary objective was to compare temperature measurements
NU
the discrepancy between febrile and afebrile patients.
SC
from noninvasive temperature devices in the adult ED. The secondary objective was to evaluate
MA
Methods
This was a prospective, observational study of adult patients presenting to the ED. Patients that
ED
required a temperature measurement based on standard of care were included. Data collection
PT
included oral and temporal artery (TA) temperature measurement taken consecutively. Data
AC
Results
CE
were evaluated using the paired Student’s t-test.
One hundred patients were identified. Mean oral temperature was 37.51ºC (SD ± 1.25) and mean TA temperature was 37.03ºC (SD ± 0.94). The mean difference was 0.48ºC (SD ± 0.8), p < 0.0001. Overall, 49% of patients had a difference in temperature measurements ≥ 0.5ºC. There were 47 febrile patients; determined by a measurement > 38ºC on oral or TA thermometer. The mean temperature difference in these patients was 0.87ºC (SD ± 0.85) compared to a mean temperature difference of 0.12ºC (SD ± 0.55) in the afebrile patients, p < 0.0001. A total of 57% of fevers recorded by the oral thermometer were not recorded by the TA thermometer.
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT
Conclusions
T
There was a statistically significant difference in measured temperatures between oral and TA
RI P
thermometers and a clinically significant difference in 49% of patients. Febrile patients had a greater discrepancy and variability between noninvasive temperature measurements. Caution
AC
CE
PT
ED
MA
NU
SC
should be taken when evaluating temperature measurements with these noninvasive devices.
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT INTRODUCTION Detection of a patient’s accurate temperature in the emergency medicine setting is an integral
T
finding in the assessment, treatment and disposition of patients. In particular, temperature is one
RI P
of the four criteria used to establish a diagnosis of systemic inflammatory response syndrome (SIRS). Identifying patients that meet SIRS criteria is important since it can be an indicator for
SC
serious infection, end organ damage and ultimately severe sepsis or septic shock. The failure or
NU
delay in determining this diagnosis has been well documented to increase morbidity and
MA
mortality [1].
Based on human physiology, the most accurate temperature measurement is intracorporeal, most
ED
notably with a pulmonary artery thermometer in the intensive care unit or with a bladder
PT
thermometer in other in-patient hospital settings. Unfortunately, invasive monitoring is not always practical in the emergency department (ED) and especially during the initial triage and
CE
evaluation of the patient. There have been technological advancements in noninvasive
AC
temperature measuring devices that are routinely used in the ED to allow the nurses and providers to obtain a quick and easy temperature measurement during triage.
The two most common noninvasive temperature measurement devices in the ED at our institution are the oral and temporal artery (TA) thermometers. However, there was anecdotal concern by our providers in the accuracy of the temperature measurements obtained by these devices. We sought to compare oral and TA thermometer measurements to determine if there was a clinically significant discrepancy in the temperature measurements obtained by these devices in the adult ED.
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT METHODS Study Design
T
This was a prospective, observational study of adult patients presenting to triage in the ED. The
RI P
primary objective of the study was to compare temperature measurements from two, commonly used, noninvasive thermometer devices. These were the General Electric Dinamap ProCare 400
SC
Auscilatory monitor with oral temperature capabilities and the Exergen Infrared Temporal
NU
Scanner TAT-5000 TA temperature device [2,3]. Secondary objectives were to determine if there was a larger discrepancy between these devices in patients that were measured as febrile
PT
Study Setting and Population
ED
from the institutional review board.
MA
(defined as a temperature > 38oC) by one or both devices. Approval for this study was obtained
This study was conducted in the adult emergency department of an 800-bed university teaching
CE
hospital. A convenience sample of patients was captured at adult triage based on investigator
AC
availability. Patients were included if they required a temperature measurement by either device based on standard of care. Patients were excluded if routine use of the oral or TA thermometer devices was not possible due to their medical condition inhibiting proper use of the device.
Study Protocol Patients were screened and enrolled by three investigators at triage of the adult emergency department during clinical shifts. Demographic information including age and sex was included. Oral and TA temperature measurements were obtained consecutively (within 1 minute) by one investigator and recorded. Our goal was to collect 50 afebrile patients and 50 febrile patients to
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT evaluate a diverse range of temperatures. This would allow us to accurately access our secondary outcome as well. We were able to capture febrile patients specifically by having the
T
nurse contact one of the investigators during their clinical shift if a febrile reading occurred at
RI P
triage by a noninvasive temperature device. The investigator was then able to obtain the
SC
consecutive oral and TA temperatures.
NU
Data Analysis
A clinically significant temperature difference between devices was defined a priori as ≥ 0.5oC.
MA
This temperature difference was defined following discussion with the emergency medicine research group that consists of experienced emergency medicine physicians. We estimated that a
ED
sample of 100 patients would provide 90% power to detect a 0.5oC difference in temperature
PT
between the oral and TA thermometer devices with a 2-sided alpha level of 0.05.
CE
Demographic data are reported with descriptive statistics. The primary and secondary outcome
AC
measures are reported as a mean difference in temperature and evaluated using the paired Student’s t test [Microsoft. (2007). Microsoft Excel [computer software]. Redmond, Washington: Microsoft]. Statistical significance was defined a priori as a p value ≤ 0.05.
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT RESULTS A total of 100 patients were identified during the study. There were 55 males and 45 females
T
with a mean age of 49 years (SD 19). Mean oral temperature was 37.51ºC (SD ± 1.25) and
RI P
mean TA temperature was 37.03ºC (SD ± 0.94). The mean difference was 0.48ºC (SD ± 0.8), p < 0.0001. Overall, there were 49% of patients that were detected to have a clinically significant
NU
SC
temperature difference of ≥ 0.5ºC between the two devices.
Patients were separated into two groups, those that were febrile (n = 47) and those that were
MA
afebrile (n = 53). The mean temperature difference in the febrile group was 0.87ºC (SD ± 0.85) compared to a mean temperature difference of 0.12ºC (SD ± 0.55) in the afebrile patients, p
38oC)
CE
on at least one noninvasive device. These data caution providers to utilize all objective and
Limitations
AC
subjective information in conjunction with these measurements during patient evaluations.
These results are not without limitations. The main limitation is that we were not able to determine which noninvasive temperature device was the most accurate. It was not feasible in our setting to obtain a core temperature at triage. However, we felt that comparing these two devices, with a reported accuracy of ± 0.1oC, to each other, would provide useful information about anecdotal concerns from our providers that already existed in regards to these devices [2,3]. Another limitation is that three different investigators performed temperature
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT measurements, which could create variability in the technique of temperature measurement and could affect the results. We tried to limit the variability by having each investigator read the
T
instruction manual for both devices and also receive a demonstration from the ED clinical
AC
CE
PT
ED
MA
NU
SC
RI P
facilities administrator prior to the start of the study.
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT CONCLUSION There was a statistical difference in recorded temperatures between oral and TA thermometers
T
and a clinically significant difference in 49% of patients. Febrile patients had a greater
RI P
discrepancy, almost 1oC, between noninvasive temperature measurements compared to those that were afebrile. These data caution providers to utilize all objective and subjective information in
AC
CE
PT
ED
MA
NU
SC
conjunction with these measurements during patient evaluations.
Noninvasive Temperature Measurements
ACCEPTED MANUSCRIPT REFERENCES 1. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of
RI P
T
severe sepsis and septic shock. N Engl J Med 2001;345:1368-1377.
2. Med-Electronics.com. Taylor-Med, Inc.
SC
http://www.medelectronics.com/GE_DINAMAP_ProCare_420_Monitor_p/1424.htm.
MA
3. Exergen.com. Exergen Corporation.
NU
Accessed February 7, 2012.
http://exergencorporation.web.officelive.com/Documents/Specifications%20TAT-
PT
ED
5000%20REV%203.pdf. Accessed February 7, 2012.
4. Fulbrook P: Core body temperature measurement: a comparison of axilla, tympanic
AC
272.
CE
membrane and pulmonary artery blood temperature. Int Crit Care Nurs 1997;13:266–
5. Teran CG, Torrez-Llanos J, Teran-Miranda TE, et al. Clinical accuracy of a non-contact infrared skin thermometer in paediatric practice. Child Care Health Development 2012;38:471-476.
6. Batra P, Goyal S. Comparison of rectal, axillary, tympanic, and temporal artery thermometry in the pediatric emergency room. Pediatr Emerg Care 2013;29:63-66.
Noninvasive Temperature Measurements
