Journal of Neuroscience Nursing:
Fever Management Practices of Neuroscience Nurses: National and Regional Perspectives
Thompson, Hilaire J.; Kirkness, Catherine J.; Mitchell, Pamela H.; Webb, Deborah J.
Questions or comments about this article may be directed to Hilaire J. Thompson, PhD APRN BC CNRN, at firstname.lastname@example.org. She is a Claire M. Fagin Fellow, John A. Hartford Foundation, National Institutes of Health Roadmap Multidisciplinary Clinical Research Scholar and assistant professor at the School of Nursing at the University of Washington, Seattle, WA.
Catherine J. Kirkness, PhD RN, is a research associate professor at the School of Nursing at the University of Washington, Seattle, WA.
Pamela H. Mitchell, PhD RN CNRN FAAN FAHA, is a Soule Distinguished Professor and associate dean for research at the School of Nursing at the University of Washington, Seattle, WA.
Deborah J. Webb, MSN RN CNRN, is a clinical nurse specialist at Harborview Medical Center, Seattle, WA.
Neuroscience patients with fever may have worse outcomes than those who are afebrile. However, neuroscience nurses who encounter this common problem face a translational gap between patient‐outcomes research and bedside practice because there is no current evidence‐based standard of care for fever management of the neurologically vulnerable patient. The aim of this study was to determine if there are trends in national practices for fever and hyperthermia management of the neurologically vulnerable patient. A 15‐item mailed questionnaire was used to determine national and regional trends in fever and hyperthermia management and decision making by neuroscience nurses. Members of the American Association of Neuroscience Nurses were surveyed (N = 1,225) and returned 328 usable surveys. Fewer than 20% of respondents reported having an explicit fever management protocol in place for neurologic patients, and 12.5% reported having a nonspecific patient protocol available for fever management. Several clear and consistent patterns in interventions for fever and hyperthermia management were seen nationally, including acetaminophen administration at a dose of 650 mg every 4 hours, ice packs, water cooling blankets, and tepid bathing. However, regional differences were seen in intervention choices and initial temperature to treat.
Both adult and pediatric traumatic brain injury (TBI) guidelines state that maintenance of normothermia should be a standard of care (Brain Trauma Foundation/American Association of Neurologic Surgeons, 2000; Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2003). However, the guidelines give no further standards or options to specifically guide practice. Current ischemic stroke guidelines state that fever should be treated with antipyretic agents and offer “cooling devices” as an option, but they do not provide specifics to guide practice (Adams et al., 2003). There continues to be an undertreatment of fever in patients with neurologic insults (Albrecht, Wass, & Lanier, 1998; Kilpatrick, Lowery, Firlik, Yonas, & Marion, 2000) despite our knowledge of the association between fever and poor outcome. Regardless of whether a protocol is in place, the bedside nurse is the primary decision maker for instituting antipyretic interventions (Kilpatrick et al.; O'Donnell, Axelrod, Fisher, & Lorber, 1997). Therefore, it is important to better understand the perspectives of neuroscience nurses across the United States regarding use of fever protocols and their independent clinical decision making in fever management. This article reports the first findings from a study of trends and differences in national and regional practices for fever management in neurologically vulnerable patients.
Significance of Fever in Neurologically Vulnerable Patients
A recent review of the TBI literature revealed that 70%‐100% of TBI patients experienced fever during their hospital stay (McIlvoy, 2005). However, traditional measures for management were largely ineffective, reducing temperature in as few as 7% of TBI patients (Albrecht et al., 1998). Similar difficulties in managing body temperature are reported in acute stroke patients, where 38% of ischemic and >50% of hemorrhagic stroke patients have been reported to experience fever (Kilpatrick et al., 2000). In patients with stroke, TBI, or intracerebral hemorrhage, the presence of hyperthermia or fever has been associated with worse outcomes, including larger infarct volumes, increased length of stay, lower Glasgow Coma Scale scores at time of transfer from the ICU, lower Glasgow Outcome Scores, and higher mortality rates (Castillo, Davalos, Marrugat, & Noya, 1998; Hajat, Hajat, & Sharma, 2000; Jiang, Gao, Li, Yu, & Zhu, 2002; Natale, Joseph, Helfaer, & Schaffner, 2000; Schwartz, Hafner, Aschoff, & Schwab, 2000). Thus, temperature management in neurologically vulnerable patients is both a prevalent and problematic challenge facing neuroscience nurses.
Fever Management Strategies in Neurologically Vulnerable Patients
The negative effect of hyperthermia and fever on outcome for neurologically vulnerable patients, coupled with the suboptimal management of fever in these patients, has led various investigators to seek innovative therapies to add to the current arsenal (Andrews, Harris, & Murray, 2005; Diringer, 2004; Marion, 2004; Mayer et al., 2001; Mayer et al., 2004). However, a paucity of evidence is available to refute the effectiveness of traditional therapies, and few of these have been applied in systematic, prospective trials (Cairns & Andrews, 2002; Price, McGloin, Izzard, & Gilchrist, 2003). Although clinical trials of new therapies have used currently available therapies as controls, the current therapies were often not used appropriately (e.g., incorrect use of cooling blankets [Polderman, 2004b; Thompson, 2005]) and thus, comparisons of new therapies with conventional therapies may be flawed and misleading. Taken together, the lack of a solid evidence base upon which to develop fever‐management protocols for neurologically vulnerable patients, such as those with TBI and stroke, is particularly disturbing given the negative effect of fever on outcomes.
The situation is further complicated because there is no clear definition of fever within the discipline of nursing. In each of three recent descriptive, exploratory studies (Edwards, Courtney, Wilson, Monaghan, & Walsh, 2001; Emmouth & Mansson, 1997; Grossman, Keen, Singer, & Asher, 1995), the authors found a lack of consistency in the way nurses described who was febrile and when patients with fevers should be treated. Both Grossman et al. and Edwards et al. reported that the body temperatures at which nurses considered a patient to be febrile or began treatment ranged from 37.2 °C to >39 °C.
These variations in definition may account for findings that 14% of neurologically vulnerable febrile patients did not receive any intervention and that some patients received only nonpharmacologic intervention, despite the presence of a management protocol specifying a first‐tier pharmacologic therapy (Kilpatrick et al., 2000). Grossman et al. evaluated nursing practices in the care of febrile patients on a mixed acute care unit and found that only 59% of patients experiencing fever were treated appropriately by nurses. These findings were recently reinforced by pilot work by the present investigators, which found that <50% of febrile episodes were adequately treated in the first week following TBI (Thompson, Kirkness, & Mitchell, 2007).
Because practice guidelines exist, in part, to standardize care across geographic boundaries (Stewart‐Amidei, 2006), gaining a firsthand understanding of neuroscience nurses' knowledge and practices in the United States is an important first step to ensuring that specific practice guidelines for neuroscience patients with fever are developed and followed.
A survey design was used to determine how nurses choose fever management interventions as well as what trends exist in the United States in patient practices for fever and hyperthermia management of the neurologically vulnerable patient. Data on institution, patient age characteristics, and hospital and nursing fever management practices were collected in an attempt to determine current national practices. In addition, regional (based on 4 census regions) practices were examined. A geographic identifier (state) was present on the survey to assist with promoting regional return rates; however no personal identifying data were present to link the participant to the survey. Participation was invited from members of the American Association of Neuroscience Nurses (AANN), whose mission is “the advancement of neuroscience nursing as a specialty through the development and support of nurses to promote excellence in patient care” (AANN, n.d.). By using this specialty organization, the investigators hoped to maximize response from nurses involved in providing day‐to‐day care to patients with neurologic insults such as stroke and TBI. Institutional review board approval was obtained for this study.
Sample, Setting, and Procedures
Partipants were drawn from the membership of AANN, which, at the time of the study, numbered more than 3,000. At the time of the study, approximately 2,400 members were on the active mailing list, which is organized in ascending zip code order. Questionnaires were sent to every other U.S. address on the AANN mailing list (N = 1,225). At 8 weeks following the initial mailing, survey return rates were examined for overall rates of return and geographic representation. No corrective action was necessary at that time. At 12 weeks, data entry and analysis began. Any survey returned after 12 weeks was not included in the analysis. In total, 328 usable responses were received (27% return).
A 15‐item questionnaire was mailed with a cover letter to participants. The survey had been piloted with nurses who were not members of AANN to determine its face and construct validity. Since participation was voluntary and anonymous, return of the survey via the accompanying self‐addressed, stamped enveloped was deemed consent.
Information was collected on type and size of practice institution, state of residence, and age range of patients for whom care is provided. Respondents were asked whether their institution has an explicit fever management protocol for neurologically vulnerable patients, and if so, at what temperature the protocol calls for treatment. Respondents were then asked to select from an available list which interventions they use as well as the order of their use. This process was repeated for unit‐ or hospital‐based fever management protocols and for nurse‐initiated management. An open‐ended question was included at the end of the survey to allow respondents to add comments that they felt were germane to the issue.
Data were coded and entered into a statistical analysis program (SPSS, Chicago, IL) to facilitate pairwise comparisons of descriptive statistics, practice patterns, and geographic regions. State of residence, as specified by respondents, had been recoded into region (Northeast, South, Midwest, West) using the U.S. Bureau of the Census (n.d.) breakdown. Simple totals and percentage of practices performed regionally were used to describe fever management for both institutional protocols and individual clinical decision making.
To reduce type I error due to the large number of tests performed, individual management strategies were not compared across regions unless the national use of the intervention was significant. In that case, Fisher's exact test or regression analysis was performed as indicated, and if significant, post hoc testing was performed. Data are presented as means plus standard deviation, with p < .05 considered statistically significant.
The characteristics of the practice environments of respondents (N = 328) are summarized in Table 1. The majority of surveys were returned by AANN members practicing in an academic medical center (68%) or in community hospitals (22%) that care for either adults only (72%) or a mix of adult and pediatric patients (21%). These findings were similar across the geographic regions (nonsignificant differences). The primary responders to the survey were staff nurses (59%), followed by clinical nurse specialists (11%) and nurse practitioners (10%; Fig 1). The primary nursing roles of survey respondents did not differ significantly across regions.
Neuro‐Speci. c Protocols
Only 62 respondents (19%) reported having a fever and hyperthermia management protocol specifically targeted to neuroscience patients. The West had the highest percentage of respondents reporting such neuro‐specific protocols (24%), while the South had the lowest (16%).
Nationally, the temperature at which protocols specified treatment should begin ranged widely from 37 °C (98.6 °F) to 40 °C (104 °F). The difference in treatment initiation temperature was significant via analysis of variance (F = 3.551, df = 3, p < .05), with the Midwest significantly higher than the Northeast and the West (p < .05; Table 2). All protocols included use of acetaminophen, although the dose and frequency varied (Table 2). Other common interventions found in neuro‐specific fever and hyperthermia management protocols included water cooling blankets (50%), ice packs (47%), use of circulating fans (39%), tepid bathing (31%), and ibuprofen administration (23%; Table 2).
Overall, respondents across regions reported using most interventions similarly; however, a few significant differences existed. In the Midwest, neuroscience nurses responded that ibuprofen was administered to neurologic patients with fever as part of a specific protocol more frequently than did respondents from other regions (Table 2). Neuroscience nurses from the Northeast were less likely than respondents from other regions to have protocols that included the use of ice packs. Tepid bathing was less likely to be included in neuro‐specific fever and hyperthermia management protocols in the Northeast and West. In the West, neuro‐specific management protocols are more likely than in other regions to include fans and are less likely to include an intravascular cooling device (Table 2).
Unit‐ or Hospital‐Speci. c Fever Management Protocols
Of respondents who stated there is a unit or hospital fever management protocol available (not specific to neurologically vulnerable patients; n = 40), the mean temperature at which protocols begin intervention is 38.4 ± 0.3 °C. This temperature did not significantly vary by region (Table 3). Acetaminophen was reported to be incorporated into protocols 80% of the time and was the most common intervention, followed by ice packs (43%), water cooling blankets (40%), and ibuprofen administration (30%). Two other medications, ketorolac and indomethacin, both nonsteroidal antiinflammatory drugs (NSAIDs), were listed by one respondent as being part of the unit or hospital protocols for fever management (Table 3). Tepid bathing was again less likely to be included in protocols from the Northeast, and circulating water cooling pads were less likely to be used in both the Northeast and Midwest (Table 3).
Individual Management of Fever and Hyperthermia in Patients with Neurologic Insults
Neuroscience nurses' responses to the question “At what temperature do you personally begin to treat fever/hyperthermia in neurologically vulnerable patients?” varied widely from 37 °C to 39.4 °C (Table 4). In all regions, the primary rationale for choosing this temperature was provider orders (47%); this percentage, although higher in the West (55%) than in other regions (Table 4), was not significant. Other rationales for choosing a treatment temperature were generally a combination of two or more of the listed rationales. No significant association between individual choice of treatment temperature and the stated rationale was seen (Fig 2).
Pharmacologic intervention was the most frequently reported intervention of choice nationally, with acetaminophen being used most commonly to treat fever and hyperthermia in neurologically vulnerable patients (Table 4). Respondents from the Midwest were significantly more likely to report using ibuprofen as part of their own treatment strategies than respondents from other regions (13.58, df = 3, p < .01; Table 4). Although the various agents differed, NSAIDs other than ibuprofen were reported as being used by those surveyed.
Of nonpharmacologic interventions used by neuroscience nurses to treat fever and hyperthermia in patients with neurologic insults, the primary interventions of choice were ice packs and water cooling blankets (both 60%), followed by circulating fans (49%) and tepid bathing (36%; Table 4). There were regional differences in respondents' choices of interventions. Neuroscience nurses in the Northeast were significantly less likely to use a fan to treat fever and hyperthermia, while their counterparts in the West were significantly more likely to use one, compared with respondents in the other two regions (12.1, df = 3, p < .01; Table 4).
Additional Open‐Ended Responses
Respondents had the opportunity to note any additional information in an open‐ended question at the end of the survey. The most frequent comments from respondents indicated that they
* are interested in a protocol for fever management (n = 12)
* do not believe that fever is treated aggressively enough or that nurses intervene early enough (n = 9)
* have implemented educational changes on unit for temperature management of neuroscience patients (n = 7).
Five respondents noted that fever management protocols were currently in development in their institutions. Also of note, four of the survey respondents commented that the route of temperature measurement was important to consider when making treatment decisions.
Several clear and consistent patterns in the use of interventions for fever and hyperthermia management were seen across regions, including acetaminophen administration at a dose of 650 mg every 4 hours, ice packs, water cooling blankets, and tepid bathing. Because 100% of respondents with a neuro‐specific protocol reported that acetaminophen (antipyretic) was being used, current practice is consistent with national guidelines in this regard (Adams et al., 2003).
For TBI patients, the AANN Core Curriculum for Neuroscience Nursing states that fever should be treated aggressively, recommends acetaminophen and cooling blankets, and lists ice packs, intravascular cooling devices, and gastric lavage as other options (March et al., 2004). In our survey we found that both acetaminophen and water cooling blankets are being used consistently, as are ice packs; thus, these could be considered the standard of care. However, a difference may exist between a generally accepted standard of care and evidence‐based care.
One example of this can be seen in the proper use of cooling blankets with neuroscience patients, which has been much discussed (Polderman, 2004b; Thompson, 2005). Blanket temperatures are often set at the lowest setting, which may induce shivering because of the increased temperature gradient (Sund‐Levander & Wahren, 2000) and thereby increase cerebral oxygen metabolism. In the only study to date that has examined multiple blanket temperatures, a warmer temperature (24 °C versus 7 °C) was as efficacious in reducing fever and provided optimal comfort (Caruso, Hadley, Shukula, Frame, & Khoury, 1992); however, both institutional protocols and individual nursing decisions often do not reflect this finding.
Another intervention not mentioned by any respondent is the use of protective wraps on the hands, feet, and groin to prevent shivering when using cooling blankets (Holtzclaw, 1992). Such protective wraps should be considered for inclusion in fever management protocols and future studies. In addition, it is unclear whether a higher dose of acetaminophen (1 g every 4 hours) should be the standard of care for patients with neurologic insults, and this question is presently being investigated (Dippel et al., 2001; van Breda et al., 2005).
We found significant differences across regions—in both institution‐specific protocols and personal clinical decision making—in the approach to care of the febrile patient with neurologic insult. Respondents reported significant variability both institutionally and individually regarding the temperature at which treatment begins for the neurologically vulnerable patient. Guidelines for the management of severe TBI state “maintain normothermia,” generally defined as a core temperature of 37 °C (Hinkle, 2004), while the stroke guidelines discuss treatment of fever (Adams et al., 2003). The AANN Core Curriculum for Neuroscience Nursing defines fever as a temperature greater than 38 °C (March et al., 2004), and Marion (2001) defined hyperthermia in the neuroscience ICU as 37.5 °C and recommended that treatment be initiated when temperatures exceed this threshold. Thus, the finding that neurospecific protocols averaged 38.6 °C in the Midwest is of particular concern as are the reports of protocols with initial treatment temperatures of up to 40 °C. We did not ask survey respondents the site of temperature measurement in these patients; however, it is important to remember that brain temperature is higher than core temperature and that the temperature gradient is larger during fever (Rossi, Zanier, Mauri, Columbo, & Stocchetti, 2001). Therefore, protocols should clarify both the treatment temperature and the route(s) of measurement. Interestingly, provider orders were the trigger for intervention at a specific temperature in patients with neurological insults for fewer than 50% of respondents, a result that indicates the importance of clinical decision making by neuroscience nurses.
We found significant differences across regions in the approach to care of the febrile patient with neurologic insult.
Regional differences were consistently seen across all questions regarding the use of a circulating fan (Tables 2, 3 and 4) to reduce body temperature via convection, which is the transfer of body heat into the surrounding air. The use of circulating fans in acute care settings has gained increased attention because of their potential to increase infection rates by spreading fomites (Polderman, 2004a). Several institutions have banned or restricted their use, which may explain the regional differences seen. Although the assertion that there is a relationship between increased infection rates and use of fans may be logical, to date no studies in acute care settings have been published to support this assertion, and only a single paper has examined the relationship in an outpatient environment (Itah & Ben, 2004).
For respondents from the Midwest, ibuprofen was listed more frequently as an intervention in both neuro‐specific protocols and individual decision making. Stocchetti and colleagues (2002) reported that although NSAID therapy was statistically more effective than physical cooling or combined NSAID and physical cooling for treating fever in TBI patients, this reduction in body temperature was clinically negligible. In the effect of paracetamol (acetaminophen) and ibuprofen on body temperature in acute stroke (PISA) study, ibuprofen at a dose of 400 mg every 4 hours was shown to have no effect on body temperature (Dippel et al., 2003). However, most of our respondents reported administering doses of 600 mg every 6 hours. Although the 24‐hour total dose of ibuprofen is the same, it is unclear whether different dosing regimens have different results. Further study in this area is warranted.
Other significant regional differences existed regarding the frequency of intravascular cooling catheterization, ice pack application, and tepid bathing for the management of fever and hyperthermia in patients with neurologic insult. No neuroscience nurses in the West reported using intravascular cooling as an intervention within their neuro‐specific protocols. This therapy, although highly successful for induced hypothermia, is still considered experimental in some settings for the treatment of fever, and not all institutions may have access to experimental therapies. For nurses who reported their neurospecific protocols, the average number of beds per institution was approximately 180 fewer in the West than in the other regions, so equipment availability may explain the differences seen.
Neuroscience nurses in the Northeast were less likely than those in other regions to use physical cooling measures such as tepid bathing and ice packs in their neuro‐specific protocols. This region had the highest percentage of academic medical centers (81%), so the availability of other equipment for use or evaluation could be a factor in the lower utilization of physical cooling. In addition, studies comparing physical cooling measures to pharmacologic therapy in general populations of patients with fever often report increased patient discomfort (i.e., shivering) with physical cooling methods (Axelrod, 2000). Given this observation and the findings of Stocchetti et al. (2002) that NSAID therapy is statistically more effective than physical cooling for treating fever in head‐injured patients, some institutions may be reluctant to include physical cooling measures in fever management protocols for patients who are vulnerable to increased cerebral metabolic demand.
Other interventions listed by neuroscience nurses in managing fever in neurologically vulnerable patients included the use of alcohol‐and‐water spray. It is important to note that this is a combination spray (Polderman, Tjong Tjin Joe, Peerdeman, Vandertop, & Girbes, 2002) and not 100% isopropyl or ethyl alcohol as alcohol toxicity and death have been reported from alcohol sponge baths in both children and older adults (Axelrod, 2000).
Mail surveys are frequently characterized by low response rates. To increase the rate of return for this survey and meet our goal of a 20% return rate, we planned to enlist the assistance of a national organization (AANN) and the chapter system, made the survey short, and enclosed a cover letter outlining specifics such as anonymity (Boynton & Greenhalgh, 2004; White & Brooker, 1997). We were able to achieve a return rate of 26.8% without having to ask the chapters for additional assistance.
The external validity of findings may be limited based on potential systematic differences between responders and nonresponders; however, survey questions were developed to attempt to minimize this bias. We piloted the tool with nurses who were not members of AANN to minimize instrument bias. Although the tool was piloted, some respondents reported difficulty following some of the directions for ranking the order of use of interventions, so some of these responses were not complete. The use of fixed‐response questions, although they are easier to answer, is a potential limitation; however, there was space for comments at the end of the survey for respondents who wished to elaborate. These responses are being analyzed with qualitative methods and will be presented separately.
In this survey, the number of nurse respondents caring exclusively for pediatric patients was small, which may be seen as a limitation. In a 2005 neuroscience nursing role delineation study, 14% of respondents' time was spent in care of pediatric patients (Villanueva, Thompson, Macpherson, Meunier, & Hilton, 2006); therefore, because 21% of our respondents reported caring for a mix of pediatric and adult patients, we have confidence in the validity of our results. While we did not ask respondents to identify the type of unit they worked in (critical care, mixed medical or surgical, neuroscience, etc.), the survey was constructed in such a way that the absence of this data did not directly affect the results of our study. Finally, this is a national survey; therefore, the results may not be representative of neuroscience nursing practice in countries other than the United States.
This study describes national and regional practices for manangement of fever and hyperthermia in neurologically vulnerable patients. Our survey results indicate that several clear and consistent patterns in the use of interventions for fever and hyperthermia management exist nationally, including acetaminophen administration at a dose of 650 mg every 4 hours, ice packs, water cooling blankets, and tepid bathing, and that regional differences exist.
In order to move forward in developing national guidelines for fever and hyperthermia management in neurologically vulnerable populations, further research needs to be conducted, particularly in the following areas: understanding resource availability within smaller institutions, the temperature at which to begin treatment, effects of larger doses of ibuprofen on body temperature, and the association between circulating fans and infection risk.
This survey reinforced previous findings that identified the bedside nurse as an institution's primary decision maker regarding fever management strategies. Given this fact and the negative impact of fever in patients under our care, neuroscience nurses are in the best position to both design further studies and leverage the results to improve patient outcomes.
This study was funded, in part, by the Integra Foundation/Neuroscience Nursing Foundation Research Grant and the National Institutes of Health (NIH T32 NR‐07106 and K12 RR023265). We wish to thank all of the survey respondents for their participation.
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