Temperature Monitoring Standards in PaediatricsHelen Edwards RN MN, Maureen Maloney RN MA

Temperature monitoring is a basic vital sign performed frequently on children to determine their acuity of illness and whether there is the requirement for a new treatment or change in regime. At The Hospital for Sick Children, a comprehensive project was undertaken to develop temperature monitoring standards/ practices/policies and recommend technology for purchase that would reflect and support the new practices. A Temperature Monitoring Task Force, with wide representation from Physicians, Nurses, Medical Engineering, as well as extensive consultation with Infection Control, Infectious Diseases, Surgery, Medicine, Emergency and Neonatology, was established to guide the project and meet the objectives.

Introduction

Practice/Equipment Review

From our review of the literature we concluded:

Axilla Temperature Measurements:• are not reliable in detecting fevers• are not an accurate reflection of core temperatures• have no direct co-relation with rectal or oral temperature measurements• can be influenced by changes in environmental temperature

Rectal Temperature Measurements:• are most comparable to core measurements• pose minimal risk for rectal perforation in neonates with newer and faster technologies and proper technique, compared to old mercury thermometers

Tympanic Temperature Measurements:• are technique dependent• are not reliable, especially in a paediatricpopulation

There are a variety of contraindications to rectal and oral temperature measurements

Benchmarking with numerous comparable paediatricinstitutions revealed:

There was a great variation in types of thermometry as well as guidelines

Many hospitals were experiencing similar challenges in the development of guidelines and choice of thermometers

We were able to validate a number of the contraindications to rectal, oral and axilla temperature measurements

Literature Review andBenchmarking

Implementation/Education

Focused on determining if practice was shifting to temperature measurement routes that best reflected the child’s core temperature

Compared to the practice review done at the beginning of this project, the number of “axilla only” temperature measurements decreased from 53% to 27%. However, there is still a tendency for nurses to utilize the axilla route even when there are no clear contraindications to the rectal or oral route. In addition, nurses are not always using a consistent route.

To address these practice issues, we plan to reinforce the new standards in collaboration with the Nurse Educators and will follow up with further evaluation in a few months.

Evaluation

Executive Support - financial commitment

Dedicated personnel

Wide consultation efforts to ensure broad representation in development of new standards

Use of existing approval processes to ensure organizational acceptance

Collaboration with many other departments in the hospital to ensure a coordinated effort to implement –Medical Engineering, Plant Operations, Housekeeping

Committed partnership with the thermometer vendor to ensure a comprehensive training program and go-live support

Key Success Factors

A review of flowsheets to determine the frequency and methods of temperature measurements

Identification of practice issues through:• Informal interviews with nursing staff• Questionnaires distributed to Nurse Educators, Advanced Practice Nurses and Physicians

A detailed thermometer inventory to determine thermometer requirements

The review revealed:

An increase in axilla temperature measurement as opposed to rectal (compared to a similar review performed 10 years ago)

Inconsistent practice, especially with the choice of route (rectal, axilla, oral)

Inadequate numbers of thermometers and accessories

The thermometers were not located close to patient rooms, resulting in nursing staff taking significant amounts of time to find a thermometer

The thermometers in use were old and requiring extensive maintenance and repairs by the Medical Engineering department

Cleaning practices did not consistently meet infection control standards

In addition, that in a recent staff survey, nursing staff identified that a primary concern regarding job satisfaction was not having the necessary equipment to perform their jobs, with thermometers being mentioned specifically

The practice changes and new thermometers were rolled out to the clinical areas on an area-by-area basis, over a period of four weeks. Education was focused on the changes in practice and the new technology.

Practice Changes

Nurse Educators received a Power Point presentation that could be adapted to suit the given clinical area

SuperUser classes were offered to identified nursing staff in clinical leadership positions in the hospital to ensure some “local” experts

An online tutorial provided highlights of the new standards and a link to the policy document.

New Thermometers

Vendor provided inservices/ support over the length of the implementation

Online tutorial on the new thermometers

The most significant change in practice is the shift from axilla temperature measurements to more appropriate route choices:

Rectal RouteNeonate to whenever able to safely have an oral

temperature taken

Oral Routewhenever able to safely have an oral temperature taken

– approximately 3 to 5 years old until adulthood

Axilla Routeonly when the other routes are contraindicated

Important Considerations related to the new standards:

consistent route for accurate trending

decreasing temperature frequency for stable patients / clustering care

educating parents, who frequently use non-invasive methods of temperature measurement at home

Evidence-Based Standards