...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.

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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.

Background

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[degrees]C to >39[degrees]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.

Methods

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...

NOTE: All illustrations and photos have been removed from this article.



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