The Use of Non-Invasive Thermometers in Healthcare Facilities: a Scoping Review Protocol

SYSTEMATIC REVIEW PROTOCOL

The use of non-invasive thermometers in healthcare facilities: a scoping review protocol

1,2 3 1 Siti Zubaidah Mordiffi Micah D.J. Peters Emily N.K. Ang

1Singapore National University Hospital (NUH) Centre for Evidence-Based Nursing: a Joanna Briggs Institute Centre of Excellence, Singapore, 2Nursing Department, National University Hospital, Singapore, and 3The Joanna Briggs Institute, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia

Review objective and questions: The objective of the review is to map the available evidence to provide an overview of the use of non-invasive thermometers in the general context of health care. The specific questions, in regards to the available international published and unpublished literature, are: What types of non-invasive thermometers have been used? What manufacturers/brand of thermometers have been used? What routes have been used for the thermometers? What thermometers have been used as reference thermometers? What measures of accuracy have been reported in studies comparing different thermometers and routes of temperature measurement? How have included studies reported on comparisons of different thermometers in terms of frequency of thermometer readings, time that temperature is measured and factors affecting accuracy? Keywords Accuracy; body temperature; in-patient; temperature; thermometer

Background Failure of thermometers to accurately measure n healthcare facilities, vital signs are measured to body temperature may result in missed abnormal I monitor the patient’s physiological condition and body temperatures, which may compromise patient progress of their illness. Body temperature is one of safety when deterioration is not detected in a timely four vital signs that are monitored when a person is manner.1 The normothermic range is between 368C ill.1 Abnormal body temperature, such as hypother- and 37.58C.1,3 Early signs of hyperthermia may mia or hyperthermia, may indicate signs of illness manifest in giddiness, confusion, delirium and and warrant treatment.2 The temperature of patients exhaustion, whereas persons with hypothermia who are admitted to healthcare facilities is measured may manifest loss of memory, depression, poor judg- as part of standard routine medical care. Indications ment, decreased heart rate, respiration rate and for measuring the patient’s body temperature are, for blood pressure.4 In people with fever (hyperther- the purpose of establishing the baseline temperature, mia), for every 18C rise in temperature, there is a close observations for timely detection of hypother- 10% increase in the rate of enzyme controlled chemi- mia or hyperthermia, for observing and monitoring cal reactions.5 At 438C or higher, irreparable cell fever (a sign of infection), monitoring effects of damage and enzyme denaturation occurs, resulting antimicrobial therapy and observing for signs of in death. Conversely, in the case of hypothermia, as transfusion reaction.1 body temperature decreases below 338C, cellular processes become sluggish.5 As the metabolic rate falls, loss of consciousness may occur and, poten- Correspondence: Siti Zubaidah Mordiffi, [email protected] tially, death. Body temperatures should therefore be The authors SZM and ENKA declare that they possess no conflicts of measured accurately and reliably as temperature is interest in relation to this protocol or proposed review. The author MDJP declares that he is an Associate Editor of the JBI Database of an important factor that influences diagnoses and 1 Systematic Reviews and Implementation Reports and that he has the determination of the resulting treatment plan. had no input into the editorial process for this manuscript. Core temperature at sites such as the heart and the DOI: 10.11124/JBISRIR-2016-003173 brain are the most accurate ‘‘true’’ representation of

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body temperature.6 The temperature at these areas used at various sites (rectal, pulmonary artery, oral, are tightly regulated and are most accurate.7 How- brain and bladder).11 The temporal artery ther- ever, they are invasive and are not easily accessible or mometers measured the body temperature on the convenient.7 While there are different views regard- forehead and behind the ear. While findings of the ing which site is the most accurate, the most accurate review were inconclusive, temporal artery ther- core temperature can only be taken through invasive mometers were slightly more accurate than in-ear routes such as via the esophagus and pulmonary thermometers. A limitation of this review was that artery.1,4,8 This degree of accuracy may be required the focus was solely on contact temporal artery and for critically ill patients and these invasive methods tympanic thermometers; this proposed scoping are most feasible in highly acute care areas such as review will not have these restrictions. Furthermore, intensive care units4,8 or operating rooms.7 In less- the review reported no information on the brands acute care settings, invasive measurement of core evaluated. An additional limitation of the older temperature is unduly complex, carries an unnecess- review is that more recently published evidence ary risk to patients and is summarily unfeasible.1,7,9 around non-contact temporal artery thermometers For these reasons, a less-invasive, simpler and safe is now available. For these reasons, a broader, more method is likely to be a preferred option for both detailed scoping review is warranted to map the patients and clinicians. Non-invasive sites that pro- current literature. vide the best estimation of core temperatures include The search also sought existing systematic oral, axillary, temporal artery and external auditory reviews on the accuracy of non-invasive ther- canal (tympanic) due to their proximity to the core mometers. Two were located. One evaluated regions of the body and the presence of large blood accuracy of infrared tympanic, rectal and oral per- vessels.6 Thus, temperatures taken from peripheral ipheral thermometers and compared them with pul- or ‘‘near core’’ sites are more commonly and con- monary artery and bladder thermometers in febrile veniently used.7 However, these thermometers have patients.8 This review concluded that tympanic and limitations as they are more likely to be affected oral thermometers provide an accurate measure of by ambient temperatures.7 This explanation high- core temperature and highlighted the dearth of lights the significance of the differences between papers on some brands of peripheral thermometers the measurement of core temperature and surface currently used in clinical practice. The review also temperature and concomitantly, the necessity of reported major statistical flaws in many studies. This accurate thermometers for the measurement of both. resulted in the exclusion of studies considering blad- User technique can also impact upon accuracy of der thermometers. The exclusion of a number of temperature readings.1 This has been identified in papers was acknowledged by the authors as a poten- previous studies. In one study, the accuracy of a tial source of publication bias. As the present scoping temporal artery scanner thermometer was measured review will seek to map all relevant literature regard- against a disposable temporal artery thermometer.10 less of quality, this limitation will be avoided. The The temporal artery scanner thermometer was not as other systematic review12 evaluated the accuracy of sensitive as the disposable temporal artery scanner infrared tympanic, temporal artery, axilla and oral thermometer in detecting patients with fever.10 The peripheral thermometers against pulmonary, results of this study led to a recommendation that urinary bladder, esophageal or rectal central ther- more research is required to identify accurate and mometers in both adults and children from acute reliable non-invasive thermometers. care or ambulatory facilities.12 In contrast to the An initial search of the JBI Database of System- previous review,8 this review concluded that the atic Reviews and Implementation Reports, the peripheral thermometers do not have clinically Cochrane Database of Systematic Reviews, MED- acceptable accuracy and should not be recom- LINE (PubMed) and CINAHL, Google and Google mended in acute settings.12 Nevertheless, in less- Scholar was conducted in November-December acute areas, electronic oral and tympanic membrane 2015. A published scoping report was located thermometers were recommended for practical related to this topic.11 This scoping report evaluated reasons.12 This review included studies that eval- temporal artery thermometers, infrared in-ear ther- uated mercury thermometers that are now obsolete mometers and reference standard thermometers due to toxicity risks.12 In both reviews, the studies

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included were from inception up to 2010,8 and July Concept 2015,12 respectively. These existing reviews8,11,12 The concepts examined by this scoping review are focused upon differing issues and reported conflict- the various types, routes and brands of non-invasive ing results that limit their usability for improving thermometers to measure peripheral body tempera- clinical practice; however, as a scoping review, the ture and where comparisons are made with reference present review will include these papers. To provide thermometers in terms of accuracy. The non-inva- necessary clarity, it is important that a scoping sive thermometers to be included are hospital-grade review that also reports additional information such thermometers used in the clinical context. as the brand and route of thermometer is conducted. Thermometers for home-use and mercury-in-glass This scoping review will adopt the methodology for thermometers will be excluded. JBI scoping reviews.13,14 Specific data to be extracted from the included In summary, accurate measurement of body studies will include: temperature is integral to the identification of many Reported types of non-invasive thermometers illnesses and provision of efficient and good quality including test and reference thermometers. health care.1 Currently in practice, a diverse range Reported manufacturers/brand of thermometers. of thermometers are used for the measurement of Reported routes that are used for the patients’ body temperature and frequently vary both thermometers. in terms of type and manufacturer.11 Furthermore, Reported measures of accuracy in studies com- there are a number of routes used by clinicians to paring different thermometers and routes of measure patient body temperature.15 Each of these temperature measurement. variables are known to be potentially influential Data pertaining to comparisons of different upon the accuracy of body temperature estimation.7 thermometers in terms of, for example, frequency Because there is currently no ‘‘gold standard’’ ther- of thermometer readings, time that temperature mometer type, manufacturer or route, published and is measured and factors affecting accuracy. unpublished studies do not use a standard reference thermometer in comparison studies of the accuracy Context of thermometers. This also means that there is cur- The current scoping review will consider studies that rently a lack of clarity around what a ‘‘hospital have been conducted in healthcare facilities of any grade’’ thermometer is. How thermometers are com- type including, but not restricted to, hospitals, pared and accuracy is measured also appears to be medical centers and long-term care facilities. Studies inconsistently reported across studies, including from any geographic setting will be eligible for previous systematic reviews. It is therefore important inclusion. that a scoping review be conducted to provide a clear map of thermometer use within health care; what Types of studies thermometers are used in terms of type and manu- The current scoping review will consider method- facturer, what routes are commonly used for each comparison studies, quasi-experimental studies, and what thermometers are most commonly used as diagnostic studies and so on for inclusion. Other reference thermometers. In addition, it will also be types of studies such as systematic reviews and important to develop an understanding of how quality improvement projects will be also accuracy has been measured and thermometers com- considered. pared across the available literature. Search strategy Inclusion criteria The search strategy will aim to find both published Types of participants and unpublished English language studies. An initial The current scoping review will consider studies limited search of MEDLINE (PubMed) and that include adults and children of all ages where CINAHL will be undertaken to identify articles on body temperature is taken non-invasively this topic, followed by analysis of the text words regardless of whether they are normothermic or contained in the titles and abstracts, and of the index hypo/hyperthermic. terms used to describe these articles. This will inform

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the development of a search strategy including Presenting the data identified keywords and index terms that will be The extracted data will be presented in diagram- tailored for each information source. A full search matic or tabular form in a manner that aligns to the strategy is provided in Appendix I. Due to advance- objectives and questions of this scoping review. The ments in the last 15 years away from mercury-in- tables and/or charts will report on distribution of glass thermometers that are now widely considered 16 studies by type, brand, route and reported accuracy to be obsolete, this scoping review will include measures of non-invasive thermometers, year of only evidence relevant to present clinical practice publication, countries of origin, area of practice published from 2001 to present. The reference lists (clinical), research methods and findings. Additional of all included studies will be screened for additional data identified that is relevant to the review objec- studies. tives will also be presented in diagrammatic or The databases to be searched will include: tabular form. A narrative summary will accompany CINAHL the tabulated and/or charted results and will describe MEDLINE (Ovid) how the results relate to the review’s objective Science Direct and questions. Embase Scopus References Health Source 1. McCallum L. Measuring body temperature. Nurs Times Cochrane Central Register of Controlled Trial 2012;108(45):20–2. (CENTRAL) 2. Khorshid L, Eser I, Zaybak A, Yapucu U¨ . Comparing mercury- Health Technology Assessment Database (HTA) in-glass, tympanic and disposable thermometers in measur- Cochrane Database of Systematic Reviews ing body temperature in healthy young people. J Clin Nurs JBI Database of Systematic Reviews and Imple- 2005;14(4):496–500; 5p. mentation Reports 3. Docherty B, Foudy C. Homeostasis part 3: temperature The search for unpublished studies will include: regulation. Nurs Times 2006;102(16):20–1; 2p. ProQuest Dissertation and Theses 4. Fetzer SJ. Vital signs. In: Porter PA, Perry AG, editors. Fundamentals of nursing. Canada: Elsevier, 2009;502–51. Google Scholar/Google 5. Marieb EN, Hoehn K. Human anatomy and physiologh. 8ht ed. San Francisco: Pearson Benjamin Cummings; 2010;1114p. Data extraction 6. Pusˇnik I, Miklavec A. Dilemmas in measurement of human Data will be extracted by two independent reviewers body temperature. Instrum Sci Technol 2009;37(5):516–30. from papers included in the scoping review using the 7. Sessler DI. Temperature monitoring and perioperative ther- draft data extraction tool listed in Appendix II. The moregulation. J Am Soc Anesthesiol 2008;109(2):318–38. data extracted will include specific details about the 8. Jefferies S, Weatherall M, Young P, Beasley R. A systematic review of the accuracy of peripheral thermometry in esti- populations, concept, context and study methods of mating core temperatures among febrile critically ill significance to the scoping review questions and patients. Crit Care Resusc 2011;13(3):194–9. specific objectives. Any disagreements that arise 9. Uleberg O, Eidstuen S, Vangberg G, Skogvoll E. Temperature between the reviewers will be resolved through measurements in trauma patients: is the ear the key to the discussion or with a third reviewer. Authors of core? Scand J Trauma Resusc Emerg Med 2015;23(1):1–8. papers will be contacted to request missing or 10. Bahr SJ, Senica A, Gingras L, Ryan P. Clinical nurse specialist- additional data where required. The draft data led evaluation of temporal artery thermometers in acute extraction tool will be modified and revised as care. Clin Nurse Spec 2010;24(5):238–44. necessary during the process of extracting data from 11. Healthcare Improvement Scotland. Technologies scoping each included study.17,18 Additional types of report: What is the clinical and cost effectiveness of relevant data may be extracted from included stud- temporal artery thermometers compared with infrared in-ear thermometers for temperature measurement in rou- ies as determined by the review team during the tine clinical practice? 2012. course of the conduct of the scoping review in line 12. Niven DJ, Gaudet JE, Laupland KB, Mrklas KJ, Roberts DJ, with the Joanna Briggs Institute methodology. Stelfox HT. Accuracy of peripheral thermometers for esti- Modifications will be detailed in the full scoping mating temperature: a systematic review and meta- review report. analysis. Ann Intern Med 2015;163(10):768–77.

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13. Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, 16. Latman NS, Hans P, Nicholson L, DeLee ZS, Lewis K, Shirey Soares CB. Guidance for conducting systematic scoping A. Evaluation of clinical thermometers for accuracy reviews. Int J Evid Based Healthc 2015;13(3):141–6. and reliability. Biomed Instrum Technol 2001;35(4): 14. Peters MD, Godfrey CM, McInerney P, Soares C, Khalil H, 259–65. Parker D. Methodology for JBI scoping reviews. In: Aroma- 17. Khalil H, Peters M, Godfrey CM, McInerney P, Soares CB, taris E, editor. The Joanna Briggs Institute Reviewers’ Parker D. An evidence-based approach to scoping reviews. manual 2015. Adelaide, Australia: The Joanna Briggs Worldviews Evid Based Nurs 2016;13(2):118–23. Institute, 2015; 1–24. 18. Peters MD. In no uncertain terms: the importance of a 15. Frommelt T, Ott C, Hays V. Accuracy of different devices to defined objective in scoping reviews. JBI Database System measure temperature. Medsurg Nurs 2008;17(3):171. Rev Implement Rep 2016;14(2):1–4.

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Appendix I: Logic grid for initial search

Draft search terms Participants Adult OR children of all ages Concept Surface body temperature: - Route – e.g. oral OR temporal artery OR tympanic OR axilla OR ‘‘body temperature’’ - Brands – all brands (hospital grade), thermometer(s) Reference temperature: - Route – e.g. pulmonary artery OR, esophageal, OR bladder OR rectal Context Healthcare facilities e.g. tertiary hospital, rehabilitation hospital, com- munity hospitals, medical centers, nursing homes etc. Study types Method-comparison, quasi-experimental and diagnostic Systematic reviews, technical reports and quality improvement

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Appendix II: Draft data extraction instrument

Author Setting/ Method/statistical Reference Comparison Author’s Reviewer (y) population analysis thermometer thermometer Results conclusion comments

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