Emergency department rectal temperatures in over 10 years: A retrospective observational study

doi:10.5847/wjem.j.issn.1920-8642.2013.02.004

Abstract

Abstract:

BACKGROUND: Fever in patients can provide an important clue to the etiology of a patient's symptoms. Non-invasive temperature sites (oral, axillary, temporal) may be insensitive due to a variety of factors. This has not been well studied in adult emergency department patients. To determine whether emergency department triage temperatures detected fever adequately when compared to a rectal temperature.
METHODS: A retrospective chart review was made of 27 130 adult patients in a high volume, urban emergency department over an eight-year period who received first a non-rectal triage temperature and then a subsequent rectal temperature.
RESULTS: The mean difference in temperatures between the initial temperature and the rectal temperature was 1.3 °F (P<0.001), with 25.9% of the patients having higher rectal temperatures ≥2 °F, and 5.0% having higher rectal temperatures ≥4 °F. The mean difference among the patients who received oral, axillary, and temporal temperatures was 1.2 °F (P<0.001), 1.8 °F (P<0.001), and 1.2 °F (P<0.001) respectively. About 18.1% of the patients were initially afebrile and found to be febrile by rectal temperature, with an average difference of 2.5 °F (P<0.001). These patients had a higher rate of admission (61.4%, P<0.005), and were more likely to be admitted to the hospital for a higher level of care, such as an intensive care unit, when compared with the full cohort (12.5% vs. 5.8%, P<0.005).
CONCLUSIONS: There are significant differences between rectal temperatures and non-invasive triage temperatures in this emergency department cohort. In almost one in five patients, fever was missed by triage temperature.

Key words: Rectal temperatures, Oral temperatures, Axillary temperatures, Emergency department

Graham A. Walker, Daniel Runde, Daniel M. Rolston, Dan Wiener, Jarone Lee. Emergency department rectal temperatures in over 10 years: A retrospective observational study[J]. World Journal of Emergency Medicine, 2013, 4(2): 107-112.

Figures/Tables 4

Table 1

Table 2

Table 3

Table 4

References 31

1	Blainey CG. Site selection in taking body temperature. Am J Nurs 1974; 74:1859-1861.
2	Rotello LC, Crawford L, Terndrup TE. Comparison of infrared ear thermometer derived and equilibrated rectal temperatures in estimating pulmonary artery temperatures. Crit Care Med 1996; 24:1501-1506.
3	Schmitz T, Bair N, Falk M, Levine C. A comparison of five methods of temperature measurement in febrile intensive care patients. Am J Crit Care 1995; 4:286-292. pmid: 7663592
4	Neff J, Ayoub J, Longman A, Noyes A. Effect of respiratory rate, respiratory depth, and open versus closed mouth breathing on sublingual temperature. Res Nurs Health 1989; 12:195-202. pmid: 2727326
5	Quatrara B, Coffman J, Jenkins T, Mann K, McGough K, Conaway M, et al. The effect of respiratory rate and ingestion of hot and cold beverages on the accuracy of oral temperatures measured by electronic thermometers. Medsurg Nurs 2007; 16:105-108, 100. pmid: 17547268
6	Rogers IR, Brannigan D, Montgomery A, Khangure N, Williams A, Jacobs I. Tympanic thermometry is unsuitable as a screening tool for hypothermia after open water swimming. Wilderness Environ Med 2007; 18:218-221. doi: 10.1580/06-WEME-BR-044R2.1 pmid: 17896842
7	Tandberg D, Sklar D. Effect of tachypnea on the estimation of body temperature by an oral thermometer. N Engl J Med 1983; 308:945-946.
8	Terndrup TE, Allegra JR, Kealy JA. A comparison of oral, rectal, and tympanic membrane-derived temperature changes after ingestion of liquids and smoking. Am J Emerg Med 1989; 7:150-154. doi: 10.1016/0735-6757(89)90127-7 pmid: 2920076
9	Brun-Buisson C, Doyon F, Carlet J, Dellamonica P, Gouin F, Lepoutre A, et al. Incidence, risk factors, and outcome of severe sepsis and septic shock in adults. A multicenter prospective study in intensive care units. French ICU Group for Severe Sepsis. JAMA 1995; 274:968-974. doi: 10.1001/jama.1995.03530120060042
10	Marx JA, Hockberger RS, Walls RM, Adams J, Rosen P. Rosen's emergency medicine : concepts and clinical practice. 7th ed. Philadelphia: Mosby/Elsevier; 2010.
11	Mandell GL, Bennett JE, Dolin R. Mandell, Douglas, Bennett's principles and practice of infectious diseases. 7th ed. Philadelphia, PA: Churchill Livingstone/Elsevier; 2010.
12	Cecil RL, Goldman L, Ausiello DA. Cecil medicine. 23rd ed. Philadelphia: Saunders Elsevier; 2008.
13	Newsham KR, Saunders JE, Nordin ES. Comparison of rectal and tympanic thermometry during exercise. South Med J 2002; 95:804-810.
14	Roth RN, Verdile VP, Grollman LJ, Stone DA. Agreement between rectal and tympanic membrane temperatures in marathon runners. Ann Emerg Med 1996; 28:414-417.
15	Couilliet D, Meyer P, Grosshans E. Comparative measurements of oral and rectal temperatures in 224 hospitalized patients. Ann Med Interne (Paris) 1996; 147:536-538.
16	Erickson RS, Meyer LT. Accuracy of infrared ear thermometry and other temperature methods in adults. Am J Crit Care 1994; 3:40-54. doi: 10.4037/ajcc1994.3.1.40
17	Smith LS. Reexamining age, race, site, and thermometer type as variables affecting temperature measurement in adults-A comparison study. BMC Nurs 2003; 2:1. doi: 10.1186/1472-6955-2-1
18	Cronin K, Wallis M. Temperature taking in the ICU: which route is best? Aust Crit Care 2000; 13:59-64.
19	Fulbrook P. Core body temperature measurement: a comparison of axilla, tympanic membrane and pulmonary artery blood temperature. Intensive Crit Care Nurs 1997; 13:266-272. pmid: 9538713
20	Robinson JL, Seal RF, Spady DW, Joffres MR. Comparison of esophageal, rectal, axillary, bladder, tympanic, and pulmonary artery temperatures in children. J Pediatr 1998; 133:553-556. doi: 10.1016/s0022-3476(98)70067-8 pmid: 9787697
21	El-Radhi AS, Patel S. An evaluation of tympanic thermometry in a paediatric emergency department. Emerg Med J 2006; 23:40-41. pmid: 16373802
22	Schmitz T, Bair N, Falk M, Levine C. A comparison of five methods of temperature measurement in febrile intensive care patients. Am J Crit Care 1995; 4:286-292. pmid: 7663592
23	Ronneberg K, Roberts Wo, Mcbean Ad, Center Ba. Temporal artery temperature measurements do not detect hyperthermic marathon runners. Med Sci Sports Exerc 2008; 40:1373-1375. doi: 10.1249/MSS.0b013e31816d65bb
24	Suleman M-I, Doufas AG, Ak√ßa O, Ducharme M, Sessler DI. Insufficiency in a new temporal-artery thermometer for adult and pediatric patients. Anesthesia & Analgesia 2002; 95:67-71. doi: 10.1097/00000539-200207000-00012 pmid: 12088945
25	Kimberger O, Cohen D, Illievich U, Lenhardt R. Temporal artery versus bladder thermometry during perioperative and intensive care unit monitoring. Anesth Analg 2007; 105:1042-1047.
26	Kresovich-Wendler K, Levitt MA, Yearly L. An evaluation of clinical predictors to determine need for rectal temperature measurement in the emergency department. Am J Emerg Med 1989; 7:391-394. doi: 10.1016/0735-6757(89)90045-4 pmid: 2786721
27	Varney SM, Manthey DE, Culpepper VE, Creedon JF. A comparison of oral, tympanic, and rectal temperature measurement in the elderly. J Emerg Med 2002; 22:153-157. pmid: 11858919
28	Green MM, Danzl DF, Praszkier H. Infrared tympanic thermography in the emergency department. J Emerg Med 1989; 7:437-440.
29	Brooks S, Khan A, Stoica D, Griffith J, Friedeman L, Mukherji R, et al. Reduction in vancomycin-resistant Enterococcus and Clostridium difficile infections following change to tympanic thermometers. Infect Control Hosp Epidemiol 1998; 19:333-336. pmid: 9613694
30	Brooks SE, Veal RO, Kramer M, Dore L, Schupf N, Adachi M. Reduction in the incidence of Clostridium difficile-associated diarrhea in an acute care hospital and a skilled nursing facility following replacement of electronic thermometers with single-use disposables. Infect Control Hosp Epidemiol 1992; 13:98-103. doi: 10.2307/30147068
31	Jernigan JA, Siegman-Igra Y, Guerrant RC, Farr BM. A randomized crossover study of disposable thermometers for prevention of Clostridium difficile and other nosocomial infections. Infect Control Hosp Epidemiol 1998; 19:494-499. doi: 10.1086/647855 pmid: 9702571

Parameters	n (%)
Age (years)
18-30	3 512 (12.9)
31-40	2 976 (11.0)
41-50	4 282 (15.8)
51-60	3 805 (14.0)
61-70	3 695 (13.6)
71-80	4 139 (15.3)
81-90	3 594 (13.2)
91+	1 127 (4.2)
Gender
Female	16 085 (59.3)
Male	11 044 (40.7)
Disposition
ICU / OR	1 575 (5.8)
Inpatient Admission	14 457 (53.3)
Discharge	10 647 (39.2)
Eloped/AMA	398 (1.5)
Expired	53 (0.2)

Variables	Results
Initial triage non-rectal temperature (°F)	98.3 (98.2±1.7); range: 80-107.6
Rectal temperature (°F)	99.4 (99.5±1.6); range: 82.7-108
Difference (°F)	1.3 (-10.3 to 18.6),P<0.001
Pulse (beats per minute)	93 (24-275)
Respiratory rate (breaths per minute)	19.3 (6-68)
Initial temperature to rectal temperaturetime (minutes)	119.3 (0-3 032)
Patients febrile (n, %)	6 668 (24.6)
Patients receiving antipyretic before rectal temperature (n, %)	2 070 (7.6)

Variables	Oral	Axillary	Temporal
Patients (n, %)	25 558 (94.1)	638 (2.3)	988 (3.6)
Initial temperature (°F)	98.3 (98.3±1.7);	97.8 (98.0 ±2.1);	98.0 (98.1±1.6);
	range: 80-107.6	Range: 90-106.7	Range: 80-106.6
Rectal temperature (°F)	99.4 (99.5±1.5);	99.6 (99.8±2.0);	99.2 (99.3±1.9);
	Range: 82.7-108	Range: 88.8-106.0	Range: 89.1-105
Difference (°F)	1.2 (-10.3 to 18.6),P<0.001	1.8 (-7.2 to 9.2),P<0.001	1.2 (-7.9 to 13.1),P<0.001
Pulse (beats per minute)	92.3 (24-275)	98.9 (42-189)	93.3 (30-175)
Respirations (breaths per minute)	19.2 (6-68)	23.6 (12-60)	19.9 (10-56)
Initial to rectal temperature time (minutes)	118.8 (0-3 032)	113.9 (10-1 464)	135.5 (1-1 641)
Initial temperature to antipyretic time (minutes)	136.6 (0-1 936)	117.5 (0-829)	176.3 (0-1 651)
Febrile patients (n, %)	6 168 (24.1)	229 (35.9)	271 (27.4)
Febrile patients receiving antipyretics (n, %)	4 338 (70.3)	174 (76.0)	216 (80.0)

Variables	Overall	Oral	Axillary	Temporal
Number of patients (n, %)	5 093 (18.8)	4 714 (17.4)	160 (0.6)	219 (0.8)
Initial temperature (°F)	98.9 (90.2-100.3)	98.9 (90.2-100.3)	98.5 (93.5-100.3)	98.5 (96-100.3)
Rectal temperature (°F)	101.3 (100.4-108)	101.3 (100.4-108)	101.5 (100.4-105.3)	101.5 (100.4-104.8)
Average difference (°F)	2.5 (0.1-14.3),P<0.01	2.4 (0.1-14.3),P<0.01	3.0 (0.2-9.2),P<0.01	3.0 (0.1-7.4),P<0.01
Pulse (beats per minute)	101.2 (35-208)	101 (35-208)	105 (44-160)	102.2 (42-175)
Respirations (breaths per minute)	19.6 (6-60)	19.6 (6-60)	26.3 (12-60)	20.3 (12-52)
Initial to rectal temperature time (minutes)	107.2 (0-2 159)	106. (0-2 159)	89.5 (12-1 464)	128.2 (12-1 641)
Initial temperature to antipyretic time (minutes)	139.3 (0-1 747)	138.5 (0-1 747)	119.2 (0-829)	165.8 (0-1 651)
Received antipyretics (n, %)	3 355 (65.9)	3 071 (65.1)	112 (70.0)	172 (78.5)

[1]	Lori Stolz, Elaine Situ-LaCasse, Josie Acuña, Matthew Thompson, Nicolaus Hawbaker, Josephine Valenzuela, Uwe Stolz, Srikar Adhikari. What is the ideal approach for emergent pericardiocentesis using point-of-care ultrasound guidance? [J]. World Journal of Emergency Medicine, 2021, 12(3): 169-173.
[2]	Kasım Turgut, Erdal Yavuz, Mine Kayacı Yıldız, Mehmet Kaan Poyraz. Violence toward emergency physicians: A prospective-descriptive study [J]. World Journal of Emergency Medicine, 2021, 12(2): 111-116.
[3]	Marin Pavlov, Lucija Klobučar, Iva Klobučar, Kristina Žgela, Vesna Degoricija. Does shifting to professional emergency department staffing affect the decision for chest radiography? [J]. World Journal of Emergency Medicine, 2021, 12(2): 87-92.
[4]	Hady Zgheib, Aline El Zakhem, Cynthia Wakil, Mohamad Ali Cheaito, Rola Cheaito, Antoine Finianos, Ralphe Bou Chebl, Rima Kaddoura, Nader Al Souky, Imad El Majzoub. Role of urine studies in asymptomatic febrile neutropenic patients presenting to the emergency department [J]. World Journal of Emergency Medicine, 2021, 12(2): 99-104.
[5]	William Gilliam, Jackson F. Barr, Brandon Bruns, Brandon Cave, Jordan Mitchell, Tina Nguyen, Jamie Palmer, Mark Rose, Safura Tanveer, Chris Yum, Quincy K. Tran. Factors associated with refractory pain in emergency patients admitted to emergency general surgery [J]. World Journal of Emergency Medicine, 2021, 12(1): 12-17.
[6]	Rebekah Shaw, Erica Popovsky, Alyssa Abo, Marni Jacobs, Nicole Herrera, James Chamberlain, Andrea Hahn. Improving antibiotic prescribing in the emergency department for uncomplicated community-acquired pneumonia [J]. World Journal of Emergency Medicine, 2020, 11(4): 199-205.
[7]	Hai-jiang Zhou, Tian-fei Lan, Shu-bin Guo. Outcome prediction value of National Early Warning Score in septic patients with community-acquired pneumonia in emergency department: A single-center retrospective cohort study [J]. World Journal of Emergency Medicine, 2020, 11(4): 206-215.
[8]	Chuan-qi Ding, Yu-ping Zhang, Yu-wei Wang, Min-fei Yang, Sa Wang, Nian-qi Cui, Jing-fen Jin. Death and do-not-resuscitate order in the emergency department: A single-center three-year retrospective study in the Chinese mainland [J]. World Journal of Emergency Medicine, 2020, 11(4): 231-237.
[9]	Maybritt I. Kuypers, Adinda Klijn, Nieke E. Mullaart-Jansen, Frans B. Plötz. Availability and quality of procedural sedation and analgesia in emergency departments without emergency physicians: A national survey in the Netherlands [J]. World Journal of Emergency Medicine, 2020, 11(2): 69-73.
[10]	Emily Shao, Chantelle Judge, Erin McMeniman, Tina Bazianas, Rob Eley. Presenting patterns of dermatology conditions to an Australian emergency department [J]. World Journal of Emergency Medicine, 2020, 11(2): 74-78.
[11]	Zhenghong Liu, Mingwei Ng, Dinesh V. Gunasekeran, Huihua Li, Kishanti Ponampalam, R Ponampalam. Mobile technology: Usage and perspective of patients and caregivers presenting to a tertiary care emergency department [J]. World Journal of Emergency Medicine, 2020, 11(1): 5-11.
[12]	Wirachin Hoonpongsimanont, Preet Kaur Sahota, Yanjun Chen, Maria Nguyen, Christine Louis, Jonathan Pena, Andrew Wong, Maxwell Jen. Emergency department patient experience: Same location, same provider, different scores by different survey methods [J]. World Journal of Emergency Medicine, 2019, 10(3): 138-144.
[13]	Chang Pan, Xiao-ran Huang, Jiao-jiao Pang, Kai Cheng, Feng Xu, Yu-guo Chen. Trends in mortality of emergency departments patients in China [J]. World Journal of Emergency Medicine, 2019, 10(3): 152-155.
[14]	Rakesh Gupta, Isaac Siemens, Sam Campbell. The use of outcome feedback by emergency medicine physicians: Results of a physician survey [J]. World Journal of Emergency Medicine, 2019, 10(1): 14-18.
[15]	Elaine Situ-LaCasse, Ryan W. Grieger, Stephen Crabbe, Anna L. Waterbrook, Lucas Friedman, Srikar Adhikari. Utility of point-of-care musculoskeletal ultrasound in the evaluation of emergency department musculoskeletal pathology [J]. World Journal of Emergency Medicine, 2018, 9(4): 262-266.