Running head: TEMPERATURE PROBE PLACEMENT

Temperature Probe Placement in Preterm Neonates Kellie Fowke University of South Florida

TEMPERATURE PROBE PLACEMENT

Inadequate thermoregulation in preterm, low birth weight (LBW) neonates has proven to be an issue in the neonatal intensive care unit (NICU). In order to prevent these neonates from becoming hypothermic or hyperthermic, it is important for clinical staff to implement interventions in a timely manner. By accurately and continuously monitoring body temperature, nurses and physicians will be more likely to intervene at the moment the neonate begins experiencing thermal distress. By utilizing transcutaneous probe placement, body temperature can be accurately and continuously monitored without invasive measures such as rectal probe placement. This evidence-based practice project explores the PICOT question, in preterm neonates in the NICU, is transcutaneous temperature probe placement as accurate compared with invasive rectal probe placement in measuring body temperature? This project will include nurse educators, nurse managers, nurses, physicians, physician assistants, and nurse practitioners. The budget needed should be relatively low, but would include purchasing transcutaneous probes and equipment. Management has agreed to support the five month project and the budget needed to complete the project. The management staff in the NICU is willing to work with the staff nurses and educators in completing the project. This paper will utilize current evidence-based resources to develop a protocol in the NICU for monitoring body temperature in the preterm neonate. Summary of Synthesis In order to find clinically relevant articles that address this topic, EBSCO and PubMed were searched. Keywords used in searching through these databases include neonatal body temperature, preterm neonate, probe placement, temperature measurement, transcutaneous measurement, and rectal thermometer. Four relevant and current evidence-based research studies were found to support the project along with a clinical practice guideline. The guideline recommends measuring the axillary temperature to accurately identify core body temperature,

TEMPERATURE PROBE PLACEMENT and it states that the infants temperature should remain between 97.7 and 99.3 degrees Fahrenheit for a minimum of twelve hours before discharge (Agency for Healthcare Research and Quality [AHRQ], 2011). Van der Spek, van Lingen, and van Zoeren-Grobben (2008) used a two-tailed t-test, and found no significant difference between temperatures when measuring preterm neonate body temperature rectally or trancutaneously. Rollins and Flannery-Bergey (2011) reported that statistical differences found through ANOVA were small when comparing the temporal and axillary temperatures to the rectal temperature (p<.01). These statistical differences did not

represent clinical significance. Helder, Twisk, van Goudoever, and van Elburg (2011) stated that the analyses showed that back temperature was more similar to rectal temperature when compared to abdomen temperature, and skin temperature was most strongly correlated to rectal temperature in the lowest birth weight group. Duran, Vatansever, Acunas, and Sut (2009) found the mid-forehead thermometer to be a more reliable way of measuring body temperature when compared to temporal artery and axillary methods. Research demonstrates that there are alternate methods for accurately taking temperature in preterm neonates when compared to rectal temperatures as a baseline. All four of the studies found a transcutaneous method for temperature measurement that provided accuracy when compared to rectal thermometry. Van der Spek et al. (2008), Duran et al. (2009), and Rollins and Flannery-Bergey (2011) all found the transcutaneous method to not only be reliable and valid, but also less discomforting for the infant. All of the studies also eliminated patients who had underlying medical conditions causing them to be unstable, and focused solely on the healthy, preterm, low weight neonates.

TEMPERATURE PROBE PLACEMENT Van der Spek et al. (2008) utilized the zero heat flow probes placed between the skin and mattress either on the abdomen or on the back skin while Helder et al. (2011) utilized skin pads. These different methods caused van der Spek et al. (2008) to report a higher temperature

when compared to rectal, while Helder et al. (2011) reported a lower temperature. The method in which the probes are attached proves to be a gap in research, although the studies came to the conclusion that the transcutaneous method was still as effective as the rectal method. Another gap in the studies would be whether or not the neonate was placed in an incubator with controlled humidity and temperature. Other variables may also play a part, such as specific gestational age, specific weight of the neonate, and any medications the neonate is receiving. Proposed Practice Change The proposed practice change for the stated PICOT question is to implement a protocol where body temperature will be measured through transcutaneous probe placement in LBW, preterm neonates in the NICU. By reducing the amount of rectal measurements, the risk for bowel perforation and neonatal discomfort will be greatly reduced. According to current evidence-based research studies, transcutaneous methods of measuring neonatal body temperature are just as reliable and accurate when compared to the baseline rectal measurement. Therefore, transcutaneous methods of measuring body temperate are not only less distressing on the neonate and propose less risk of harm to the neonate, but they are also just as accurate. The proposed practice change will educate nurses and physicians on the importance of using transcutaneous temperature measurement and implement a new protocol for measuring temperature continuously.

TEMPERATURE PROBE PLACEMENT Change Strategy In order to promote staff engagement, the staff will be educated on the effectiveness and

validity of transcutaneous probe placement in neonates. There will be luncheon seminars held for both the day shift and the night shift to educate the nursing staff as well as the physicians. During the seminars the clinicians will be presented with evidence-based research findings to stimulate understanding of the new practice protocol. The unit educatorsv will educate the staff on how to properly attach transcutaneous probes and read the measurements while also educating them on the decreased risks as well as benefits of continuous temperature readings. The nurses will be required to demonstrate properly attaching the skin probes in order to evaluate the educational seminars. Larrabees EBP model for change (as cited in Melnyk & Fineout-Overholt, 2011) will be used to implement the change strategy from rectal measurement to continuous transcutaneous measurement. This model for change is a six step process. Table 1: EBP Model for Change Step 1: Assess the need for change by including nurses, nurse managers, physicians, physician assistants, and nurse practitioners. Collect the NICU data on temperature measuremen t readings. Identify the Step 2: Locate the best external evidence by researchin g evidencebased studies. Compare the external evidence to the NICUs evidence. Step 3: Critically analyze the evidence, synthesiz e the evidence, and identify the risks and benefits of the new practice protocol. Step 4: Design the practice change by proposing the change and identifying needed resources and budget. Evaluate the pilot by comparing transcutaneous temperature readings to rectal readings. Design the implementatio n plan. Step 5: Implement the study by taking the readings from preterm, LBW neonates in the NICU. Evaluate the costs of the transcutaneous probe equipment, as well as the processes and outcomes. Develop conclusions and recommendation s for implementing the protocol. Step 6: Integrate and maintain the change in practice. Communicate the recommendation s to all clinicians in the NICU, integrate the protocol as a standard of practice, and monitor the outcomes periodically. The results of the project should be disseminated to

TEMPERATURE PROBE PLACEMENT problem and determine interventions and outcomes. every employee in the NICU.

Roll Out Plan Table 2: Roll Out Plan Month 1 Month 2 Hire/train nurse managers, nurse educators, and research assistants to conduct the project. Collect the data by collecting temperature measurement readings from neonates in the NICU. Collect both the rectal measurement and the transcutaneous measurement from the neonate to compare the accuracy of the readings. Enter the data into a specific file in a computer system of both the rectal and transcutaneous measurements to determine the outcome measures based off of accuracy. Analyze all the data to determine accuracy. Prepare a final report to deliver the data and the information to the clinicians in the NICU in order to establish a new protocol

Month 3

Month 4 Month 5

Project Evaluation The specific data to be collected will be the temperature measurement readings from the neonates in the NICU. Each neonate will have both rectal readings and transcutaneous readings with the rectal reading utilized as the baseline. The nurse assigned to the individual neonates will collect the data and the nurse manager will keep the records of all of the neonates in an online file. The research assistants will then evaluate the data to determine statistical significance. The main outcome is to determine that transcutaneous readings are just as accurate as the rectal readings. When the data is collected, the readings will be compared to determine accuracy. If it is determined that transcutaneous readings are as accurate as rectal readings (p<.01), this will indicate success because transcutaneous methods will be implemented for all of the neonates. The p value was determined using the parameters from the research studies used in this project.

TEMPERATURE PROBE PLACEMENT Dissemination of EBP The protocol will be disseminated locally by being presented to all areas of the NICU in the hospital. Data will continue to be collected to ensure accuracy and effectiveness of the new temperature measurement protocol. The information can also be distributed to other hospitals with NICUs through educational meetings and seminars. The data will be available to be presented to any NICU floor interested in implementing the change.

TEMPERATURE PROBE PLACEMENT References Agency for Healthcare Research and Quality (AHRQ). (2011). Assessment and care of the late preterm infant. Evidence-based clinical practice guideline. Retrieved from http://www.guideline.gov/content.aspx?id=24066 Duran, R., Vatansever, U., Acunas, B., & Sut, N. (2009). Comparison of temporal artery, mid-forehead skin and axillary temperature recordings in preterm infants <1500 g of birthweight. Journal of Paediatrics and Child Health, 45, 444-447. doi: 10.1111/j.1440-1754.2009.01526.x. Helder, O.K., Twisk, J.W.R., van Goudoever, J.B., & van Elburg, R.M. (2011). Skin and rectal temperature in newborns. Acta Paediatrica, 101, e240-e242. doi:10.1111/j.1651-2227.2011.02583.x

Melnyk, B.M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: a guide to best practice (2nd ed.). Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins. Rollins, K., & Flannery-Bergey, D. (2011). Accuracy of temporal artery thermometry in neonatal intensive care unit infants. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 40, s85-s119. doi: 10.1111/j.1552-6909.2011.01243.x van der Spek, R.G., van Lingen, R.A., & van Zoeren-Grobben, D. (2008). Body temperature measurement in VLBW infants by continuous skin measurement is a good or even better alternative than continuous rectal measurement. Acta Paediatrica, 98, 282-285. doi:10.1111/j.1651-2227.2008.01063.x.