66 Journal of Neuroscience Nursing

Fever Management Practices of Neuroscience

Nurses: What Has Changed?
Hannah Rockett, Hilaire J. Thompson, Patricia A. Blissitt

ABSTRACT
Current evidence shows that fever and hyperthermia are especially detrimental to patients with neurologic
injury, leading to higher rates of mortality, greater disability, and longer lengths of stay. Although clinical
practice guidelines exist for ischemic stroke, subarachnoid hemorrhage, and traumatic brain injury, they lack
specificity in their recommendations for fever management, making it difficult to formulate appropriate
protocols for care. Using survey methods, the aims of this study were to (a) describe how nursing practices for
fever management in this population have changed over the last several years, (b) assess if institutional
protocols and nursing judgment follow published national guidelines for fever management in neuroscience
patients, and (c) explore whether nurse or institutional characteristics influence decision making. Compared
with the previous survey administered in 2007, there was a small increase (8%) in respondents reporting
having an institutional fever protocol specific to neurologic patients. Temperatures to initiate treatment either
based on protocols or nurse determination did not change from the previous survey. However, nurses with
specialty certification and/or working in settings with institutional awards (e.g., Magnet status or Stroke Center
Designation) initiated therapy at a lower temperature. Oral acetaminophen continues to be the primary choice
for fever management, followed by ice packs and fans. This study encourages the development of a stepwise
approach to neuro-specific protocols for fever management. Furthermore, it shows the continuing need to
promote further education and specialty training among nurses and encourage collaboration with physicians
to establish best practices.

Keywords: clinical decision making, fever, hyperthermia, nursing intervention

T
he link between fever and resulting neurologic
injury has slowly grown over the years after pos-
itive findings in animal models and supportive
evidence in human studies of stroke, but definitive out-
come measures are still lacking (Albrecht, Wass, &
Lanier, 1998; Greer, Funk, Reaven, Ouzounelli, &
Uman, 2008). Fever is thought to induce secondary brain
injury, which is associated with worse outcomes and
higher mortality rates (Reith et al., 1996; Stocchetti et al.,
Hannah Rockett, MN ARNP CNRN, was an Adult-Gerontology
Nurse Practitioner Student, University of Washington School of
Nursing at the time of acceptance. She is now a Nurse Practitioner
in the Regional Epilepsy Center at Harborview Medical Center,
Seattle, WA.
Questions or comments about this article may be directed to
Hilaire J. Thompson, PhD RN CNRN ACNP-BC FAAN, at hilairet@uw.edu.
She is an Associate Professor, Biobehavioral Nursing and Health
Systems, University of Washington School of Nursing, Seattle, WA.
Patricia A. Blissitt, RN PhD CCRN CNRN CCNS CCM ACNS-BC,
is a Clinical Associate Professor, Biobehavioral Nursing Health
Systems, University of Washington School of Nursing, and Neu-
roscience Clinical Nurse Specialist, Harborview Medical Center
and Swedish Medical Center, Seattle, WA.
The authors declare no conflicts of interest.
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journal’s Web site
(www.jnnonline.com).
Copyright B 2015 American Association of Neuroscience Nurses
DOI: 10.1097/JNN.0000000000000118
2002; Thompson, Tkacs, Saatman, Raghupathi, &
Mcintosh, 2003). Research specific to ischemic stroke
supports this inference (Castillo, Davalos, Marrugat,
& Noya, 1998; Reith et al., 1996; Saini, Saqqur,
Kamruzzaaman, Lees, & Shuaib, 2009); however, ques-
tions have emerged in recent literature about the evi-
dence for treatment of fever in all persons with traumatic
brain injury (TBI; Childs et al., 2010). Currently
available clinical practice guidelines (CPGs) support
the use of interventional therapies to maintain normo-
thermia for ischemic stroke and subarachnoid hem-
orrhage (SAH), but the American Association of
Neurological Surgeons/Brain Trauma Foundation
(AANS/BTF) TBI guidelines fail to mention fever man-
agement entirely (Connolly et al., 2012; Jaunch et al.,
2013; Morgenstern et al., 2010; O’Grady et al., 2008).
Furthermore, when guidelines support treatment of fever,
evidence-based standardized protocols are not avail-
able to neuroscience nurses who initiate these thera-
pies. Rather, many of the protocols available are based
on anecdotal evidence. Without standardized protocols,
nurses are restricted by individual physician orders as
well as their own knowledge of fever management. Neu-
roscience nurses are frequently called on to manage fe-
ver and now must consider if the febrile state in different
neurological disorders should be treated in a similar
fashion or if there is a need for individualization based
on the specific cause of brain injury. Previous studies

Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.

have shown that nurse decision making varies widely
and nurses may be undertreating fever (Thompson,
Kirkness, & Mitchell, 2007). Therefore, the purpose of
this study is to identify characteristics that influence
nurse selection of treatment for fever in the absence of
a protocol and if changes in guidelines have influenced
practice patterns or availability of protocols nationally
and regionally. The clinical neuroscience community
can utilize this information to work together to create
more specific and uniform guidelines for fever
management practices in patients with traumatic and
nontraumatic brain injuries.
Hyperthermia/Fever in Neuroscience
Patients
O’Grady et al. (2008) define normal body temperature
as 37-C, with diurnal variation of 0.5-CY1.0-C. Eleva-
tions in body temperature experienced by brain-injured
patients/neuroscience patients may not always be febrile
in nature. Fever is a cytokine-mediated immune re-
sponse to an immune challenge (e.g., bacteria) resulting
in a systemic response, which includes an increase
in temperature (Mackowiak, 2000). The temperature
increase seen after a brain injury may also be hyper-
thermia, which results directly from hypothalamic dys-
regulation and an altered set point (Mcilvoy, 2012).
Current evidence shows that fever and hyperthermia
are especially detrimental to patients experiencing brain
injury, leading to higher rates of mortality, greater dis-
ability and dependence, loss of function, and longer
lengths of stay (Greer et al., 2008). After an initial
brain injury, multiple factors including fever or hyper-
thermia can lead to secondary brain injury. The under-
lying pathophysiologic mechanism for this is the
heightening of the inflammatory response by the ele-
vation in temperature making the blood brain barrier
more permeable to immune cells, leading to cerebral
edema and neuronal death. In addition, fever increases
the production of oxidants and free radicals and pro-
motes release of glutamate causing excitotoxicity (Globus,
Busto, Lin, Schnippering, & Ginsberg, 1995; Laws &
Jallo, 2010; Morimoto, Ginsberg, Dietrich, & Zhao,
1997; Takagi, Ginsberg, Globus, Martinez, & Busto,
1994). The occurrence of fever/hyperthermia is not un-
common in persons after brain injury. Within 72 hours
of admission, 70% of patients with SAH and 68%
with TBI have temperatures of 38-C or higher, and
within 48 hours of ischemic stroke, greater than 25%
of patients are febrile (Albrecht et al., 1998; Commichau,
Scarmeas, & Mayer, 2003; Grau et al., 1999). Neu-
rocritical care patients with a length of stay of at least
14 days experienced fever at a rate of 93% (Kilpatrick,
Lowry, Firlik, Yonas, & Marion, 2000). Given that these
populations are at high risk for developing a fever, it is
Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 47 & Number 2 & April 2015 67
These authors examine the lack
of evidence in the evaluation of fever
and long-term clinical outcomes
as well as the clinical decision
making based on the short-term
measures being implemented by
neuroscience nurses.
important to understand the consequences of fever in
these patients.
Ischemic Stroke
Evidence concerning the negative impact of fever on
ischemic and hemorrhagic stroke is well established in
the literature. Using a temperature greater than 37.2-C
as the criteria to define fever, Saini et al. (2009) found
that patients with ischemic stroke with delayed fever
at 7 days had worse outcomes and higher mortality.
Other studies have shown that hyperthermia upon
admission and within the first 24 hours are associated
with larger infarct volume and worse neurologic out-
come at 3 months (Castillo et al., 1998; Reith et al.,
1996). However, these earlier studies only evaluated
temperatures up to 72 hours versus 7 days. This high-
lights a key issue: evidence is lacking in the evaluation
of fever on long-term outcomes. Yet clinical decision
making is based on these short-term measures, making
it necessary for nurses to evaluate best practices.
A recent study by Karaszewski and colleagues (2013)
utilized H-magnetic resonance spectroscopy, a non-
invasive imaging technique, to evaluate pyrexia in
ischemic tissue and healthy brain tissue and compare
it with tympanic body temperature in humans with
stroke. The authors found that ischemic brain had a
higher temperature than healthy brain on admission,
but this temperature difference had no significant effect
on patient outcome. Rather, a higher temperature in
contralateral healthy brain tissue correlated with poorer
National Institutes of Health Stroke Scale score, larger
lesion size at 5 days, and worse functional outcome at
3 months. Body temperature elevation correlated with
rise in contralateral normal brain tissue temperature,
reflecting a mechanism of secondary brain injury as a
result of a systemic response to the stroke (Karaszewski
et al., 2013). These results encourage focused ef-
forts on developing interventions to suppress the ad-
verse physiological effects of stroke on healthy brain
tissue.
68 Journal of Neuroscience Nursing
Subarachnoid Hemorrhage
Similar to ischemic stroke, fever in patients with SAH
has been associated with increased morbidity and
decreased functionality at 3 months (Diringer, Reaven,
Funk, & Uman, 2004; Fernandez et al., 2007; Oliveira-
Filho et al., 2001). These studies generally included a
mix of spontaneous and traumatic SAH. More severe
grades of SAH were correlated with more frequent and
higher increases in temperature over 10 days (Fernandez
et al., 2007). The presence of fever was also associated
with worse outcomes and vasospasm regardless of
the size of SAH (Oliveira-Filho et al., 2001). Although
these studies show significant associations between
fever and worse outcomes in persons with SAH, they
do not reflect causality or explain long-term outcomes.
Traumatic Brain Injury
The role of fever in patients with TBI is a bit more
controversial. Although current opinion and a recent
meta-analysis by Greer and colleagues (2008) support
the link between fever in patients with TBI to worse
outcomes, newer information has challenged this as-
sertion (Childs et al., 2010). This is because, in persons
without brain injury, the immune response to fever
may be beneficial (Schulman et al., 2005). Fever is
beneficial to the host in that it supports actions of the
immune system; activates the coagulation response;
and recruits T-cells, neutrophils, and macrophages to
the site of infection (Laws & Jallo, 2010). Childs and
colleagues (2010) argued against fever being detri-
mental for all brain-injured patients and questioned
whether research specific to ischemic stroke can be
translated to TBI because they are not the same disease
process. This assertion was supported by their earlier
work where they found no relationship between worse
outcomes of patients with TBI and increased temper-
ature upon admission (Childs et al., 2006) in contrast
to findings in ischemic stroke (Castillo et al., 1998;
Reith et al., 1996). Rather, they found that extremes
of high or low temperature led to increased mortality,
although patients with a temperature of 36-CY38.5-C
were most likely to survive (Sacho, Vail, Rainey, King,
& Childs, 2010). Further complicating the issue is that
work from Stochetti et al. (2005) found no significant
changes in a number of brain tissue measures during
febrile episodes in patients with TBI (e.g. pH, CO2,
glucose, lactateYpyruvate ratio), and there was an ade-
quate supply of oxygen to brain tissue. They hypoth-
esize that, in TBI, fever correlates with increased cerebral
blood flow to meet metabolic demands. Therefore, they
argue that fever does not clearly negatively impact pa-
tients with TBI because the brain is able to compensate
for the rise in temperature (Stochetti et al., 2005) in
contrast to ischemic stroke where there is a mismatch
Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
between cerebral blood flow and greater metabolic
demand.
Controversy currently exists regarding whether
hyperthermia/fever leads to increases in intracranial
pressure (ICP) in persons with TBI. Patients with TBI
with a Glasgow Coma Scale of 9 or less more com-
monly have early and ongoing fevers with greater
length of stay (Stocchetti et al., 2002, 2005). Clinical
therapy for TBI focuses on managing ICP and second-
ary insults such as fever. Rossi, Zanier, Mauri, Columbo,
and Stocchetti (2001) found that ICP was significantly
increased during febrile episodes. However, multiple
research groups have failed to find any clear relation-
ship between absolute brain temperature and absolute
ICP (Huschak et al., 2008; Mcilvoy, 2007; Rossi et al.,
2001). Although the available evidence fails to show
a clear causal relationship between fever and ele-
vated ICP, the effects of therapeutic interventions
contradict this (Huschak et al., 2008; Mcilvoy, 2007).
Evidence from animal models of TBI clearly supports
the negative impact of fever on the brain, showing in-
creased mortality, contusion volume, axonal damage,
and cerebral edema (Clasen, Pandolfi, Laing, & Casey,
1974; Dietrich, Alonso, Halley, & Busto, 1996). How-
ever, it is uncertain whether data from animal research
can be translated to human models of TBI. Current
research does not absolutely support treating fever to
decrease ICP and postulates the need for randomized
clinical trials to weigh the risk-versus-benefit ratio of
hyperthermia intervention on both short- and long-
term outcomes in patients with TBI specifically.
Meningitis
A recent clinical trial conducted in 49 intensive care
units (ICUs) in France examined if therapeutic hypo-
thermia improved outcome in patients with severe bac-
terial meningitis (Mourvillier et al., 2013). Patients
were randomized to either control or hypothermia
(32-CY34-C for 48 hours) conditions. The trial was
stopped early for safety reasons because there was a
higher incidence of mortality in the hypothermia group
(relative risk = 1.99, 95% CI [1.05, 3.77]; Mourvillier
et al., 2013). However, the mean temperature in the
control group at time 0 was lower than 38-C and was
37-C at 24 hours (normothermic). Thus, because the
study did not examine hyperthermia/fever versus normo-
thermia, no conclusions can be drawn from this study
regarding the treatment of fever in this population,
and further investigation in this area is needed.
Current CPGs
CPGs for SAH and ischemic stroke recommend normo-
thermia, defined as a core temperature of 37-C, as best
practice for neurologically vulnerable patients (Connolly
et al., 2012; Jaunch et al., 2013; Morgenstern et al.,

2010, O’Grady et al., 2008). However, guidelines are
vague, lacking details necessary to establish standard-
ized institutional fever management protocols. The
American Association of Neuroscience Nurses (AANN)
practice guidelines recommend treatment intervention for
patients with ischemic stroke at 38-C using antipy-
retics (Pugh, Mathiesen, Meighan, Summers, & Zrelak,
2008) and recommend maintenance of normothermia
in persons with severe TBI (McIlvoy & Meyer, 2008).
The American Heart Association and American Stroke
Association (AHA/ASA) ischemic stroke guidelines con-
sider hyperthermia to be a temperature of 937.6-C,
whereas the Society of Critical Care Medicine defines
fever as 938.3-C (O’Grady et al., 2008). The AHA/
ASA aneurysmal SAH and spontaneous intracerebral
hemorrhage guidelines recommend aggressive fever
management but do not specify a specific temperature
to initiate treatment (Connolly et al., 2012; Morgenstern
et al., 2010). All three AHA/ASA guidelines support
the use of antipyretics but do not endorse particular
medications. Studies of treatment with aspirin or acet-
aminophen have been inconclusive, showing modest
effects, but none has been statistically significant (Kasner
et al., 2002; Sulter et al., 2004). Whereas prior severe
TBI guidelines discussed temperature management,
the newest Brain Trauma Foundation Guidelines (Brain
Trauma Foundation et al., 2007) do not refer to fever
management at all; only therapeutic hypothermia as a
treatment strategy is mentioned. Together, the avail-
able guidelines for neuroscience patients reflect the lack
of specificity in fever management. Published guide-
lines that do mention treatment specifically support the
use of antipyretics but do not name specific medications,
dosing regimens, or follow-up assessment and treatment.
Gaining a national perspective of fever management
practices by neuroscience nurses enables the identifi-
cation of translational gaps between available evidence
and clinical implementation at the patient bedside. Fur-
thermore, in the absence of explicit practice guidelines
in areas where evidence is currently lacking, a national
survey of current practices will allow for benchmarking
of national trends.
State of the Science in the Treatment of
Elevated Temperature in the Neuroscience
Patient
Nurses are the first to identify and initiate treatment of
fever and thus are in a unique position for its manage-
ment. Fever presenting in neurologically vulnerable
patients may be undertreated by nurses. Thompson,
Kirkness, and Mitchell (2007) found that nurses failed
to initiate any form of treatment in 69% of docu-
mented febrile episodes occurring in adult patients
with TBI. The interventions that were initiated were
Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 47 & Number 2 & April 2015 69
delayed in 57.7% of cases. In 2007, nurses reported a
wide variance in their threshold for febrile interven-
tion based on both institutional protocols and self-
determination of treatment ranging from 37-C to
greater than 40-C (Thompson, Kirkness, Mitchell, &
Webb, 2007). One potential cause of underrecognition
may be related to the chosen monitoring route for body
temperature. Most equipment that nurses have access to
reflect core temperature rather than brain temperature.
Yet, research shows that brain temperature exceeds
core temperature by 0.39-CY2.5-C (Mcilvoy, 2004).
For core temperatures, the most accurate routes of
monitoring are pulmonary artery thermistor, bladder
thermistor, esophageal, and rectal probes, followed by
oral and tympanic. Temporal artery and axillary routes
are least accurate and not recommended for ICU
(O’Grady et al., 2008). Thus, by measuring core tem-
perature with less accurate devices, nurses may not be
identifying fevers at their onset, leading to underdi-
agnosis and undertreatment of fevers. In evaluating
nurse decision making, Thompson and Kagan (2011)
found that nurses chose to do ‘‘what works,’’ making
decisions based on personal knowledge or trying dif-
ferent interventions until one was successful. It is unclear
whether nurses have the tools available (defined neuro-
specific protocols (NSPs) and equipment), physician
support, and personal knowledge to treat patients ap-
propriately. The development of fever management pro-
tocols specific to neuro patients would enable a standard
of care. These findings highlight the need for further
education among nurses working with neuroscience
patients and reflect the need to have explicit evidence-
based guidelines to manage fever.
Therefore, the purpose of this study was to describe
current nursing fever management practices for neuro-
logically vulnerable patients and to describe if or how
fever management practices have shifted over the past
several years since a 2006 survey on the same topic.
Methods
Study Design and Sample
A survey design was used to understand the current
state of the science in the treatment of fever using list
servs from two national nursing organizations: AANN
and American Association of Critical-Care Nurses
(AACN). AANN members received an individual on-
line invitation to participate, whereas AACN members
caring for neuroscience patients were invited to par-
ticipate in their weekly online newsletter. Participants
had the option to enter a random drawing for one of
four $25 gift certificates. Institutional review board ap-
proval from the University of Washington was obtained
for this study. Return of the survey was deemed consent
to participate.
70 Journal of Neuroscience Nursing
Instrument
An adapted version of the original survey from
Thompson, Kirkness, Mitchell, and Webb (2007) was
created online using Catalyst Web Tools (University
of Washington, Seattle, WA). The survey was composed
of 30 items and included new items about participants’
nursing experience, characteristics of their associated
institutions, and new treatment options such as intra-
venous acetaminophen.
Data Analysis
The survey was accessible to AANN and AACN mem-
bers for 4 weeks. Upon survey closure, data were down-
loaded and entered into a statistical analysis program
(SPSS 19.0, IBM, Armonk, NY). Respondents’ state
of residence was organized by region (Northeast,
South, Midwest, West) using the U.S. Bureau of the
Census classification. Simple descriptive statistics were
used to describe participant and institutional charac-
teristics. Comparisons between groups (participant, in-
stitutional, regional) were made using chi-square,
analysis of variance (ANOVA), and Fisher exact tests.
In addition, data were compared between the current
survey and data from the prior 2007 survey using
pairwise comparisons. A value of p G .05 was con-
sidered statistically significant.
Results
Institutional and Participant Characteristics
The characteristics of the practice environments of
respondents (N = 291) are summarized in Table 1,
available as Supplemental Digital Content 1 at http://
links.lww.com/JNN/A18. Most surveys were filled out
by AANN and AACN members who care for adult
patients (87%). The most common practice settings of
respondents were either community or private hospitals
(49%) and academic institutions (48%). Most respon-
dents (88%) worked in an institution who had received
some type of award or certification such as Primary
Stroke Center designation (74%) or Magnet Status (52%;
Table 1, available as Supplemental Digital Content 1
at http://links.lww.com/JNN/A18). The Midwest had
higher reports of Magnet Status and Primary Stroke
Center Certification (PSCC).
The primary survey responders were staff nurses
(62%), with half of responders reporting highest level
of education as a Bachelor of Science in Nursing (BSN;
Table 1, available as Supplemental Digital Content 1 at
http://links.lww.com/JNN/A18). Of those nurses who
reported specialty certification (70%), the most com-
mon were Critical Care Registered Nurse (41%) and
Certified Neuroscience Registered Nurse (CNRN, 38%;
Table 1, available as Supplemental Digital Content 1 at
http://links.lww.com/JNN/A18).
Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Route of Temperature Monitoring
Of the 291 respondents, 90% reported using the oral
route as the primary method of monitoring tempera-
ture. The next most common was rectal (82%), axillary
(75%), urine thermistor (65%), and pulmonary therm-
istor (41%). Nurses in the West region reported using
temporal monitoring significantly more frequently as
the primary method of temperature measurement com-
pared with other regions (13.15, df = 3, p G .01). No
other regional differences were noted in temperature
monitoring.
Neuro-Specific Protocols
Only 80 respondents (27%) reported having a fever
and hyperthermia management protocol specifically
targeted to neuroscience patients. In the present survey,
most protocols were standardized for all neuroscience
patients (43%), followed by one protocol specifically
for patients with stroke, TBI, or SAH only (31%). Of
those respondents reporting having institutional pro-
tocols in place for an individual type of brain injury,
stroke was the most likely to have an NSP (8%). The
West (35%) had the highest percentage of respondents
reporting the availability of an NSP, with the Midwest
(20%) having the fewest. A summary of results can be
found in Table 2, available as Supplemental Digital
Content 2 at http://links.lww.com/JNN/A19.
The temperature at which to initiate treatment based
on the NSP varied widely from 36-C (96.8-F) to 40-C
(104-F). The difference in treatment initiation temper-
ature was not significant across regions. The primary
medication included in NSPs was acetaminophen
(99%), with the most common dose being 650 mg. The
first-line interventions included oral (PO) acetamino-
phen (75%), ice packs (24%), fans (14%), and intravenous
acetaminophen (14%). The most common second-
line interventions were water-cooling blankets (23%),
ibuprofen (19%), acetaminophen PO (19%), and
circulating cooling pads (16%). Third-line therapy
led with water-cooling blankets (25%), circulating
cooling pads (23%), and air convection blankets (14%).
Finally, fourth-line interventions included circulating
cooling pads and intravascular cooling devices both at
14% and ice packs (10%).
Respondents across regions reported using most
interventions similarly. Nurses who work at institutions
with a PSCC reported having oral acetaminophen in the
protocol more often than those in non-PSCCs (Fisher’s
exact test, p G .01). Nurses who work at institutions with
an established NSP report higher rates of institutional
awards and/or recognition (Fisher’s exact test, p G .05).
Although not statistically significant, these institutions
are also more likely to have a PSCC award (Fisher’s
exact test, p = .051). Nurses who work at institutions

with NSPs and report having specialty certification are
more likely to treat fever at lower temperatures (ANOVA,
p G .05).
General Fever Management Protocols
Respondents who stated there is a unit or hospital fever
management protocol at their institution (not specific
to patients with neurological disorders, n = 62) reported
a mean temperature at which to initiate treatment to be
38.4-C T 0.3-C. This mean temperature is identical to
the value found in the previous survey and, again, did
not significantly vary by region. The range of tem-
peratures reported for beginning fever management
was smaller than for the NSPs, at 37.6-CY39.4-C.
The primary medication used was oral acetaminophen
(89%) and intravenous acetaminophen (11%), with
the most common treatments including ice packs (13%)
and fans (8%). There were no significant differences in
first-line treatments among regions.
Individual Management of Fever in Patients
With Neurological Insults
On the basis of their personal decision making, nurses
reported initiating treatments at lower levels: a mean
temperature of 38-C in comparison with both insti-
tutional protocols (Table 3, available as Supplemental
Digital Content 3 at http://links.lww.com/JNN/A20).
The minimum temperature at which nurses reported
intervening for fever or hyperthermia was 34.5-C with
a maximum of 39.4-C. Again, the primary medication
of choice was acetaminophen (90%) at a dose of 650 mg
(81%) every 4 hours (52%). First-line interventions in-
cluded oral acetaminophen (80%), followed by intrave-
nous acetaminophen (11%). Other first-line interventions
included ice packs (19%), fans (17%), tepid bathing
(11%), and water-cooling blankets (6%). Measures for
second-line treatment included water-cooling blankets
(24%), ice packs (22%), and Tylenol PO (14%). Third-
line interventions were water-cooling blankets and ice
packs equally (20%), fans (12%), and tepid bathing
(10%). Again, water-cooling blankets led at 17% for
fourth-line therapy, followed by circulating cooling pads
(10%). Additional results are summarized in Table 3,
available as Supplemental Digital Content 3 at http://
links.lww.com/JNN/A20.
Several significant findings regarding nurse deci-
sion making were found. On the basis of their personal
decision making, nurses who have specialty certification
initiate treatment at significantly lower temperatures
than those without certification (37.9-C; ANOVA,
p G .01). Nurses with CNRN (37.9-C) and critical-care
clinical nurse specialist (37.6-C) certification were more
likely to treat fever/hyperthermia at significantly lower
temperatures than nurses with other or no certification
(p G .05). Nurses who reported their institution had an
Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 47 & Number 2 & April 2015 71
award treated at significantly lower temperatures (p G
.05); however, there was no significant difference be-
tween individual award type and temperature to initiate
treatment.
Nurses based their individual decision to treat fever
upon healthcare provider orders (41%), independent
nursing judgment (34%), national guidelines (12%),
and per-the-unit protocol (11%). Those nurses who
based their decisions on physician orders (38.2-C) were
more likely to initiate treatment at higher temperatures
than nurses who followed national guidelines (37.7-C).
There was no significant effect of years of nursing
experience or level of nursing education on personal
decision making with regards to fever management.
Additional Open-Ended Responses
We asked participants, ‘‘Is there anything else regard-
ing fever management practices that you would like
to share with us?’’ The most frequent comments by
respondents indicated that they
 are often confronted with disagreements among prac-
titioners on how to manage fever in the same patient
and with highly variable approaches that can create
confusion (n = 11);
 noted the importance of shivering assessment and
management to include counterwarming measures,
protocol (n = 12); and
 identified that pan cultures were ordered as a standard
of care in patients with fever/hyperthermia (n = 11).
The frequency of culturing varied from every 24 to
72 hours.
In addition, several additional interventions were
identified as important such as changes in room tem-
perature (n = 5) and removing covers/clothing (n = 8).
With regards to medication management, several re-
spondents (n = 4) identified that they alternated ibu-
profen and acetaminophen. Similar to the prior survey,
several respondents (n = 4 each) indicated that (a)
they do not believe fever/hyperthermia is taken as se-
riously or is treated as aggressively as it should be by
practitioners, (b) more education of all levels of pro-
viders is needed regarding fever and its management
in neuroscience patients, and (c) there is a need for a
standardized approach to fever and its management.
Discussion
In comparison with the previous survey results, our
results show several similarities and differences. Acet-
aminophen continues to be the primary medication
administered at a dose of 650 mg every 4 hours both in
neuro-specific and general protocols and is the most
frequently selected by nurses to treat fever. The data
show the intravenous form of acetaminophen, which
72 Journal of Neuroscience Nursing
gained U. S. Food and Drug Administration approval
in 2010, is now the second most common medication
used. The use of an antipyretic follows the recommen-
dations of national guidelines (Jaunch et al., 2013).
Despite nonspecific guidelines, this study can allow
institutions to benchmark against national usage patterns
to formulate or revise a step-by-step process to initiate
care of patients with brain injury. The most common
first-line interventions in the current survey included ice
packs, fans, and tepid bathing, whereas the previous
survey had higher reports of water-cooling blanket use.
The AANN Guidelines for SAH recommend the use of
surface or intravascular cooling devices if medications
are ineffective (Alexander, Gallek, Presciutti, & Zrelak,
2007). Our results support this guideline, with water-
cooling blankets being the most common second-line
intervention (23%) in NSPs.
The finding that rates of NSP utilization have in-
creased, from 19% in the previous survey (Thompson,
Kirkness, Mitchell, & Webb, 2007) to 27% in this
survey, reflects a positive change in evidence-based
practice over the last several years. However, it is un-
clear whether this change is related to an increased
clinical awareness, improved education, or efforts by
institutions or healthcare providers. On the basis of
the questions asked, we know institutions with NSP
in place are more likely to have received recognition
and/or awards. Institutions with awards are required
to meet certain standards that follow up-to-date evidence-
based practices. For PSCC, The Joint Commission
(2012) states that programs applying must display com-
pliance with CPGs, specifically mentioning the AHA/
ASA recommendations.
On the basis of NSP and independent decision
making, nurses continue to initiate treatment of fever
or hyperthermia over a wide range of temperatures.
The ischemic stroke AANN and AHA/ASA Guide-
lines recommend the lowest temperature to initiate
therapy at 37.6-C (Jaunch et al., 2013; Summers et al.,
2009), whereas the Society of Critical Care Medicine
and AANN Guidelines for SAH recommend 38.3-C
as a starting point (Alexander et al., 2007; O’Grady
et al., 2008). In the previous survey, the Midwest
NSPs averaged 38.6-C, greater than all guideline recom-
mendations. However, the current survey showed no
significant differences among regions and a maximum
NSP average of 38.2-C in the South. This shows pro-
gress in the field of NSPs aligning with national guide-
line recommendations. Of note are the reports of NSP’s
withholding treatment until 40-C and the nursing de-
cision to initiate treatment at temperatures below 37-C
(normothermia). We are unable to determine whether
patients treated at higher temperatures reflect type of
injury, infection versus noninfection, or institutional or
provider philosophy on the benefits of fever. Temperatures
Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
below normothermia may be related to hypothermia
induction measures.
Importantly, nurses with any type of additional cer-
tification chose to treat fever at lower temperatures,
particularly those with CNRN and critical-care clinical
nurse specialist certification. Nurses who gain CNRN
certification show specific knowledge in the care of
neuroscience patients. Clinical nurse specialists are
experts in their field, capable of improving patient out-
comes (National Association of Clinical Nurse Spe-
cialists, 2013). Studies show that hospitals with a larger
proportion of nurses with baccalaureate and higher
degrees have lower rates of 30-day mortality and failure
to rescue (Blegen, 2012; Kendall-Gallagher, Aiken,
Sloane, & Cimiotti, 2011). Nurses with specialty cer-
tification who also have a BSN show similar rates of
decreased mortality and failure to rescue (Kendall-
Gallagher et al., 2011). In the current study, 72% of
respondents reported having a BSN or Master’s degree,
and 70% reported having specialty certification. The
high number of respondents with this level of educa-
tion and specialty credentials lends further support for
these as an indicator of greater knowledge of evidence-
based practices.
Limitations
Of the 1,068 AANN members who opened the e-mail
inviting participation, 244 nurses (22.8%) clicked on
the link to participate. This is a similar response rate to
the previous paper-and-pencil survey, showing that the
online format failed to enhance participation. We were
unable to collect response information from AACN
because of the manner in which the invitation to par-
ticipate was sent, and therefore, actual return rates
may be lower than expected. Participation may have
been influenced by the lack of a reminder to fill out
the survey. The assumed benefits of an online survey
were the minimal time requirement, ease of use, and
accessibility. The Catalyst Web Tools format could
have been difficult to navigate or been slow to access
because of server bandwidth, which several respondents
reported.
Because of the anonymity of the survey, it is not
known whether the participants worked at only a few
institutions or a large variety. Less institutional variety
would imply fewer variances in protocols. Respon-
dents reported information based on their knowledge
of their institutional protocols. Therefore, the accuracy
of information provided by respondents could have
been influenced based on having access to the protocol
to reference at the time of the survey. This may explain
the smaller number of general unit protocols reported,
with the assumption that neuroscience nurses are using
this protocol less frequently than the NSP. Further-
more, with most patients being adults (87%), survey

findings provide little evidence in support of refine-
ment of NSP for pediatric neuroscience populations.
Future research would benefit from a focused pediatric
questionnaire.
In the current survey, participants were asked to
rank their first- up to fourth-line interventions for fever
management, whereas the previous survey did not
obtain rankings because of difficulty understanding the
question. Therefore, the higher overall percentage rates
of use reported in the original survey reflect whether
protocols or nurses ever use particular interventions
rather than a stepwise process of utilization. We did not
specifically ask questions about hypothermia induction
in the survey; the very low values of temperature ini-
tiation reported may reflect protocols to induce hypo-
thermia as opposed to normothermia.
Conclusions
Fever management practices for neurologically vul-
nerable patients have not changed dramatically over
the past several years. However, several new findings
do assist us in understanding current practices and what
may influence the development of NSPs and nurse
decision making. Both award status and certification
influence meeting best practice standards. This sup-
ports the idea that striving for specialty certification
and institutional awards benefits patient care, institu-
tions, and nurses alike. Although oral acetaminophen
is the primary medication prescribed, this survey shows
what nurses and NSPs use for second-, third-, and
fourth-line therapy. However, because of limited num-
bers of respondents with NSPs focused on specific
neuroscience subpopulations (e.g., stroke, SAH, TBI),
we cannot provide additional granularity to provide
benchmarking recommendations by patient condition.
Further work in this area is needed. Our data show that
NSPs appear to take a more aggressive route of fever
management, whereas individual nurse decision making
is less aggressive, especially when reaching third- and
fourth-line measures. Whether these steps are evidence-
based treatments is a question that can only be answered
with additional research not yet occurring in the field.
Future inquiries to be undertaken include whether
fever management could benefit from being included
in bundled care practices. The Awakening, Breathing,
Coordination, Delirium Monitoring and Management,
and Early Mobility (‘‘ABCDE’’) bundle combines
evidence-based practices from a few discrete fields to
improve patient outcomes. This model applies spe-
cifically to ICUs, delineating a stepwise process
performing routine assessments to progress patients
back to their baseline more effectively (Balas et al.,
2012). Neuroscience nurses could adapt this protocol
to include fever management (‘‘ABCDEF’’), which
would make hyperthermia a priority and a focus of
Copyright © 2015 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 47 & Number 2 & April 2015 73
every patient’s treatment plan. As of now, there is no
evidence evaluating long-term outcomes of neuroscience
patients experiencing fever. A multitude of individual
circumstances influence outcomes, including severity
of injury, social and financial support, rehabilitation, in-
fection, and healthcare providers, among others. There-
fore, next steps to improve short-term quality of care
include nurse-driven management, education of nurses
on CPGs, and working with physicians to develop
institutional-based NSPs.
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