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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

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he link between fever and resulting neurologic injury has slowly grown over the years after positive findings in animal models and supportive evidence in human studies of stroke, but definitive outcome 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 [email protected]. 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 Neuroscience 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, questions have emerged in recent literature about the evidence 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 normothermia for ischemic stroke and subarachnoid hemorrhage (SAH), but the American Association of Neurological Surgeons/Brain Trauma Foundation (AANS/BTF) TBI guidelines fail to mention fever management 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 available to neuroscience nurses who initiate these therapies. 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. Neuroscience nurses are frequently called on to manage fever 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

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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. Elevations in body temperature experienced by brain-injured patients/neuroscience patients may not always be febrile in nature. Fever is a cytokine-mediated immune response 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 hyperthermia, which results directly from hypothalamic dysregulation 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 disability and dependence, loss of function, and longer lengths of stay (Greer et al., 2008). After an initial brain injury, multiple factors including fever or hyperthermia can lead to secondary brain injury. The underlying pathophysiologic mechanism for this is the heightening of the inflammatory response by the elevation 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 promotes 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 uncommon 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). Neurocritical 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

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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 outcome 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 highlights 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 noninvasive 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 efforts on developing interventions to suppress the adverse physiological effects of stroke on healthy brain tissue.

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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; OliveiraFilho 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 assertion (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 detrimental 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 temperature 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 adequate supply of oxygen to brain tissue. They hypothesize that, in TBI, fever correlates with increased cerebral blood flow to meet metabolic demands. Therefore, they argue that fever does not clearly negatively impact patients 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

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 commonly have early and ongoing fevers with greater length of stay (Stocchetti et al., 2002, 2005). Clinical therapy for TBI focuses on managing ICP and secondary 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 relationship 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 elevated 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 increased mortality, contusion volume, axonal damage, and cerebral edema (Clasen, Pandolfi, Laing, & Casey, 1974; Dietrich, Alonso, Halley, & Busto, 1996). However, 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 longterm outcomes in patients with TBI specifically.

Meningitis A recent clinical trial conducted in 49 intensive care units (ICUs) in France examined if therapeutic hypothermia improved outcome in patients with severe bacterial 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 normothermia, 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 normothermia, 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.,

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2010, O’Grady et al., 2008). However, guidelines are vague, lacking details necessary to establish standardized 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 antipyretics (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 consider 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 acetaminophen 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 available guidelines for neuroscience patients reflect the lack of specificity in fever management. Published guidelines 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 identification of translational gaps between available evidence and clinical implementation at the patient bedside. Furthermore, 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 management. 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 documented febrile episodes occurring in adult patients with TBI. The interventions that were initiated were

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delayed in 57.7% of cases. In 2007, nurses reported a wide variance in their threshold for febrile intervention based on both institutional protocols and selfdetermination 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 temperature with less accurate devices, nurses may not be identifying fevers at their onset, leading to underdiagnosis 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 different interventions until one was successful. It is unclear whether nurses have the tools available (defined neurospecific protocols (NSPs) and equipment), physician support, and personal knowledge to treat patients appropriately. The development of fever management protocols 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 evidencebased guidelines to manage fever. Therefore, the purpose of this study was to describe current nursing fever management practices for neurologically 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 online invitation to participate, whereas AACN members caring for neuroscience patients were invited to participate in their weekly online newsletter. Participants had the option to enter a random drawing for one of four $25 gift certificates. Institutional review board approval from the University of Washington was obtained for this study. Return of the survey was deemed consent to participate.

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Instrument

Route of Temperature Monitoring

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 intravenous acetaminophen.

Of the 291 respondents, 90% reported using the oral route as the primary method of monitoring temperature. The next most common was rectal (82%), axillary (75%), urine thermistor (65%), and pulmonary thermistor (41%). Nurses in the West region reported using temporal monitoring significantly more frequently as the primary method of temperature measurement compared with other regions (13.15, df = 3, p G .01). No other regional differences were noted in temperature monitoring.

Data Analysis The survey was accessible to AANN and AACN members for 4 weeks. Upon survey closure, data were downloaded 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 characteristics. Comparisons between groups (participant, institutional, 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 considered 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 respondents (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 common 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).

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 protocols 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 temperature 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) acetaminophen (75%), ice packs (24%), fans (14%), and intravenous acetaminophen (14%). The most common secondline 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

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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 temperatures 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 institutional 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 included oral acetaminophen (80%), followed by intravenous 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%). Thirdline 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 decision 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

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award treated at significantly lower temperatures (p G .05); however, there was no significant difference between 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 regarding 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 practitioners 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 temperature (n = 5) and removing covers/clothing (n = 8). With regards to medication management, several respondents (n = 4) identified that they alternated ibuprofen and acetaminophen. Similar to the prior survey, several respondents (n = 4 each) indicated that (a) they do not believe fever/hyperthermia is taken as seriously or is treated as aggressively as it should be by practitioners, (b) more education of all levels of providers 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. Acetaminophen 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

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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 recommendations 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 watercooling blankets being the most common second-line intervention (23%) in NSPs. The finding that rates of NSP utilization have increased, 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 unclear 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 evidencebased practices. For PSCC, The Joint Commission (2012) states that programs applying must display compliance 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 Guidelines 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 recommendations. However, the current survey showed no significant differences among regions and a maximum NSP average of 38.2-C in the South. This shows progress in the field of NSPs aligning with national guideline recommendations. Of note are the reports of NSP’s withholding treatment until 40-C and the nursing decision 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

below normothermia may be related to hypothermia induction measures. Importantly, nurses with any type of additional certification 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 outcomes (National Association of Clinical Nurse Specialists, 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 certification who also have a BSN show similar rates of decreased mortality and failure to rescue (KendallGallagher 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 education and specialty credentials lends further support for these as an indicator of greater knowledge of evidencebased 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 participate 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. Respondents 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. Furthermore, with most patients being adults (87%), survey

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findings provide little evidence in support of refinement 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 initiation reported may reflect protocols to induce hypothermia as opposed to normothermia.

Conclusions Fever management practices for neurologically vulnerable 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 supports the idea that striving for specialty certification and institutional awards benefits patient care, institutions, 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 numbers 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 evidencebased 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 specifically 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

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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, infection, and healthcare providers, among others. Therefore, 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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