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Development and Evaluation of an Evidence-Based Nursing Protocol for Fever Management in Adult Patients

Yong Soon Shin1, Sung Reul Kim2, Sung-Hee Yoo3, Sun Hwa Kim4, Jeoung Hee Kim4, Hyun Jung Kim4, Na-Ra 4, Jee Sun Chae4, Hye Jin Lee4, Young Hee An4, Kyoung-Ok Kim4
Korean Journal of Adult Nursing 2013;25(3):250-262.
Published online: June 18, 2013

1Department of Nursing, Changwon National University, Changwon

2College of Nursing, Chonbuk National University, Jeonju

3College of Nursing, Chonnam National University, Gwangju

4Department of Nursing, Asan Medical Center, Seoul, Korea

Corresponding author: Kim, Sung Reul College of Nursing, Chonbuk National University, 567 Baekje-daero, Deokjin-gu, Jeonju 561-756, Korea. Tel: +82-63-270-3118, Fax: +82-63-270-3127, E-mail: srkim@jbnu.ac.kr
• Received: January 2, 2013   • Accepted: June 17, 2013

© 2013 Korean Society of Adult Nursing

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Purpose
    This study was designed to develop, to implement and evaluate a fever management nursing protocol for adult patients.
  • Methods
    This study was conducted through seven steps following both the guideline development procedures of the Scottish Intercollegiate Guidelines Network and the Model of the Asan Medical Center Evidence-Based Practice, as follows: 1) identifying the clinical needs and composition of the protocol development group; 2) identifying and evaluating the evidence; 3) assessing the level of evidence and grading recommendations; 4) forming a protocol; 5) evaluating the protocol using an expert group validity test and identifying barriers to its implementation; 6) protocol development; and 7) evaluation of practical improvement measures following implementation of the protocol.
  • Results
    The evidence-based protocol for fever management in adult patients was completed and includes five domains and 15 items. The protocol had good content validity (CVI=.90) and nursing practice could be improved after implementation of the protocol.
  • Conclusion
    This nursing protocol can be used as a guide for nursing in febrile adult patients. We recommend that further guidelines be updated in an interdisciplinary manner in order to foster local adaptation of the best clinical practices.
  • Key Words: Adult; Fever; Evidence-Based Practice; Nursing protocol
Table 1.
Perception on Fever Management by Nurses and Physicians (N=246)
Contents Nurses (n=189) Physicians (n=57)
n (%) Median (range) n (%) Median (range)
I consider fever that BT is over () (℃)
  Tympanic temperature   37.5 (37.0~38.0)   37.6 (36.7~38.3)
  Axillary temperature   37.5 (36.5~38.0)   37.5 (37.0~38.0)
I start nursing intervention at BT (℃)   37.5 (37.0-38.0)   38.0 (37.0-38.3)
Cryotherapy may be useful method for febrile patients 171 (90.5)   46 (80.7)  
I define fever based on my experiences 95 (50.3)   25 (43.9)  
Fever guideline is needed. 186 (98.4)   56 (98.2)  

BT=body temperature.

Table 2.
Number of Literature Review by Web Search Engines
Clinical questions (Key words) 1st Searching Primary Selection n 2nd Searching Final Selection
NGC JBI RCN GIN Cochrane PubMed CINAHL KoreaMed KERIS KISS
1. Definition of a fever ("adult" AND "fever guideline") 388 2 0 2 43 732 3 12 0 0 3 1 4
2. The most appropriate measurement of BT ("adult" AND "fever" AND "body temperature measurement" OR "temperature measurement") 502 3 0 2 1,517 331 456 125 221 1,346 20 - 3 (2)
3. Interval of rechecking BT (Same as above) 0 0 0 0 0 1 0 0 0 0 0 1 1
4. Tympanic temperature measurement ("adult" AND "tympanic temperature" AND "body temperature measurement") 3 1 0 1 0 200 92 4 4 0 3 1 4 (3)
5. External cooling ("adult" and "fever" OR "fever control" AND "cryotherapy" OR "cold compression" OR "ice bag" OR "ice pack" OR "cold pack" OR "external cooling") 23 1 0 0 65 295 35 9 76 1 26 1 10
6. Tepid massage ("adult" AND "fever" AND "tepid massage" OR "tepid sponging") 0 0 0 0 0 0 0 0 0 0 0 - 0
7. Body exposure ("adult" AND "fever" AND "body exposure") 0 0 0 0 0 0 0 0 0 0 0 - 0
8. Hydration ("adult" AND "fever" AND "hydration") 46 2 0 0 9 122 10 12 415 9 1 - 1
9. Shivering control ("adult" AND "fever" AND "shivering") 2 2 0 0 45 8 25 3 7 2 0 1 1
Total 294 11 0 5 1,679 1,688 621 165 723 1,358   58 24 (22)

Note. A number in parenthesis is number of papers excluding overlapped. NGC=National Guideline Clearinghouse; JBI=Joanna Briggs Institute; RCN=Royal College of Nursing; GIN=Guidelines International Network; CINAHL=Cumulative Index to Nursing and Allied Health Literature; KERIS=Korea Education and Research Information Service; KISS=Korean Studies Information Service System; BT=body temperature.

Table 3.
Evaluation on the Evidence of Fever Management
Clinical questions Evidence Level of evidence
Question 1. What is the definition of a fever? SR (2), Guideline (1), Expert opinion (1) 2++
Question 2. What is the most appropriate measurement of body temperature? SR (1), Guideline (1), RCT (1) 1+
Question 3. When should nurses recheck body temperature after the first measurement in febrile patients? Cohort study (1) 2+
Question 4. What is the most accurate way to measure tympanic temperature?    
  1) Is it necessary to pull the auricle of the ear in an upward and backward direction? SR (1) 2++
  2) Which side of ear is measured? SR (1) 1+
  3) Could using a pillow affect the tympanic temperature? SR (1) 1+
  4) How should a lens filter be managed? SR (1), Guideline (1) 1+
  5) When should a lens filter be changed? Manufacturer's guideline (1) 4
  6) Should nurses record the site of temperature measurement? Guideline (1) 1++
Question 5.    
  1) Would external cooling help to reduce body temperature in febrile patients? SR (1), Meta-analysis (1), RCT (7) 1+
  2) Should adverse effects be assessed following application of external cooling? Non-RCT (1) 2+
Question 6. Would a tepid massage help to reduce the body temperature in febrile patients? Unpublished expert opinion (1) 4
Question 7. Would removing clothing and increasing skin exposure help to reduce the body temperature in febrile patients? Unpublished expert opinion (1) 4
Question 8. Would hydration help to reduce body temperature in febrile patients? Guideline (1) 1+
Question 9. What interventions could help to control shivering and to improve the comfort level in febrile patients who are shivering? Cohort study (1) 2+

SR=systematic review; RCT=randomized controlled Trial.

Table 4.
Grade of Recommendation and Content Validation by Expert Panel
Domain Evidence statement LE GR 1st CVI 2nd CVI
Definition of fever 1. A new onset of temperature of≥38.3℃ is considered as a fever in critically ill adult patients. 2++ C .44  
2. Fever is defined as: (1) A single oral temperature＞37.8℃; or 2) repeated oral temperatures＞37.2℃ or rectal temperatures＞37.5℃; or 3) an increase in temperature of＞1.1℃ over the baseline temperature. 1+ B .55  
＜Revised Statement for 2nd CVI＞   1.00
A new onset of temperature of＞37.7℃ is considered as a fever in adult patients.  
Temperature measurement 3. Fever is defined as the temperature of the tympanic membrane (although the body temperature can be measured at the axilla if tympanic membrane temperature measurement is not possible). 1+ B .66  
＜Revised Statement for 2nd CVI＞   .88
Fever is defined as the temperature of the tympanic membrane, but measurement of the temperature of axilla do not recommend in febrile patients  
4. When fever onset, the body temperature should be rechecked () minutes later. 2+ C NS  
＜Revised Statement for 2nd CVI＞   1.00
Body temperature should be rechecked after the new onset of fever.
5. An ear tug should be used during measurement of the tympanic temperature in order to straighten the external auditory canal. The tug technique pulls the auricle of the ear in an upward and backward direction. 2++ B 1.00
6. An ear nearest examiner should be used for stability of measurement of the tympanic temperature. 1+ B 1.00
7. If a patient has been using a pillow, the tympanic temperature should be measured in the opposite ear so as to avoid a falsely elevated temperature. 1+ B 1.00
8. The lens filter should be clear and dry before using an infrared ear thermometer. 1+ B 1.00
9. The lens filter should be exchanged for a new one before every temperature measurement. 4 D .88
10. The site of the temperature measurement should be recorded along with the temperature in the patient's chart. 1++ A 1.00
External cooling 11. External cooling can be used as a fever management intervention 1+ A .88
12. Side effects such as shivering, hunting phenomenon, tingling sense or discomfort about cold, should all be assessed following the application of external cooling. 2+ C 1.00
13. It is not clear whether tepid massage is helpful in reducing the body temperature in adult febrile patients. 4 D .88
14. It is not clear whether body exposure helps to reduce the body temperature in adult febrile patients. 4 D .88
Hydration shivering control 15. It is not clear whether hydration is helpful for reducing the body temperature in adult febrile patients, although hydration should be considered in order to avoid dehydration in adult patients in a febrile condition. 1+ A 1.00
16. Skin counter warming should be used when febrile adult patients are shivering. 2+ C 1.00
Average CVI       .88 .90

LE=Level of evidence; GR=Grade of recommendation; CVI=content validity index; NS=not stated.

Table 5.
Comparison of Nursing Intervention for Adult Febrile Patients Before and After Implementation of the Fever Management Protocol (N=434)
Characteristics Before (n=228) After (n=206) x2 or Z p
n (%) or Median (range) n (%) or Median (range)
Age (year) 59 (18~93) 61 (20~96) -0.282 .778
Gender     0.559 .500
  Male 110 (48.2) 91 (44.7)    
  Female 118 (51.8) 114 (55.3)    
Department of Admission     51.834 ＜.001
  Neurosurgery 11 (4.8) 22 (13.6)
  Orthopedic surgery 72 (31.6) 85 (41.3)
  Neurology 24 (10.5) 22 (10.7)
  Rehabilitation medicine 57 (25.0) 35 (17.0)
  Psychiatry 8 (3.5) 25 (12.1)
  Others 56 (24.6) 11 (5.3)
Notification 135 (72.4) 179 (86.9) 13.890 ＜.001
BT at notification (℃) 37.9 (37.0~40.0) 38.0 (37.1~39.3) -3.632 ＜.001
Nursing intervention 217 (95.2) 200 (97.1) 1.051 .305
BT for nursing intervention (℃) 37.8 (36.5~39.9) 38.0 (37.0~39.3) -4.739 ＜.001
Site of temperature measurement     186.723 ＜.001
  Tympanic membrane 15 (6.6) 143 (69.4)
  Axilla 160 (70.2) 51 (25.2)
  Both 45 (19.7) 12 (5.3)
  Not mentioned 8 (3.5) 0 (0.0)
External cooling 96 (42.1) 107 (51.9) 4.206 .040
Follow up interval (hour) 4 (1~4) 1 (0.3~12) -4.692 ＜.001
Tepid massage 116 (50.9) 69 (33.5) 13.370 ＜.001
Shivering assessment 113 (71.8) 173 (84.0) 9.656 .002
Shivering management 14 (21.9) 25 (45.5) 7.465 .006

BT=body temperature

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    Development and Evaluation of an Evidence-Based Nursing Protocol for Fever Management in Adult Patients
    Korean J Adult Nurs. 2013;25(3):250-262.   Published online June 30, 2013
    DOI: https://doi.org/10.7475/kjan.2013.25.3.250
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    Development and Evaluation of an Evidence-Based Nursing Protocol for Fever Management in Adult Patients
    Korean J Adult Nurs. 2013;25(3):250-262.   Published online June 30, 2013
    DOI: https://doi.org/10.7475/kjan.2013.25.3.250
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    Development and Evaluation of an Evidence-Based Nursing Protocol for Fever Management in Adult Patients
    Development and Evaluation of an Evidence-Based Nursing Protocol for Fever Management in Adult Patients

    Perception on Fever Management by Nurses and Physicians (N=246)

    Contents Nurses (n=189) Physicians (n=57)
    n (%) Median (range) n (%) Median (range)
    I consider fever that BT is over () (℃)
      Tympanic temperature   37.5 (37.0~38.0)   37.6 (36.7~38.3)
      Axillary temperature   37.5 (36.5~38.0)   37.5 (37.0~38.0)
    I start nursing intervention at BT (℃)   37.5 (37.0-38.0)   38.0 (37.0-38.3)
    Cryotherapy may be useful method for febrile patients 171 (90.5)   46 (80.7)  
    I define fever based on my experiences 95 (50.3)   25 (43.9)  
    Fever guideline is needed. 186 (98.4)   56 (98.2)  

    BT=body temperature.

    Number of Literature Review by Web Search Engines

    Clinical questions (Key words) 1st Searching Primary Selection n 2nd Searching Final Selection
    NGC JBI RCN GIN Cochrane PubMed CINAHL KoreaMed KERIS KISS
    1. Definition of a fever ("adult" AND "fever guideline") 388 2 0 2 43 732 3 12 0 0 3 1 4
    2. The most appropriate measurement of BT ("adult" AND "fever" AND "body temperature measurement" OR "temperature measurement") 502 3 0 2 1,517 331 456 125 221 1,346 20 - 3 (2)
    3. Interval of rechecking BT (Same as above) 0 0 0 0 0 1 0 0 0 0 0 1 1
    4. Tympanic temperature measurement ("adult" AND "tympanic temperature" AND "body temperature measurement") 3 1 0 1 0 200 92 4 4 0 3 1 4 (3)
    5. External cooling ("adult" and "fever" OR "fever control" AND "cryotherapy" OR "cold compression" OR "ice bag" OR "ice pack" OR "cold pack" OR "external cooling") 23 1 0 0 65 295 35 9 76 1 26 1 10
    6. Tepid massage ("adult" AND "fever" AND "tepid massage" OR "tepid sponging") 0 0 0 0 0 0 0 0 0 0 0 - 0
    7. Body exposure ("adult" AND "fever" AND "body exposure") 0 0 0 0 0 0 0 0 0 0 0 - 0
    8. Hydration ("adult" AND "fever" AND "hydration") 46 2 0 0 9 122 10 12 415 9 1 - 1
    9. Shivering control ("adult" AND "fever" AND "shivering") 2 2 0 0 45 8 25 3 7 2 0 1 1
    Total 294 11 0 5 1,679 1,688 621 165 723 1,358   58 24 (22)

    Note. A number in parenthesis is number of papers excluding overlapped. NGC=National Guideline Clearinghouse; JBI=Joanna Briggs Institute; RCN=Royal College of Nursing; GIN=Guidelines International Network; CINAHL=Cumulative Index to Nursing and Allied Health Literature; KERIS=Korea Education and Research Information Service; KISS=Korean Studies Information Service System; BT=body temperature.

    Evaluation on the Evidence of Fever Management

    Clinical questions Evidence Level of evidence
    Question 1. What is the definition of a fever? SR (2), Guideline (1), Expert opinion (1) 2++
    Question 2. What is the most appropriate measurement of body temperature? SR (1), Guideline (1), RCT (1) 1+
    Question 3. When should nurses recheck body temperature after the first measurement in febrile patients? Cohort study (1) 2+
    Question 4. What is the most accurate way to measure tympanic temperature?    
      1) Is it necessary to pull the auricle of the ear in an upward and backward direction? SR (1) 2++
      2) Which side of ear is measured? SR (1) 1+
      3) Could using a pillow affect the tympanic temperature? SR (1) 1+
      4) How should a lens filter be managed? SR (1), Guideline (1) 1+
      5) When should a lens filter be changed? Manufacturer's guideline (1) 4
      6) Should nurses record the site of temperature measurement? Guideline (1) 1++
    Question 5.    
      1) Would external cooling help to reduce body temperature in febrile patients? SR (1), Meta-analysis (1), RCT (7) 1+
      2) Should adverse effects be assessed following application of external cooling? Non-RCT (1) 2+
    Question 6. Would a tepid massage help to reduce the body temperature in febrile patients? Unpublished expert opinion (1) 4
    Question 7. Would removing clothing and increasing skin exposure help to reduce the body temperature in febrile patients? Unpublished expert opinion (1) 4
    Question 8. Would hydration help to reduce body temperature in febrile patients? Guideline (1) 1+
    Question 9. What interventions could help to control shivering and to improve the comfort level in febrile patients who are shivering? Cohort study (1) 2+

    SR=systematic review; RCT=randomized controlled Trial.

    Grade of Recommendation and Content Validation by Expert Panel

    Domain Evidence statement LE GR 1st CVI 2nd CVI
    Definition of fever 1. A new onset of temperature of≥38.3℃ is considered as a fever in critically ill adult patients. 2++ C .44  
    2. Fever is defined as: (1) A single oral temperature＞37.8℃; or 2) repeated oral temperatures＞37.2℃ or rectal temperatures＞37.5℃; or 3) an increase in temperature of＞1.1℃ over the baseline temperature. 1+ B .55  
    ＜Revised Statement for 2nd CVI＞   1.00
    A new onset of temperature of＞37.7℃ is considered as a fever in adult patients.  
    Temperature measurement 3. Fever is defined as the temperature of the tympanic membrane (although the body temperature can be measured at the axilla if tympanic membrane temperature measurement is not possible). 1+ B .66  
    ＜Revised Statement for 2nd CVI＞   .88
    Fever is defined as the temperature of the tympanic membrane, but measurement of the temperature of axilla do not recommend in febrile patients  
    4. When fever onset, the body temperature should be rechecked () minutes later. 2+ C NS  
    ＜Revised Statement for 2nd CVI＞   1.00
    Body temperature should be rechecked after the new onset of fever.
    5. An ear tug should be used during measurement of the tympanic temperature in order to straighten the external auditory canal. The tug technique pulls the auricle of the ear in an upward and backward direction. 2++ B 1.00
    6. An ear nearest examiner should be used for stability of measurement of the tympanic temperature. 1+ B 1.00
    7. If a patient has been using a pillow, the tympanic temperature should be measured in the opposite ear so as to avoid a falsely elevated temperature. 1+ B 1.00
    8. The lens filter should be clear and dry before using an infrared ear thermometer. 1+ B 1.00
    9. The lens filter should be exchanged for a new one before every temperature measurement. 4 D .88
    10. The site of the temperature measurement should be recorded along with the temperature in the patient's chart. 1++ A 1.00
    External cooling 11. External cooling can be used as a fever management intervention 1+ A .88
    12. Side effects such as shivering, hunting phenomenon, tingling sense or discomfort about cold, should all be assessed following the application of external cooling. 2+ C 1.00
    13. It is not clear whether tepid massage is helpful in reducing the body temperature in adult febrile patients. 4 D .88
    14. It is not clear whether body exposure helps to reduce the body temperature in adult febrile patients. 4 D .88
    Hydration shivering control 15. It is not clear whether hydration is helpful for reducing the body temperature in adult febrile patients, although hydration should be considered in order to avoid dehydration in adult patients in a febrile condition. 1+ A 1.00
    16. Skin counter warming should be used when febrile adult patients are shivering. 2+ C 1.00
    Average CVI       .88 .90

    LE=Level of evidence; GR=Grade of recommendation; CVI=content validity index; NS=not stated.

    Comparison of Nursing Intervention for Adult Febrile Patients Before and After Implementation of the Fever Management Protocol (N=434)

    Characteristics Before (n=228) After (n=206) x2 or Z p
    n (%) or Median (range) n (%) or Median (range)
    Age (year) 59 (18~93) 61 (20~96) -0.282 .778
    Gender     0.559 .500
      Male 110 (48.2) 91 (44.7)    
      Female 118 (51.8) 114 (55.3)    
    Department of Admission     51.834 ＜.001
      Neurosurgery 11 (4.8) 22 (13.6)
      Orthopedic surgery 72 (31.6) 85 (41.3)
      Neurology 24 (10.5) 22 (10.7)
      Rehabilitation medicine 57 (25.0) 35 (17.0)
      Psychiatry 8 (3.5) 25 (12.1)
      Others 56 (24.6) 11 (5.3)
    Notification 135 (72.4) 179 (86.9) 13.890 ＜.001
    BT at notification (℃) 37.9 (37.0~40.0) 38.0 (37.1~39.3) -3.632 ＜.001
    Nursing intervention 217 (95.2) 200 (97.1) 1.051 .305
    BT for nursing intervention (℃) 37.8 (36.5~39.9) 38.0 (37.0~39.3) -4.739 ＜.001
    Site of temperature measurement     186.723 ＜.001
      Tympanic membrane 15 (6.6) 143 (69.4)
      Axilla 160 (70.2) 51 (25.2)
      Both 45 (19.7) 12 (5.3)
      Not mentioned 8 (3.5) 0 (0.0)
    External cooling 96 (42.1) 107 (51.9) 4.206 .040
    Follow up interval (hour) 4 (1~4) 1 (0.3~12) -4.692 ＜.001
    Tepid massage 116 (50.9) 69 (33.5) 13.370 ＜.001
    Shivering assessment 113 (71.8) 173 (84.0) 9.656 .002
    Shivering management 14 (21.9) 25 (45.5) 7.465 .006

    BT=body temperature
    Table 1. Perception on Fever Management by Nurses and Physicians (N=246)

    BT=body temperature.

    Table 2. Number of Literature Review by Web Search Engines

    Note. A number in parenthesis is number of papers excluding overlapped. NGC=National Guideline Clearinghouse; JBI=Joanna Briggs Institute; RCN=Royal College of Nursing; GIN=Guidelines International Network; CINAHL=Cumulative Index to Nursing and Allied Health Literature; KERIS=Korea Education and Research Information Service; KISS=Korean Studies Information Service System; BT=body temperature.

    Table 3. Evaluation on the Evidence of Fever Management

    SR=systematic review; RCT=randomized controlled Trial.

    Table 4. Grade of Recommendation and Content Validation by Expert Panel

    LE=Level of evidence; GR=Grade of recommendation; CVI=content validity index; NS=not stated.

    Table 5. Comparison of Nursing Intervention for Adult Febrile Patients Before and After Implementation of the Fever Management Protocol (N=434)

    BT=body temperature

    Table 1.

    Table 2.

    Table 3.

    Table 4.

    Table 5.

    Korean J Adult Nurs : Korean Journal of Adult Nursing

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