Research letters
the Borgerskapet in Umeå Research Foundation, the
Detlof’s Foundation, the Västerbotten County Council, the
Umeå University Foundation of Medical Research, Gun and
Bertil Stohne’s Foundation and the Geriatric Centre at the
Umeå University Hospital.
Conflicts of interest
There are no conflicts of interests in this study. The Ethics
Committee of the Medical Faculty of Umeå University
approved the study (dnr 99–326).
MICHAEL STENVALL1*, EVA ELINGE1, PETRA VON HEIDEKEN
WÅGERT1, MARIA LUNDSTRÖM1,
YNGVE GUSTAFSON1, LARS NYBERG1,2
1
Department of Community Medicine and Rehabilitation,
Geriatric Medicine, Umeå University,
SE-901 87 Umeå, Sweden
Fax: (+46) 90 13 06 23
Email: [email protected]
2
Department of Health Sciences/Physiotherapy Unit,
Luleå University of Technology, Hedenbrovägen,
SE-961 36 Boden, Sweden
*To whom correspondence should be addressed
1. Thorngren KG, Hommel A, Norrman PO, Thorngren J,
Wingstrand H. Epidemiology of femoral neck fractures. Injury
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Cherubini A. Hip fracture in nursing homes: an Italian study
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recovery after hip fracture. Arch Phys Med Rehabil 1987; 68:
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fractures. Osteoporos Int 2004; 15: 38–42.
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2005; 34: 249–55.
12. Folstein MF, Folstein SE, McHugh PR. ‘Mini-Mental State’.
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for the clinician. J Psychiatr Res 1975; 12: 189–98.
13. Guigoz Y, Vellas B, Garry P. Mini Nutritional Assessment: a
practical assessment tool for grading the nutritional state of
elderly patients. Facts Res Gerontol 1997; 4 (suppl 2): 15–59.
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Opin Neurol Neurosurg 1992; 5: 682–6.
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Gustafson Y. Bergs balansskala: prövning av interbedömarreliabilitet. Nordisk Fysioterapi 1998; 1: 1–6.
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av The Balance Scale. Sjukgymnasten: Vetenskapligt supplement 1996: 16–9.
17. Berg KO, Wood-Dauphinee SL, Williams JI, Maki B. Measuring balance in the elderly: validation of an instrument. Can J
Public Health 1992; 83 (Suppl 2): S7–11.
18. Österlind PO. Medical and social conditions in the elderly gender and age differences. The Umeå longitudinal study. [doctoral thesis]. Umeå, Sweden: University of Umeå, 1993.
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Fratiglioni L. Institutionalization in the elderly: The role of
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2001; 54: 795–801.
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doi:10.1093/ageing/afi042
The use of the Tempa.Dot thermometer
in routine clinical practice
SIR—The Tempa.Dot single-use thermometer has been in
use in the UK for over 10 years and in the USA for nearly
30 years. Over the last 7 years it has been marketed by 3M
Health Care Limited [1]. Its use in the NHS followed the
European Union Directive to reduce the medical use of
mercury. It also has the advantages of lack of cross-infection
risk and more rapid recordings. A sensor matrix at the tip of
the thermometer consists of 50 temperature-indicating dots,
each with a melting point separation of 0.1 °C. At any given
temperature within the range 35.5–40.4 °C, all dots with a
297
Research letters
gave a correct interpretation versus only 12% of fully qualified staff (χ2 test P < 0.06). On both occasions the median
result was 37.5 °C with an interquartile range of 37.2–37.6 °C.
The temperatures recorded spanned a range of 0.7 °C in
1998 and 1.3 °C in 2001.
Comment
Figure 1. An image of the temperature-measuring end of a
thermometer showing a temperature of 37.6 °C. This image
was presented to nursing staff with the correct reading blacked
out as shown here.
melting point at or below that temperature change colour
from beige to bright blue. Temperature readings are indicated by the number on the thermometer that corresponds
with the row of the last blue dot plus 0.1 °C for every blue
dot in that row greater than one (Figure 1). Tempa.Dot
complies with European published standard EN-1247002(P2). This requires the mean accuracy to be within 0.1 °C
for each dot.
Tempa.Dot thermometers were introduced in our hospitals in 1998. We were concerned that incorrect readings were
being recorded by staff due to the non-intuitive method of
deriving the temperature value. We therefore set out to test
this concern and repeated our observations 3 years later.
Methods and results
The manufacturer’s packaging has a printed image representing a reading from the thermometer showing a temperature of 37.6 °C (Figure 1). Without prior warning on two
occasions 3 years apart, nurses on seven medical wards
(both general medicine and geriatric medicine) were shown the
image and asked what temperature they thought it represented. The nurses’ training status and their interpretation
were recorded and the results are seen in Table 1. Nurses
were either healthcare assistants (HCAs, previously known
as auxillary nurses) or fully qualified nurses (RGNs).
Interestingly, of 48 nurses approached in 2001, only 11
(23%) correctly interpreted the image, but 33% of HCAs
Table 1.
1998
Percentage
correct
2001
Percentage
correct
This is the first report of the accuracy of the interpretation
of temperature recordings by staff using the Tempa.Dot
thermometer and worrying failures were identified. Two
previous studies have shown slightly higher axillary temperatures with the Tempa.Dot thermometer than the glass
mercury thermometer [2, 3] but no difference in oral temperatures. The first of these studies used specific study
nurses rather than ward staff so it is unlikely that there will
have been inaccuracy in interpretation. In the second study,
wide variability in readings was seen at each temperature,
although mean axillary values differed by 0.25 °C (Tempa.Dot
higher than mercury glass). It is interesting that our data
suggest a trend towards improved accuracy of interpretation
in HCAs. It is not possible to fully explain this phenomenon,
but taking routine patient observations is a task often delegated to HCAs and their increased experience may be
reflected in their improved accuracy.
Although it seemed understandable that a radical change
in temperature recording procedure should result in problems,
it is worrying that 3 years later the problem persisted. There
is no suggestion that there is any inaccuracy in the temperature
recording, merely in the interpretations by staff.
The staff surveyed represented those that undertake
temperature observations in practice. Our experience is that
medical staff produce similarly unreliable recordings—
indeed this originally prompted the study. We did not test
this as medical staff are not responsible for routine temperature measurements.
Whilst staff training should correct the problem, our
data suggest that the Tempa.Dot design is not impervious
to human error. Interestingly, the two most common erroneous readings were 37.2 °C and 37.7 °C. It is easy to see
why from Figure 1. Unfortunately we have no details of the
training the nurses received in the use of the Tempa.Dot
thermometer.
We brought our data to the attention of The Medicines
and Healthcare products Regulatory Agency (MHRA) and
the manufacturers. The manufacturers confirm that despite another reported problem with the interpretation of
the Tempa.Dot thermometer they are confident that it is
accurate and readable given suitably trained staff. The
MHRA is taking no further specific action currently but
will be evaluating non-mercury thermometers in the near
future. Kings College Hospital no longer uses the Tempa.Dot
thermometer.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .
Qualified (n = 18)
HCA (n = 12)
Overall (n = 30)
22%
25%
23%
Qualified (n = 24)
HCA (n = 24)
Overall (n = 48)
12%
33%
23%
A total of 78 nurses were assessed, overall percentage correct = 23%.
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Key points
• The large majority of nurses who perform temperature
measurements with the Tempa.Dot thermometer in
Research letters
routine clinical practice are unable to interpret a standardised image depicting a temperature reading of 37.6 °C.
• These results were reproducible 3 years after the thermometers had been in regular use.
• The nurses’ interpretations of the image depicting 37.6 °C
spanned a range of 0.7 °C in 1998 and 1.3 °C in 2001.
• The errors in interpretation of thermometer readings
may lead to inappropriate medical management, potentially to the patient’s detriment.
Funding
No funding was sought.
B. C. CREAGH-BROWN*, D. ARMSTRONG JAMES, S. H. D. JACKSON
Department of Health Care of the Elderly,
Kings College Hospital,
London SE5 8PJ, UK
Email: [email protected]
*To whom correspondence should be addressed
hospital in South Trent. The second a district general hospital in Mid-Trent.
For the first survey, 200 randomly selected case notes
with a primary coding diagnosis of COPD over a 6 month
period were requested. A total of 172 notes (86%) were
obtained and of these 116 (67%) were felt, on review by a physician, to be correctly coded and thus suitable for inclusion
in the study. In the second survey, 150 randomly selected
case notes were similarly requested; 116 notes (77%) were
obtained, of which 79 (68%) were felt to be correctly coded.
A standard form was used to record clinical details of
the hospital admission in both centres. The management of
patients was analysed by age as a binary variable (74 years
and under and 75 years and above, based on a median age of
74 years) using contingency tables. Mantzel Heinz odds
ratios were calculated where appropriate. Further logistic
regression analysis was used to adjust for any potential
differences in disease severity or differences between the
two centres.
Results
References
1. 3M Introduces Single-Use Clinical Thermometers That Help
Reduce Infection Transmission. Press release 17 February
1997, www.3m.com/profile/pressbox/tempadot.html.
2. Board M. Comparison of disposable and glass mercury
thermometers. Nurs Times 1995; 91: 36–7.
3. Rogers MA. Viable alternative to the glass/mercury thermometer. Paediatr Nurs 1992; 4.
doi:10.1093/ageing/afi069
A study of the management of COPD
according to established guidelines and
the implications for older patients
SIR—COPD is common in older populations and a major
cause of mortality and morbidity. It accounts for over 1,000
consultations per 10,000 patients in the 75-and-over age
group, compared with 400 in those under 65 years of age [1].
It is a major cause of hospital admission in the elderly with
almost 20,000 admissions per million population in the year
1999/2000 in the 75-and-over age group [2].
Previous studies have shown that doctors are less likely
to give smoking cessation advice to older subjects [3], and
that pulmonary rehabilitation programmes mainly include
younger subjects [4]. We hypothesized that older patients
would have less access to interventions known to improve
the morbidity and mortality in chronic obstructive pulmonary disease (COPD).
Methods
We surveyed the management of COPD in two large hospitals
in the Trent region, over two 6 month periods between
2001 and 2003. The first hospital was a large teaching
One hundred and ninety-five case notes were included in
the study. A total of 116 notes were included from the
South Trent population and 79 notes from the Mid-Trent
population. The subjects had a mean age of 72.4 years
(range 35–92), 59% were male. By British Thoracic Society
Criteria, 45.6% were felt to have severe disease and 33.8%
mild or moderate disease; 20.5% could not be classified due
to scarcity of information in the clinical notes.
Severity of disease was also assessed based on the number
of hospital admissions over a 3 year period. Twenty-four per
cent of subjects had had no admissions in the preceding
3 years, 15% had one prior admission, 16% had two prior
admissions and 27% had three or more prior admissions. In
17% the number of previous admissions could not be accurately determined (incomplete notes). The two populations
did not differ significantly in age, sex or severity of disease.
Smoking status was recorded in 93% of individuals:
33.8% were current smokers, 55.9% ex-smokers and 3.1%
never smokers. Only 20% of subjects had evidence of
spirometry being performed either in the preceding 3 years
or 6 months after hospital admission, despite all having a
clinical diagnosis of COPD and being on regular medication.
Age did not appear to influence whether spirometry was
performed (P = 0.826).
Similarly, only 16.4% of subjects regularly using inhalers
had their inhaler technique checked during the course of
their hospital admission or on follow-up. Older patients
were not more likely to have their inhaler technique checked
than younger subjects (P = 0.518).
Of those subjects still smoking, only 16% were given
smoking cessation advice at any point during their hospital
admission. Furthermore, older patients were significantly less
likely to be given smoking cessation advice, 3% versus 27%
(odds ratio = 12.1 (95% CI 1.3–113.8), chi-squared = 7.79,
P = 0.005). These differences in smoking cessation advice
persisted after regression analysis with adjustment for disease
severity, number of admissions and centre (P = 0.002).
299