Antipyretic Orders in a University Hospital STUARTN. ISAACS,
M.D., PETER I. AXELROD, M.D., BENNETT LORBER, M.D.
PURPOSE: Antipyretics are prescribed for many hospit~liT~l patients, but details concerning prescribing practices are not known. This study was designed to determine the incidence and format of antipyretic orders in a university-based tertiarycare center, and to ascertain whether orders are correlated with patient characteristics or hospital services. PATIENTS AND METHODS:The records of 300 randomly selected patients on the medicine, general surgery, neurosurgery, and obstetrics and gynecology services, and of 75 patients admitted with pneumonia and fever were retrospectively reviewed using a standardized data form. RESULTS: Orders for acet~minophen prn (as needed), without further explanation, were interpreted by the nursing staff as antipyretic orders; 78% of patients with such an order and fever received acetaminophen during the febrile episode. If orders of this type were included, 153 (51%) of the randomly selected patients received an antipyretic order. Gender, age, duration of hospit~ll-ation, intensive care unit residence, fever, and presence of a condition worsened by fever were not significant independent predictors of antipyretic prescription, but documented infection and hospitAliTation on the medicine and neurosurgery services were, with adjusted odds ratios of 2.5 (95% confidence interval [CI] 1.3 to 5.0), 9.4 (95% CI 3.6 to 25), and 14 (95% CI 5.0 to 41), respectively. Of patients who received an antipyretic order, 70% had an admission order for antipyretics; 26%, an order prompted by fever; and 79%, an order while afebrile. In 86%, the order was written prn without further explanation. Around-the-clock dosing, automatic stop orders, and acknowledgement and justification of orders were rare. CONCLUSION:Antipyretic orders are routine and correlate more strongly with hospital service than with individual patient characteristics. They are imprecisely written and generally leave decisions about antipyretic admini.~tration to the complete discretion of the nursing staff.
From the Section of Infectious Diseases, Department of Medicine, Temple University Health Sciences Center, Philadelphia, Pennsylvania. Requests for reprints should be addressed to Bennett Lorber, M.D., Section of Infectious Diseases, Temple University Hospital, Philadelphia, Pennsylvania 19140. Manuscript submitted June 14, 1989, and accepted in revised form October 2, 1989.
Philadelphia, Pennsylvania
A
ntipyretics are among the most widely used pharmacologic agents. Traditional rationales for their use include relief of discomfort associated with fever, prevention of febrile seizures, avoidance of the high metabolic costs of fever in those who are malnourished or who have cardiac or pulmonary disease, and lessening of brain edema in central nervous system disease or trauma. However, accumulating evidence indicates that fever may be an important defense mechanism [1-91. Although antipyretics are ordered for many hospitalized patients, details concerning prescribing practices are not known. To learn more about current antipyretic prescribing, we studied antipyretic orders in a university hospital over an 18-month period. PATIENTS AND METHODS
Temple University Hospital is a 500-bed urban university adult hospital. The records of 300 patients hospitalized on the following hospital services (75 on each) were retrospectively reviewed: internal medicine, general surgery, neurosurgery, and obstetrics and gynecology. Patients were selected by a computerized randomization scheme from individuals discharged during the first week of each month between January 1986 and November 1987. Patients discharged from the surgical short-procedure unit were excluded. When patients were hospitalized on multiple hospital services, data pertaining to each service were analyzed separately. In our hospital, orders for inpatients are written almost exclusively by residents. A group of 75 patients with a discharge diagnosis of pneumonia was selected in order to determine antipyretic prescribing habits of physicians caring for patients with a documented infection and fever. Individuals were randomly chosen from the group of all such patients discharged between January 1986 and November 1987. Only those patients who had an admission temperature greater than or equal to 38°C and a new infiltrate on chest radiograph were eligible for study. Definition of Antipyretic Orders
Antipyretic orders were initially defined as physician orders for aspirin, acetaminophen, or nonsteroidal anti-inflammatory medications to treat an elevated temperature. A preliminary review of our data revealed that a large number of patients received orders for acetaminophen prn (as needed), without further explanation. To determine whether such orders, in practice, were interpreted as antipyretic orders, we determined the frequency with which nurses administered acetaminophen to the febrile patient (temperature greater than or equal to 38°C) with a prn order, without further explanation. Administration had to occur during the febrile episode, and there could be no other indication for acetaminophen made explicit in the progress or nursing notes. Orders for acetaminophen prn, without further explanation, were interpretJanuary1990 The AmericanJournalof Medicine Volume88
31
HOSPITAL ANTIPYRETIC ORDERS / ISAACS ET AL
TABLE I Patient Demographics by Hospital Service
Fever*
Documented Infection*
Receiptof Antibiotics*t
Hospitalization in ICU*
Service
MeanAge
Male Gender*
Medicine Generalsurgery Neurosurgery Obstetrics and gynecology Pneumoniagroup*
54 44 45 28
37 (49) 46 (61) 49 (65) 0 (0)
20 (27) 28 (37) 30 (40) 27 (36)
30 (40) 26 (35) 7 (9) 21 (28)
30 (40) 31 (41) 18 (24) 25 (33)
12 (16) 20 (27) 41 (55) 0 (0)
50
45 (60)
75 (100)
75 (100)
75 (100)
18 (24)
Values are numbers, with percents in parentheses. Excluding perioperative prophylaxis. * Seventy-four of 75 pneumonia group patients were on the medical service; this group was similar to the unselected medical patients in age, gender, and ICU residence (p >0.05, Student's t or chi-square).
TABLE II Associations between Epidemiologic Factors and Antipyretic Prescription
Epidemiologic Factor
Number (%) with Antipyretic Relative Order Risk 95% CI* p Value
Hospital service Obstetricsandgynecology 14/75 (19) Generalsurgery 26/75 (35) Medicine 53/75 (71) Neurosurgery 60/75(80) Gender Female 69/168(41) Male 84/132(64) Age 1-30 35/106(33) 33-44 17/73 (51) 45-60 34/46(74) >60 47/75(63) Fever Absent 85/195 (44) Present 68/105(65) Documentedinfection Absent 100/216 (46) Present 53/84(63) Receiptof antibiotics* Absent 86/196(44) Present 67/104(64) Hospitalization intCU Absent 95/226 (42) Present 58/74 (78) Surgeryt Absent 35/77 (45) Present 53/98(54) Acute coronary artery disease Absent 133/279 (48) Present 20/21 (95) Acute central nervous system disorder Absent 114/251 (45) Present 39/49 (80) Pregnancy* Absent 2/25 (8) Present 12/50(24) Duration of hospitalization(days) 1-3 23/79 (29) 3-6 58/118(49) 7-14 46/73(63) 15-21 9/12 (75) >21 17/18(94)
1.0 1.9 3.8 4.3
(1.1, 3.2) 0.042 (2.5, 5.7)
M.D., PETER I. AXELROD, M.D., BENNETT LORBER, M.D.
PURPOSE: Antipyretics are prescribed for many hospit~liT~l patients, but details concerning prescribing practices are not known. This study was designed to determine the incidence and format of antipyretic orders in a university-based tertiarycare center, and to ascertain whether orders are correlated with patient characteristics or hospital services. PATIENTS AND METHODS:The records of 300 randomly selected patients on the medicine, general surgery, neurosurgery, and obstetrics and gynecology services, and of 75 patients admitted with pneumonia and fever were retrospectively reviewed using a standardized data form. RESULTS: Orders for acet~minophen prn (as needed), without further explanation, were interpreted by the nursing staff as antipyretic orders; 78% of patients with such an order and fever received acetaminophen during the febrile episode. If orders of this type were included, 153 (51%) of the randomly selected patients received an antipyretic order. Gender, age, duration of hospit~ll-ation, intensive care unit residence, fever, and presence of a condition worsened by fever were not significant independent predictors of antipyretic prescription, but documented infection and hospitAliTation on the medicine and neurosurgery services were, with adjusted odds ratios of 2.5 (95% confidence interval [CI] 1.3 to 5.0), 9.4 (95% CI 3.6 to 25), and 14 (95% CI 5.0 to 41), respectively. Of patients who received an antipyretic order, 70% had an admission order for antipyretics; 26%, an order prompted by fever; and 79%, an order while afebrile. In 86%, the order was written prn without further explanation. Around-the-clock dosing, automatic stop orders, and acknowledgement and justification of orders were rare. CONCLUSION:Antipyretic orders are routine and correlate more strongly with hospital service than with individual patient characteristics. They are imprecisely written and generally leave decisions about antipyretic admini.~tration to the complete discretion of the nursing staff.
From the Section of Infectious Diseases, Department of Medicine, Temple University Health Sciences Center, Philadelphia, Pennsylvania. Requests for reprints should be addressed to Bennett Lorber, M.D., Section of Infectious Diseases, Temple University Hospital, Philadelphia, Pennsylvania 19140. Manuscript submitted June 14, 1989, and accepted in revised form October 2, 1989.
Philadelphia, Pennsylvania
A
ntipyretics are among the most widely used pharmacologic agents. Traditional rationales for their use include relief of discomfort associated with fever, prevention of febrile seizures, avoidance of the high metabolic costs of fever in those who are malnourished or who have cardiac or pulmonary disease, and lessening of brain edema in central nervous system disease or trauma. However, accumulating evidence indicates that fever may be an important defense mechanism [1-91. Although antipyretics are ordered for many hospitalized patients, details concerning prescribing practices are not known. To learn more about current antipyretic prescribing, we studied antipyretic orders in a university hospital over an 18-month period. PATIENTS AND METHODS
Temple University Hospital is a 500-bed urban university adult hospital. The records of 300 patients hospitalized on the following hospital services (75 on each) were retrospectively reviewed: internal medicine, general surgery, neurosurgery, and obstetrics and gynecology. Patients were selected by a computerized randomization scheme from individuals discharged during the first week of each month between January 1986 and November 1987. Patients discharged from the surgical short-procedure unit were excluded. When patients were hospitalized on multiple hospital services, data pertaining to each service were analyzed separately. In our hospital, orders for inpatients are written almost exclusively by residents. A group of 75 patients with a discharge diagnosis of pneumonia was selected in order to determine antipyretic prescribing habits of physicians caring for patients with a documented infection and fever. Individuals were randomly chosen from the group of all such patients discharged between January 1986 and November 1987. Only those patients who had an admission temperature greater than or equal to 38°C and a new infiltrate on chest radiograph were eligible for study. Definition of Antipyretic Orders
Antipyretic orders were initially defined as physician orders for aspirin, acetaminophen, or nonsteroidal anti-inflammatory medications to treat an elevated temperature. A preliminary review of our data revealed that a large number of patients received orders for acetaminophen prn (as needed), without further explanation. To determine whether such orders, in practice, were interpreted as antipyretic orders, we determined the frequency with which nurses administered acetaminophen to the febrile patient (temperature greater than or equal to 38°C) with a prn order, without further explanation. Administration had to occur during the febrile episode, and there could be no other indication for acetaminophen made explicit in the progress or nursing notes. Orders for acetaminophen prn, without further explanation, were interpretJanuary1990 The AmericanJournalof Medicine Volume88
31
HOSPITAL ANTIPYRETIC ORDERS / ISAACS ET AL
TABLE I Patient Demographics by Hospital Service
Fever*
Documented Infection*
Receiptof Antibiotics*t
Hospitalization in ICU*
Service
MeanAge
Male Gender*
Medicine Generalsurgery Neurosurgery Obstetrics and gynecology Pneumoniagroup*
54 44 45 28
37 (49) 46 (61) 49 (65) 0 (0)
20 (27) 28 (37) 30 (40) 27 (36)
30 (40) 26 (35) 7 (9) 21 (28)
30 (40) 31 (41) 18 (24) 25 (33)
12 (16) 20 (27) 41 (55) 0 (0)
50
45 (60)
75 (100)
75 (100)
75 (100)
18 (24)
Values are numbers, with percents in parentheses. Excluding perioperative prophylaxis. * Seventy-four of 75 pneumonia group patients were on the medical service; this group was similar to the unselected medical patients in age, gender, and ICU residence (p >0.05, Student's t or chi-square).
TABLE II Associations between Epidemiologic Factors and Antipyretic Prescription
Epidemiologic Factor
Number (%) with Antipyretic Relative Order Risk 95% CI* p Value
Hospital service Obstetricsandgynecology 14/75 (19) Generalsurgery 26/75 (35) Medicine 53/75 (71) Neurosurgery 60/75(80) Gender Female 69/168(41) Male 84/132(64) Age 1-30 35/106(33) 33-44 17/73 (51) 45-60 34/46(74) >60 47/75(63) Fever Absent 85/195 (44) Present 68/105(65) Documentedinfection Absent 100/216 (46) Present 53/84(63) Receiptof antibiotics* Absent 86/196(44) Present 67/104(64) Hospitalization intCU Absent 95/226 (42) Present 58/74 (78) Surgeryt Absent 35/77 (45) Present 53/98(54) Acute coronary artery disease Absent 133/279 (48) Present 20/21 (95) Acute central nervous system disorder Absent 114/251 (45) Present 39/49 (80) Pregnancy* Absent 2/25 (8) Present 12/50(24) Duration of hospitalization(days) 1-3 23/79 (29) 3-6 58/118(49) 7-14 46/73(63) 15-21 9/12 (75) >21 17/18(94)
1.0 1.9 3.8 4.3
(1.1, 3.2) 0.042 (2.5, 5.7)
