Downloaded from http://jramc.bmj.com/ on November 19, 2015 - Published by group.bmj.com
Original article
Force protection in contingency operations: an evaluation of temperature monitoring in Sierra Leone Catherine Cole,1 C Turnbull,2 W Eardley,3 P Hunt4 1
Royal Centre for Defence Medicine, Birmingham, UK 2 Frimley Park Hospital, Frimley, UK 3 Department of Trauma & Orthopaedics, Middlesbrough & Academic Department of Military Surgery and Trauma, James Cook University Hospital, Royal Centre for Defence Medicine, Birmingham, UK 4 Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK Correspondence to Will Eardley, Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough TS4 3BW, UK; [email protected] Received 19 November 2014 Revised 14 December 2014 Accepted 16 December 2014
ABSTRACT Objectives The deployment of the UK-led Joint InterAgency Taskforce to Sierra Leone in September 2014 brought the era of contingency operations into focus. Daily health screening of such deployed personnel forms a key element of medical force protection. We have performed a service evaluation of an existing screening programme and detail the comparison of the two thermometers used in this role. Methods Data from the existing screening programme were used to inform a sample size required to enable statistically and clinically significant differences to be detected between the two interchangeably used thermometer systems in use. A prospective service evaluation on these devices was then carried out over a 10-day period and the data analysed by parametric tools. 10 personnel had their temperature recorded by both devices at the same time by a single operator every day. Results For the screened population, a mean temperature of 36.55°C and SD of 0.32°C was revealed. Powered to 80% with a two-tailed α of 0.05, the evaluation of the two thermometers revealed no significant difference between recordings taken with either device ( p=0.115). The low SD meant that a pyrexial patient (>37.5°C) would require a recording over 3 SD from the population mean. Discussion Evaluations of medical force protection will carry increasing consequence as the UK deploy on short notice operations to regions of considerable endemic threat. Presence of pyrexia is a key early indicator of illness affecting deployed personnel, and two different thermometer types are provided for this function. We have shown for the first time with statistical and clinical significance that the two thermometers used in contingency force protection are interchangeable. The narrow variance is reassuring and confirms that the chosen trigger (>37.5°C) would warrant further investigation in the pyrexial patient.
INTRODUCTION
To cite: Cole C, Turnbull C, Eardley W, et al. J R Army Med Corps Published Online First: [ please include Day Month Year] doi:10.1136/ jramc-2014-000388
The declaration in August 2014 by World Health Organization (WHO) that the outbreak of Ebola virus disease (EVD) in West Africa was a ‘Public Health Emergency of International Concern’1 brought to global attention a disease previously thought of as a self-limiting tropical phenomenon.2 The virus has accounted for small outbreaks of disease in Sub-Saharan Africa since its discovery in 1976, but in 2014 the profile of EVD radically changed as it became a global concern. Sub-Saharan Africa carries a quarter of the global burden of disease, has the lowest life expectancy3 but has 3 SD, derived as 1.0°C, above the mean was accepted as being sufficiently out of the normal measured range and clinically significant enough to warrant a pyrexial illness response with further medical assessment and isolation (Figure 3). This also confirmed the ‘trigger’ value, currently in use as decreed by Commander Medical, of 37.5°C as being appropriate for the pyrexial illness screening process used at UK Forces bases. Analysis of the pilot data allowed us to calculate the sample size required to identify any significant differences in measured temperatures between the Braun Thermoscan tympanic thermometer and the HuBDIC FS-700 Thermofinder non-contact Cole C, et al. J R Army Med Corps 2015;0:1–4. doi:10.1136/jramc-2014-000388
Downloaded from http://jramc.bmj.com/ on November 19, 2015 - Published by group.bmj.com
Original article
Figure 2 Categorical organisation of measured temperatures demonstrating normal distribution centred around the mean: pooled results (n=100). skin thermometer. With a known mean of 36.55°C and SD of 0.32°C, it was calculated that 10 subjects were required to have their temperatures compared in order to detect a clinically significant difference (α=0.05, two-tailed). Figure 4 shows the mean measured temperatures for both probes for all 10 subjects. Although the skin probe did record a slightly lower mean temperature (0.25°C) compared with the tympanic probe, there was no statistically significant difference between the data values ( p=0.115). We concluded that the temperature devices could be used interchangeably for health surveillance purposes with sufficient discrimination to detect a clinically significant temperature outlier.
DISCUSSION Medical force protection underpins the health surveillance of military personnel on deployment. Following the drawdown of the Afghanistan conflict and the broad reform of the Defence Medical Services in line with the recent manpower review,
shorter ‘small footprint’ contingency operations represent a new era in deployed medical care. Rapid insertion of logistician troops supported by medical personnel in such contingency operations has occurred and is ongoing in support of GoSL. Temperature screening is central to such medical force protection and affords commanders an opportunity to monitor the health of their personnel in order to maximise effectiveness. It is beholden on deployed clinical staff to evaluate and adopt the philosophy of kaizen: overall improvement in care through continual incremental change. There is requirement to balance risk over accuracy of measurement when using thermometers to either record or estimate core body temperature. Peripheral devices, such as the infrared skin sensors currently used for force medical protection in Sierra Leone, allow a minimal contact approach. This offers clear advantages over other devices, such as tympanic infrared probes or intraoral thermometers, in the setting of a serious, potentially life-threatening viral health threat. Measuring core temperature is the gold standard in collecting such data and in screening populations at risk. Clearly the invasive nature of oesophageal or rectal temperature measurement along with the resources required and the time taken render this an unfeasible and potentially risky technique for population screening. One example of the many articles attempting to quantify the gap between core measurement and estimation by peripheral testing is that of Allegaert et al stating that, in the paediatric setting, while rectal measurement is the gold standard, less invasive tools have become available to reflect this.8 In their assessment of the accuracy of tympanic, infrared skin, or temporal artery scan thermometers compared with rectal measurement to reflect core temperature, they found that all of the non-invasive methods underperformed compared with rectal monitoring. A non-invasive method must be used however in screening, and so, as discussed by El-Radhi recently in the home nation setting, the search for the ideal thermometer goes on.9 This is a search for the means of measuring body temperature that best combines accuracy, speed, convenience, safety and costeffectiveness. Infrared scanning of the skin or the tympanic membrane appears to offer such a combination.
Figure 3 Distribution of daily subject mean against overall mean and 3 SD over time (n=10). Cole C, et al. J R Army Med Corps 2015;0:1–4. doi:10.1136/jramc-2014-000388
3
Downloaded from http://jramc.bmj.com/ on November 19, 2015 - Published by group.bmj.com
Original article >37.5°C, represents a value +3 SD from the mean and is unlikely to go undetected during routine screening processes.
CONCLUSIONS
Figure 4 Graph showing mean measured temperature and range between tympanic and skin infrared probes (n=10). The literature surrounding these devices is heterogeneous and mainly concerned with the paediatric population. Numerous thermometers are available performing similar roles, and as such the standardisation of device usage and reporting is poor. The literature is supportive of the use of tympanic thermometry10 11 and suggests that infrared skin scanning thermometers are less reliable.12 In the adult population, the ability to accurately estimate core temperature is demonstrated by these devices, although there is unsatisfactory agreement when comparing them against each other.13 Existing literature is not generalisable to the deployed population when attempting to assess the use of such thermometers in military deployments. In light of the recent return to contingency operations with the need to rapidly deploy troops to countries where early identification of illness may be heralded by a temperature rise, the importance of evaluation of any screening method is clear. We have described a pragmatic evaluation of the use of temperature screening during the initial stages of Operation GRITROCK, the UK-led JIATF mission to Sierra Leone. ‘Gold standard’ temperature assessment such as oesophageal or rectal recording available in more resource-intense home nation critical care settings is neither appropriate nor sustainable in deployed force protection screening. Other devices such as those used frequently in the paediatric setting are more appropriate and are what has been chosen for the deployed screening role. For the first time we have shown that, for medical force protection purposes, tympanic and infrared screening devices perform similarly within clinically and statistically significant parameters. We have also concluded that the devices may be used interchangeably. Recordings taken with either of the two devices we assessed are shown to be clustered tightly around the mean body temperature with low variance. The clinically significant individual temperature outlier, identified by a reading of
4
Short notice deployments, with the attendant logistic challenges that typically characterise the insertion phase, represent a significant future consideration for contemporary ‘contingency’ military operations. Medical force protection is paramount in such deployments, particularly where significant endemic disease threats endure. In light of heterogeneous and non-generalisable literature, we have provided for the first time evidence that either tympanic or skin infrared thermometers may be used effectively for population at risk temperature screening. Contributors All authors contributed to this work. The data were collected by CC and CT. Data analysis was by WE and PH. The manuscript was prepared by all authors. WE is the guarantor of the project. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
2 3
4 5 6 7 8
9 10
11
12
13
With spread of ebola outpacing response, security council adopts resolution 2177 (2014) urging immediate action, end to isolation of affected states [Internet]. The United Nations: United Nations; 2014 [updated 18th September 2014; cited 10th October 2014]. http://www.un.org/press/en/2014/sc11566.doc.htm Brown CS, Cropley IM. Ebola virus disease: Where are we now and where do we go? Postgrad Med J 2014;90:610–2. Mash RJ, de Villiers MR, FamMed M, et al. Guiding the development of family medicine training in Africa through collaboration with the medical education partnership initiative. Acad Med 2014;89 (Suppl):S73–7. Mullan F, Omaswa F, Frehywot S. Academic medicine. preface. Acad Med 2014;89 (8 Suppl):S3–4. Fletcher TE, Beeching NJ. Malaria. J R Army Med Corps 2013;159:158–66. Whitman TJ, Coyne PE, Magill AJ, et al. An outbreak of plasmodium falciparum malaria in U.S. marines deployed to Liberia. Am J Trop Med Hyg 2010;83:258–65. Tuck JJ, Green AD, Roberts KI. A malaria outbreak following a British military deployment to Sierra Leone. J Infect 2003;47:225–30. Allegaert K, Casteels K, van Gorp I, et al. Tympanic, infrared skin, and temporal artery scan thermometers compared with rectal measurement in children: A real-life assessment. Curr Ther Res Clin Exp 2014;76:34–8. El-Radhi AS. Determining fever in children: The search for an ideal thermometer. Br J Nurs 2014;23:91–4. Jefferies S, Weatherall M, Young P, et al. A systematic review of the accuracy of peripheral thermometry in estimating core temperatures among febrile critically ill patients. Crit Care Resusc 2011;13:194–9. Park YJ, Park SH, Kang CB. Systematic review and meta-analyses of diagnostic accuracy of infrared thermometer when identifying fever in children. J Korean Acad Nurs 2013;43:746–59. Basak T, Aciksoz S, Tosun B, et al. Comparison of three different thermometers in evaluating the body temperature of healthy young adult individuals. Int J Nurs Pract 2013;19:471–8. Sener S, Karcioglu O, Eken C, et al. Agreement between axillary, tympanic, and mid-forehead body temperature measurements in adult emergency department patients. Eur J Emerg Med 2012;19:252–6.
Cole C, et al. J R Army Med Corps 2015;0:1–4. doi:10.1136/jramc-2014-000388
Downloaded from http://jramc.bmj.com/ on November 19, 2015 - Published by group.bmj.com
Force protection in contingency operations: an evaluation of temperature monitoring in Sierra Leone Catherine Cole, C Turnbull, W Eardley and P Hunt J R Army Med Corps published online February 9, 2015
Updated information and services can be found at: http://jramc.bmj.com/content/early/2015/02/09/jramc-2014-000388
These include:
References Email alerting service
This article cites 12 articles, 3 of which you can access for free at: http://jramc.bmj.com/content/early/2015/02/09/jramc-2014-000388 #BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Original article
Force protection in contingency operations: an evaluation of temperature monitoring in Sierra Leone Catherine Cole,1 C Turnbull,2 W Eardley,3 P Hunt4 1
Royal Centre for Defence Medicine, Birmingham, UK 2 Frimley Park Hospital, Frimley, UK 3 Department of Trauma & Orthopaedics, Middlesbrough & Academic Department of Military Surgery and Trauma, James Cook University Hospital, Royal Centre for Defence Medicine, Birmingham, UK 4 Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK Correspondence to Will Eardley, Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough TS4 3BW, UK; [email protected] Received 19 November 2014 Revised 14 December 2014 Accepted 16 December 2014
ABSTRACT Objectives The deployment of the UK-led Joint InterAgency Taskforce to Sierra Leone in September 2014 brought the era of contingency operations into focus. Daily health screening of such deployed personnel forms a key element of medical force protection. We have performed a service evaluation of an existing screening programme and detail the comparison of the two thermometers used in this role. Methods Data from the existing screening programme were used to inform a sample size required to enable statistically and clinically significant differences to be detected between the two interchangeably used thermometer systems in use. A prospective service evaluation on these devices was then carried out over a 10-day period and the data analysed by parametric tools. 10 personnel had their temperature recorded by both devices at the same time by a single operator every day. Results For the screened population, a mean temperature of 36.55°C and SD of 0.32°C was revealed. Powered to 80% with a two-tailed α of 0.05, the evaluation of the two thermometers revealed no significant difference between recordings taken with either device ( p=0.115). The low SD meant that a pyrexial patient (>37.5°C) would require a recording over 3 SD from the population mean. Discussion Evaluations of medical force protection will carry increasing consequence as the UK deploy on short notice operations to regions of considerable endemic threat. Presence of pyrexia is a key early indicator of illness affecting deployed personnel, and two different thermometer types are provided for this function. We have shown for the first time with statistical and clinical significance that the two thermometers used in contingency force protection are interchangeable. The narrow variance is reassuring and confirms that the chosen trigger (>37.5°C) would warrant further investigation in the pyrexial patient.
INTRODUCTION
To cite: Cole C, Turnbull C, Eardley W, et al. J R Army Med Corps Published Online First: [ please include Day Month Year] doi:10.1136/ jramc-2014-000388
The declaration in August 2014 by World Health Organization (WHO) that the outbreak of Ebola virus disease (EVD) in West Africa was a ‘Public Health Emergency of International Concern’1 brought to global attention a disease previously thought of as a self-limiting tropical phenomenon.2 The virus has accounted for small outbreaks of disease in Sub-Saharan Africa since its discovery in 1976, but in 2014 the profile of EVD radically changed as it became a global concern. Sub-Saharan Africa carries a quarter of the global burden of disease, has the lowest life expectancy3 but has 3 SD, derived as 1.0°C, above the mean was accepted as being sufficiently out of the normal measured range and clinically significant enough to warrant a pyrexial illness response with further medical assessment and isolation (Figure 3). This also confirmed the ‘trigger’ value, currently in use as decreed by Commander Medical, of 37.5°C as being appropriate for the pyrexial illness screening process used at UK Forces bases. Analysis of the pilot data allowed us to calculate the sample size required to identify any significant differences in measured temperatures between the Braun Thermoscan tympanic thermometer and the HuBDIC FS-700 Thermofinder non-contact Cole C, et al. J R Army Med Corps 2015;0:1–4. doi:10.1136/jramc-2014-000388
Downloaded from http://jramc.bmj.com/ on November 19, 2015 - Published by group.bmj.com
Original article
Figure 2 Categorical organisation of measured temperatures demonstrating normal distribution centred around the mean: pooled results (n=100). skin thermometer. With a known mean of 36.55°C and SD of 0.32°C, it was calculated that 10 subjects were required to have their temperatures compared in order to detect a clinically significant difference (α=0.05, two-tailed). Figure 4 shows the mean measured temperatures for both probes for all 10 subjects. Although the skin probe did record a slightly lower mean temperature (0.25°C) compared with the tympanic probe, there was no statistically significant difference between the data values ( p=0.115). We concluded that the temperature devices could be used interchangeably for health surveillance purposes with sufficient discrimination to detect a clinically significant temperature outlier.
DISCUSSION Medical force protection underpins the health surveillance of military personnel on deployment. Following the drawdown of the Afghanistan conflict and the broad reform of the Defence Medical Services in line with the recent manpower review,
shorter ‘small footprint’ contingency operations represent a new era in deployed medical care. Rapid insertion of logistician troops supported by medical personnel in such contingency operations has occurred and is ongoing in support of GoSL. Temperature screening is central to such medical force protection and affords commanders an opportunity to monitor the health of their personnel in order to maximise effectiveness. It is beholden on deployed clinical staff to evaluate and adopt the philosophy of kaizen: overall improvement in care through continual incremental change. There is requirement to balance risk over accuracy of measurement when using thermometers to either record or estimate core body temperature. Peripheral devices, such as the infrared skin sensors currently used for force medical protection in Sierra Leone, allow a minimal contact approach. This offers clear advantages over other devices, such as tympanic infrared probes or intraoral thermometers, in the setting of a serious, potentially life-threatening viral health threat. Measuring core temperature is the gold standard in collecting such data and in screening populations at risk. Clearly the invasive nature of oesophageal or rectal temperature measurement along with the resources required and the time taken render this an unfeasible and potentially risky technique for population screening. One example of the many articles attempting to quantify the gap between core measurement and estimation by peripheral testing is that of Allegaert et al stating that, in the paediatric setting, while rectal measurement is the gold standard, less invasive tools have become available to reflect this.8 In their assessment of the accuracy of tympanic, infrared skin, or temporal artery scan thermometers compared with rectal measurement to reflect core temperature, they found that all of the non-invasive methods underperformed compared with rectal monitoring. A non-invasive method must be used however in screening, and so, as discussed by El-Radhi recently in the home nation setting, the search for the ideal thermometer goes on.9 This is a search for the means of measuring body temperature that best combines accuracy, speed, convenience, safety and costeffectiveness. Infrared scanning of the skin or the tympanic membrane appears to offer such a combination.
Figure 3 Distribution of daily subject mean against overall mean and 3 SD over time (n=10). Cole C, et al. J R Army Med Corps 2015;0:1–4. doi:10.1136/jramc-2014-000388
3
Downloaded from http://jramc.bmj.com/ on November 19, 2015 - Published by group.bmj.com
Original article >37.5°C, represents a value +3 SD from the mean and is unlikely to go undetected during routine screening processes.
CONCLUSIONS
Figure 4 Graph showing mean measured temperature and range between tympanic and skin infrared probes (n=10). The literature surrounding these devices is heterogeneous and mainly concerned with the paediatric population. Numerous thermometers are available performing similar roles, and as such the standardisation of device usage and reporting is poor. The literature is supportive of the use of tympanic thermometry10 11 and suggests that infrared skin scanning thermometers are less reliable.12 In the adult population, the ability to accurately estimate core temperature is demonstrated by these devices, although there is unsatisfactory agreement when comparing them against each other.13 Existing literature is not generalisable to the deployed population when attempting to assess the use of such thermometers in military deployments. In light of the recent return to contingency operations with the need to rapidly deploy troops to countries where early identification of illness may be heralded by a temperature rise, the importance of evaluation of any screening method is clear. We have described a pragmatic evaluation of the use of temperature screening during the initial stages of Operation GRITROCK, the UK-led JIATF mission to Sierra Leone. ‘Gold standard’ temperature assessment such as oesophageal or rectal recording available in more resource-intense home nation critical care settings is neither appropriate nor sustainable in deployed force protection screening. Other devices such as those used frequently in the paediatric setting are more appropriate and are what has been chosen for the deployed screening role. For the first time we have shown that, for medical force protection purposes, tympanic and infrared screening devices perform similarly within clinically and statistically significant parameters. We have also concluded that the devices may be used interchangeably. Recordings taken with either of the two devices we assessed are shown to be clustered tightly around the mean body temperature with low variance. The clinically significant individual temperature outlier, identified by a reading of
4
Short notice deployments, with the attendant logistic challenges that typically characterise the insertion phase, represent a significant future consideration for contemporary ‘contingency’ military operations. Medical force protection is paramount in such deployments, particularly where significant endemic disease threats endure. In light of heterogeneous and non-generalisable literature, we have provided for the first time evidence that either tympanic or skin infrared thermometers may be used effectively for population at risk temperature screening. Contributors All authors contributed to this work. The data were collected by CC and CT. Data analysis was by WE and PH. The manuscript was prepared by all authors. WE is the guarantor of the project. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1
2 3
4 5 6 7 8
9 10
11
12
13
With spread of ebola outpacing response, security council adopts resolution 2177 (2014) urging immediate action, end to isolation of affected states [Internet]. The United Nations: United Nations; 2014 [updated 18th September 2014; cited 10th October 2014]. http://www.un.org/press/en/2014/sc11566.doc.htm Brown CS, Cropley IM. Ebola virus disease: Where are we now and where do we go? Postgrad Med J 2014;90:610–2. Mash RJ, de Villiers MR, FamMed M, et al. Guiding the development of family medicine training in Africa through collaboration with the medical education partnership initiative. Acad Med 2014;89 (Suppl):S73–7. Mullan F, Omaswa F, Frehywot S. Academic medicine. preface. Acad Med 2014;89 (8 Suppl):S3–4. Fletcher TE, Beeching NJ. Malaria. J R Army Med Corps 2013;159:158–66. Whitman TJ, Coyne PE, Magill AJ, et al. An outbreak of plasmodium falciparum malaria in U.S. marines deployed to Liberia. Am J Trop Med Hyg 2010;83:258–65. Tuck JJ, Green AD, Roberts KI. A malaria outbreak following a British military deployment to Sierra Leone. J Infect 2003;47:225–30. Allegaert K, Casteels K, van Gorp I, et al. Tympanic, infrared skin, and temporal artery scan thermometers compared with rectal measurement in children: A real-life assessment. Curr Ther Res Clin Exp 2014;76:34–8. El-Radhi AS. Determining fever in children: The search for an ideal thermometer. Br J Nurs 2014;23:91–4. Jefferies S, Weatherall M, Young P, et al. A systematic review of the accuracy of peripheral thermometry in estimating core temperatures among febrile critically ill patients. Crit Care Resusc 2011;13:194–9. Park YJ, Park SH, Kang CB. Systematic review and meta-analyses of diagnostic accuracy of infrared thermometer when identifying fever in children. J Korean Acad Nurs 2013;43:746–59. Basak T, Aciksoz S, Tosun B, et al. Comparison of three different thermometers in evaluating the body temperature of healthy young adult individuals. Int J Nurs Pract 2013;19:471–8. Sener S, Karcioglu O, Eken C, et al. Agreement between axillary, tympanic, and mid-forehead body temperature measurements in adult emergency department patients. Eur J Emerg Med 2012;19:252–6.
Cole C, et al. J R Army Med Corps 2015;0:1–4. doi:10.1136/jramc-2014-000388
Downloaded from http://jramc.bmj.com/ on November 19, 2015 - Published by group.bmj.com
Force protection in contingency operations: an evaluation of temperature monitoring in Sierra Leone Catherine Cole, C Turnbull, W Eardley and P Hunt J R Army Med Corps published online February 9, 2015
Updated information and services can be found at: http://jramc.bmj.com/content/early/2015/02/09/jramc-2014-000388
These include:
References Email alerting service
This article cites 12 articles, 3 of which you can access for free at: http://jramc.bmj.com/content/early/2015/02/09/jramc-2014-000388 #BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
![[Craniotomy in Sierra Leone?].](/assets/img/hold.png)
