








key: cord-345864-87b5qdjx
authors: Rudolph, James L.; Halladay, Christopher W.; Barber, Malisa; McCongehy, Kevin; Mor, Vince; Nanda, Aman; Gravenstein, Stefan
title: Temperature in Nursing Home Residents Systematically Tested for SARS-CoV-2
date: 2020-06-09
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.06.009
sha: 
doc_id: 345864
cord_uid: 87b5qdjx

Abstract Objectives Many nursing home residents infected with SARS-CoV-2 fail to be identified with standard screening for the associated COVID-19 syndrome. Current nursing home COVID-19 screening guidance includes assessment for fever defined as a temperature of at least 38.0°C. The objective of this study is to describe the temperature changes before and after universal testing for SARS-CoV-2 in nursing home residents. Design Cohort study Setting and Participants: The Veterans Administration (VA) operates 134 Community Living Centers (CLC), similar to nursing homes, that house residents who cannot live independently. VA guidance to CLCs directed daily clinical screening for COVID-19 that included temperature assessment. Measures All CLC residents (n=7325) underwent SARS-CoV-2 testing. We report the temperature in window of the 14 days before and after universal SARS-CoV-2 testing among CLC residents. Baseline temperature was calculated for 5 days prior to the study window. Results SARS-CoV-2 was identified in 443 (6.0%) residents. The average maximum temperature in SARS-CoV-2 positive residents was 37.66 (0.69) compared to 37.11 (0.36) (p=0.001) in SARS-CoV-2 negative residents. Temperatures in those with SARS-CoV-2 began rising 7 days prior to testing and remained elevated during the 14-day follow up. Among SARS-CoV-2 positive residents, only 26.6% (n=118) met the fever threshold of 38.0°C during the survey period. Most residents (62.5%, n=277) with confirmed SARS-CoV-2 did experience two or more 0.5°C elevations above their baseline values. One cohort of SARS-CoV-2 residents’ (20.3%, n=90) temperatures never deviated >0.5°C from baseline. Conclusions and Implications A single screening for temperature is unlikely to detect nursing home residents with SARS-CoV-2. Repeated temperature measurement with a patient-derived baseline can increase sensitivity. The current fever threshold as a screening criteria for SARS-CoV-2 infection should be reconsidered.

Conclusions and Implications: A single screening for temperature is unlikely to detect nursing 24 home residents with SARS-CoV-2. Repeated temperature measurement with a patient-derived 25 baseline can increase sensitivity. The current fever threshold as a screening criteria for SARS-26

CoV-2 infection should be reconsidered. 27 28 29 Introduction: 30 Older people with chronic illness are at greatest risk for severe COVID-19 outcomes. In early 31

March 2020, 34 of 101 (33.7%) SARS-CoV-2 infected residents died in a 130-bed Washington 32 state King County nursing home facility; overall mortality was 18%. A total of 50 of 170 33 healthcare personnel were infected along with 16 visitors. 1 These findings led to aggressive 34 monitoring to detect disease, and to efforts to reduce transmission by keeping visitors and 35 symptomatic staff out of the building, while isolating residents in whom COVID-19 was 36 suspected or confirmed. However, when 76 residents with SARS-CoV-2 laboratory confirmed 37 infection, 57% were asymptomatic, 2 suggesting that symptomatic monitoring will fail to provide 38 timely disease detection and undermine effective outbreak control. 39 40 Because threshold symptoms and signs, such as a temperature of at least 38°C, have been used to 41 determine who is tested, their frequency may underestimate SARS-CoV-2 population 42 prevalence. Standard screening processes now routinely screen for COVID-19 by assessing for 43 temperature >38.0°C. From the King County experience 1,3 , "fever" is limited as a screening 44 criterion for COVID-19 in nursing facilities. 4 While the utility of fever as an indicator has been 45 debated for older adults, 5,6 studies have reported that nursing home residents with pneumonia 46 often present without fever 7,8 and have a lower basal temperature than community dwelling older 47 adults. 9 The 'older and colder' adage for nursing home residents may have statistical validity but 48 poses challenges in guiding nursing facilities about fever during a pandemic. 49 50 While COVID and pneumonia can elevate temperature from within an individual's usual range, 51 an absolute, universal cut-off for fever may miss potentially important temperature perturbations. 52

With infection control practices presently dependent on a threshold temperature criterion to 53 determine fever, we need to better understand the value and limitations such a threshold adds to 54 identifying people infected with SARS-CoV-2 or appropriate actions for additional screening, 55 especially in a nursing home context. We hypothesized that most residents of Veterans 56

Administration Community Life Centers (CLCs) infected with SARS-CoV-2 do have 57 temperature elevations well ahead of a confirmatory test, but also that peak temperatures will not 58 typically meet the current screening criterion threshold of 38°C that follows the Centers for 59 Disease Control's (CDC) guidance. 10 testing of all CLC residents and staff. The purpose of this analysis is to compare temperature 73 trends and identify maximum temperatures in nursing home residents fourteen days prior to and 74 following systematic testing for SARS-CoV-2 throughout VHA CLCs. 75

Cohort 76

Using VHA electronic records, we identified Veterans residing in CLCs during the period of 77 March 1, 2020 until May 4, 2020. Veterans who were not tested for COVID-19 were excluded 78 as were those tested prior to admission to the CLC. In addition, we excluded those who were 79 symptomatically tested because of symptoms prior to universal testing. Demographic descriptors 80 were collected from the electronic medical records. 81

Each CLC uses standard equipment to measure temperature, and enters the reading into the 83 electronic medical record. In most CLCs temperature is uploaded directly to the electronic 84 medical record from the vital signs machine. Based on CDC guidance, the fever threshold was 85 established at 38.0° C. 10, 11 For this analysis, we selected the first temperature after 4am for 86 analysis. We assessed temperatures in the two weeks before and after SARS-CoV-2 testing. To 87 establish a baseline temperature for each resident, we calculated the mean of 5 temperatures prior 88 to our window of interest. 89

We identified SARS-CoV-2 PCR testing results from the VA's electronic medical records. 

The funder had no role in the design, data collection, analysis, interpretation, or writing. 101

The cohort consisted of Veterans (n=7325) residing in CLCs. A total of 453 (6.0%) Veterans 7 maximum temperature (37.7 vs. 37.1°C, p<.001). In both cohorts, the baseline temperature was 107 36.6°C (SD ±0.2) and a temperature deviation of 2 SD is approximately 0.5°C. 108 109 Figure 1 illustrates the first daily temperatures of those with and without SARS-CoV-2 infection. Table 1 lists single timepoint temperature screening thresholds. 123 124 Measurement of temperature deviation from baseline has been proposed as a mechanism to 125 detect underlying infectious disease in nursing home residents. The majority of residents (79.7%, 126 n=353) with confirmed SARS-CoV-2 did experience a 0.5°C elevation of their baseline values, 127 and this elevation was noted at least twice in 62.5% (n=277) ( Table 2 ). Figure 3 examines 128 potential temperature change from baseline values (0°C to 2.5°C) occurring more than once 8 ( Figure 3 , Panel A) and more than twice (Figure 3, Panel B) . Using a threshold increase from 130 baseline occurring in multiple readings offers a favorable balance of sensitivity and specificity 131 relative to a single reading. 132

We describe peak and daily morning temperature variation two weeks before and after COVID-134 19 testing among VA CLC residents and the Tmax occuring during that interval. The morning 135 temperatures in CLC residents with SARS-CoV-2 typically began rising a week or more before 136 reaching Tmax. Most residents (74%) did not reach a peak temperature over 38°C. The 137 temperature for those with SARS-CoV-2 whose Tmax was at least 0. 

Table 1: Temperature Cutoffs and SARS-CoV-2 213 214 SARS-CoV-2 -SARS-CoV-2 + N

Epidemiology of Covid-19 in a Long-Term Care Facility 219 in King County, Washington

Residents of a Long-Term Care Skilled Nursing Facility -King County

Presymptomatic SARS-CoV-2 infections and 226 transmission in a skilled nursing facility

Spread of SARS-CoV-2 in the Icelandic 228

Clinical 230 practice guideline for the evaluation of fever and infection in older adult residents of long-term 231 care facilities: 2008 update by the Infectious Diseases Society of America

Vital signs in older patients: Age-related changes

The significance of pneumonia in the elderly

Role of Body Temperature in Diagnosing Bacterial 238 Infection in Nursing Home Residents

Fever response in elderly nursing home residents: are the 10. Centers for Disease Control. Evaluating and Testing Persons for Coronavirus Disease

Department of Health and Human Services

SARS−CoV2 + (Tmax >= 38.0)

SARS−CoV2 + (Tmax low 25%)



