A research study about finding the most accurate, economically viable, and user friendly alternative to mercury thermometer for the Lebanese healthcare industry

1. Comparative Evaluation of Non-Mercury
Thermometers in a Hospital Setting
Rafic Hariri School of Nursing
June 1, 2011
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2. Background
Purpose
Literature review
Research Methods
Results
Recommendations
Limitations
Outline
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3. Phasing out MERCURY
WHY???
 Toxic
 Pollutant
 Bioaccumulative
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4. Phasing out MERCURY
Mercury in the atmosphere has increased 20
times since 1840
Human activities account for about 70% of
the mercury emissions compared to natural
sources
[Source: US Geological Survey, 2002]
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5. Phasing out MERCURY
Mercury Baseline Information from LEBANON (2001 –
2005)
Average Mass Imported (Kg Hg per year) 214
Quantity of Thermometers Imported 427517
Estimated Releases (Kg Hg per year) 31
Percentage Releases 14.5
United Nations Development Programme (August, 2007). UNDP project document: Government of Argentina, India,
Latvia, Lebanon, Philippines, Senegal, Kingdom of Tanzania and Vietnam. Retrieved on November 20, 2010 from
http://gefmedwaste.org/downloads/ProDoc.pdf
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6. WHO Policy on Mercury in Health Care
(August 2005)
 Short Term: Address mercury clean up, waste
handling and storage procedures. Develop and
implement plans to reduce the use of mercury
equipment and replace with mercury free
alternatives.
 Medium Term: Increase efforts to reduce use of
unnecessary mercury equipment
 Long Term: Support a ban of mercury containing
devices and promote alternatives.
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7. Purpose
The objectives of the study are:
 To determine the available thermometry technologies
available in the Lebanese market and their cost
effectiveness for a model healthcare facility.
 To determine the suitability of use of two alternative
thermometers in a hospital setting based on differences
in their essential characteristics and preferences of
healthcare professional staff.
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8. Literature
 incomprehensive and inconclusive
 difficult for meta-analysis because studies target different
patient populations and utilize a variety of devices
 Overall, electronic thermometers have the widest
support as reliable, accurate, and safe alternatives to
mercury thermometers.
The problem is that they are thought to be expensive
Crawford, D. C., Hicks, B., & Thompson, M. J. (2006). Which thermometer? Factors
influencing best choice for intermittent clinical temperature assessment. Journal of
Medical Engineering & Technology, 30(4), 199 – 211. 8

9. Research Methods
 Market survey
 Nursing leadership preferences
 Comparative costing
 Clinical comparison
- comparative accuracy
- ease of use
 Nursing staff perspective
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10. Market survey
 Ten vendors were identified and contacted
 Brands available
- 10 compact electronic
- one electronic
- 5 infrared tympanic
- 3 infrared temporal
- one Galinstan-in-glass
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11. Nursing Leadership Preferences
 Eight nurse managers
 questionnaire (seven multiple-choice questions + add
on)
Analysis of preferred criteria showed that the selected
thermometer should display the result digitally and have
the ability to measure the temperature from different
sites.
ELECTRONIC or COMPACT ELECTRONIC
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12. Selection of the two non-mercury thermometers
 Electronic
Suretemp Plus 690
(Welch Allyn – USA)
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13. Selection of the two non-mercury thermometers
 Compact Electronic
10 brands
Peak temperature alarm Fever warning
Flexible probe tip Start-up self-check
Memory function Meet standards
MT 200 (Microlife, Switzerland)
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14. Comparative costing of thermometers
Types of costs included in the analysis are:
Alexander, D., & Kelly, B. (1991). Cost effectiveness of tympanic thermometry in the
pediatric office setting. Clinical Pediatrics, 30(4 Suppl), 57-59.
Cost type Examples Sources of data
thermometer costs Thermometer,
accessories
Vendor’s
quotations
disposable supply
costs
Batteries, Alcohol
swabs, Probe covers
Hospital data
personnel costs Nurses' time User manual
equipment service
costs
medical engineer time,
Maintenance, Calibration
Personal
experience
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15. Comparative costing of thermometers (USD)
Type of
thermometers
Electronic Compact
electronic
Infrared
tympanic
Infrared
temporal
Mercury
Total
investment
cost
10,029 2,719 3,292 6,580 23,092
Total annual
running cost 8,807 15,603 30,543 33,556 31,213
Total cost at
year one 18,836 18,322 33,835 40,136 54,305
Total cost at
year ten 98,099 158,749 308,722 342,140 543,050
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16. Clinical evaluation: accuracy
o 150 readings from five clinical departments (30 each)
o Measurement sites included oral cavity (40 %), axilla
(40%), and rectum (20%)
o 62% of readings were taken on female patients
Age Frequency Percentage
≤ 1 month 30 20
1 month – 18 years 32 21
19 years – 60 years 61 41
≥60 years 27 18
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17. Clinical evaluation: accuracy
Total sample Oral Axillary Rectal
Sample Size
(readings)
150 60 60 30
Mean difference of
readings (SD*)
0.45 (0.49) 0.2 (0.35) 0.775 (0.47) 0.31 (0.41)
Range of difference
of readings
-0.7 to +2.2 -0.7 to +1.4 0 to +2.2 -0.4 to +1.3
95% confidence
interval
0.37-0.53 0.11-0.29 0.65-0.89 0.15-0.46
t-test 11.27 4.46 12.64 4.11
P value ˂ 0.001 ˂ 0.001 ˂ 0.001 ˂ 0.001
Correlation
coefficient (Pearson
R)
0.64 0.7 0.65 0.81
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19. Clinical evaluation: accuracy
Total sample Oral Axillary Rectal
Limits of agreement [-0.534, 1.434] [-0.505, 0.905] [-0.194, 1.724] [-0.510, 1.136]
Number with 0.5°C or
more difference (%)
45 (31.3) 8 (13.3) 33(55) 6(20)
Number of readings
higher with compact
electronic (%)
127 (84.6) 45(75) 59(98.3) 23(76.6)
Number of identical
readings (%)
7 (4.6) 5 (8.3) 1(1.6) 1(3.3)
Number of lower
readings (%)
16 (10.6) 10 (16.6) 0 6(20)
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20. Clinical evaluation: ease of use
o Ten healthcare staff (RNs & PNs) took the temperature
of a volunteer three times by each thermometer.
o Such a difference translates to a 1392 $ in savings from
personnel cost annually.
Comparison of the measurement time of both thermometers in seconds
Thermometer
type
Mean (SD) Mean
difference
Level of
significance
Number of
steps (range)
Electronic 21.55 (2.07)
14.84 P<0.001
6 to 7
Compact
electronic
36.39 (4.45) 6 to 7
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21. Healthcare personnel perspective
 Five healthcare personnel (practical nurses)
 Five days
Question Compact
electronic
Electronic
Both are the
same
Which thermometer is more
likely to be broken during
use?
- 80% 20%
Which thermometer do you
think is more accurate? 20% 40% 40%
Which thermometer is easier
to use? 20% 80% -
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22. Healthcare personnel perspective
“The nylon probe covers of the MT200 are not enough
protection from nosocomial infections since micro-tears
may happen to the probe cover during measurement
which might affect its integrity.”
“Equipments used on isolation patients are kept in their
rooms, which might increase the possibility of losing the
MT200 because of its small size.”
“Removal of the probe cover of MT200 may pose a risk of
contamination.”
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23. Healthcare personnel perspective
“Adult patients were pleased more with the electronic
thermometer”
“Probes of electronic thermometer are thick causing
discomfort for the neonates.”
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24. Recommendations
 Electronic thermometers are the most cost-effective type
of thermometers in the Lebanese setting.
 Compact electronic thermometers cannot replace
electronic thermometers from the accuracy point of view.
 Electronic thermometers are easier to use than compact
electronic thermometers.
 Most of healthcare personnel's comments favor the
electronic thermometer.
 The Electronic thermometer is the recommended
replacement for the mercury thermometer in
Lebanon.
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25. Limitations
 The study was done in a rural governmental hospital that
may differ from other Lebanese healthcare institutions in
various ways.
 the clinical evaluation of the thermometers regarding
accuracy lacked a standard reference thermometer for
comparison thereby limiting the validity of the
comparison.
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