Forehead Temperature Checks May Miss Fevers in Black Patients

Temporal temperature measurement was associated with a lower odds of detecting fever compared with oral measurement in Black patients hospitalized with suspected infection, but not white patients, a retrospective cross-sectional study showed.

Among over 4,300 patients, the prevalence of fever in Black patients was 10.1% with temporal measurement and 13.2% with oral measurement (OR 0.74, 95% CI 0.61-0.90, P=0.002), while in white patients, prevalence was 10.8% and 10.2%, respectively (OR 1.07, 95% CI 0.89-1.29, P=0.47), reported Sivasubramanium Bhavani, MD, MS, of Emory University School of Medicine in Atlanta, and colleagues.

This association held true for Black patients across multiple fever cutoff temperatures — from 37.8 °C to 38.5 °C, they noted in a research letter published in JAMA.

“Health care systems routinely use fever cutoffs to trigger notification pathways such as sepsis alerts to systematize timely triage and antibiotic administration. Although the absolute difference between oral and temporal temperatures was small, the findings suggest that this discrepancy combined with commonly used fever cutoffs may lead to fever going undetected in many Black patients,” Bhavani and team wrote.

“The next step is to evaluate whether the inaccurate temporal temperatures are leading to delays in antibiotics and other medical care for Black patients,” Bhavani told MedPage Today. “And if this is the case, that would call for a transition to other temperature measurement sites, such as oral measurement until the temporal devices are evaluated and fixed.”

Forehead thermometers used to detect fevers in the temporal artery are often used in hospitals, but studies on their efficacy “lack details on racial composition of study populations,” Bhavani’s group noted. Previous recent studies have reported missed hypoxemia with pulse oximetry among Black patients.

Prior research has also suggested that skin emissivity may play a role in variability in fever measurements, but any relationship between skin emissivity and skin pigmentation remains unknown, they added.

For this multicenter study, Bhavani and colleagues retrospectively examined data on 2,344 white patients (median age 62, 53.9% men) and 2,031 Black patients (median age 56, 47.8% men) hospitalized across four Emory hospitals from 2014 to 2021 for suspected infection, defined as a combination of body fluid cultures and antibiotics within 24 hours of hospital presentation. Because of small sample sizes, Asian and Hispanic patients were excluded.

Common comorbidities that were more prevalent among Black patients included hypertension (72% vs 58%), kidney disease (42% vs 26%), and diabetes (39% vs 29%).

Within the first day of hospitalization, each patient had the first pair of oral and temporal temperatures taken within an hour of each other. Measurements taken after receiving acetaminophen were excluded. Oral temperatures were measured by the Welch Allyn SureTemp Plus device, while temporal temperatures were obtained by the Exergen TAT-5000 device, which has been evaluated in over 100 prior trials.

Temporal temperature was 36.98 °C and oral temperature was 37.05 °C in Black patients, and 36.97 °C and 36.95 °C in white patients.

In a smaller subgroup of Black patients with paired measurements within the first hour of presentation (n=265), fever prevalence was 23.4% with temporal measurement and 35.8% with oral measurement, while prevalence was 27.8% and 26.0%, respectively, in 281 white patients, with a lower odds of detection of fever in Black patients with temporal measurement (OR 0.54, 95% CI 0.37-0.79, P=0.002), but not white patients (OR 0.91, 95% CI 0.62-1.34, P=0.62).

“The racial difference found may stem from the medical device or from systemic mishandling of the device (e.g., not scanning the forehead sufficiently),” Bhavani and team noted.

Bhavani and team acknowledged several limitations to their study, including its retrospective nature and the potential selection bias of patients with paired measurements.

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