Curbside Consult with Dr. Jayne 10/6/14

Given the recent events at Texas Health Presbyterian Hospital Dallas, the Ebola virus is all our hospital can talk about. We’ve been combing through our infectious disease protocols and scheduling education sessions to ensure people have access to all the resources available.

It’s daunting to think of what might happen should the disease get a toehold in the US. Many of our hospitals are already taxed with the usual communicable diseases. During flu season last year, one of the local pediatric hospitals had to put a M*A*S*H style tent in the parking lot to handle all the cases coming in.

Although Ebola is statistically less infectious than other diseases (including HIV, SARS, mumps, and measles), the lack of available treatments and high mortality rate frighten the average person. NPR had a great graphic that we’re using to help educate staff and patients about the need to ensure we have appropriate precautions in place to treat all communicable diseases, not just the most worrisome ones.

We have measles outbreaks in our community every couple of years due to some concentrated populations who do not vaccinate. Measles has a fatality rate of around 25 percent in underdeveloped nations, compared with an average fatality rate of 50 percent with Ebola (although specific outbreaks have ranged from 25 percent to 90 percent). For readers who don’t have a clinical background, the World Health Organization fact sheet provides good information about what your clinical co-workers are contemplating.

According to WHO, single travelers have spread the disease to countries including Nigeria and Senegal, which adds to the worry around a traveler bringing it to the US. Unfortunately, the early phases look a lot like other viral illnesses – fever, fatigue, muscle aches, and headache.

I probably saw 10 patients with those symptoms in the emergency department during my last shift. If we had treated each one like a potential carrier, it would have brought our patient flow to a screeching halt. From an epidemiology standpoint, IT resources are going to be critical for surveillance and identification of potential cases in the US.

I’m glad Texas Health Resources released a clarification on their earlier statement that cited a “flaw” in the EHR as contributing to the release of the patient at his initial presentation. Ultimately, it’s up to the physician to take a detailed history and physical. We all know that even with the best nursing protocols, patients will occasionally add details when a second (or third) interviewer talks with them.

It used to drive me crazy as a student when a patient would tell the resident (or worse, the attending) a detail that they had omitted even when I asked specifically about it. It may be the time between evaluations that makes the patient think about other details, or maybe one feels more empowered and able to formulate thoughts after telling the story previously.

My initial response to their statement about a flawed EHR was to take offense on behalf of their physicians. It was almost like saying their physicians aren’t responsible for thinking about elements not prompted by the EHR, or that they’ve totally given themselves over to cookbook medicine. I reached out to a friend on staff there who shared my opinion. Whether there was pressure from Epic to update the press release or whether it was from the medical staff, it was the right thing to do.

Now I’d like to see their root cause analysis on why the history was not taken fully into account and whether the presence of scribes was contributory. I’d also like to know what kind of providers saw the patient and whether there were other circumstances at play, such as shift change, a full patient board, staff who called out sick, etc. Those factors have led to mistakes at my institution and they’re much harder to place solutions around than making sure the EHR fires alerts and that personal protective equipment and isolation rooms are readily available.

I’m curious as to what other institutions are doing to prepare themselves for a potential outbreak. Are you modifying your EHR workflows? Email me.

Email Dr. Jayne.