BY MICHAEL MILLENSON
There’s an infection that afflicts thousands of Americans yearly, killing an estimated one in five of those who contract it, and costs tens of thousands of dollars per person to treat. Though there’s a proven way to dramatically reduce or even eliminate it, the Centers for Disease Control and Prevention (CDC) inexplicably seems in no hurry to do so.
Unlike Ebola, this infection isn’t transmitted from person to person, with the health care system desperately racing to keep up. Instead, it’s caused by the health care system when clinicians don’t follow established anti-infection protocols – very much like what happened when Texas Health Presbyterian Hospital encountered its first Ebola patient. That hospital’s failure flashes a warning sign to all of us.
The culprit in this case is called CLABSI, short for “central-line associated bloodstream infection.” A central line is a catheter placed into a patient’s torso to make it easier to infuse critical medications or draw blood. Because the lines are inserted deep into patients already weakened by illness, an infection can be catastrophic.
CLABSIs are deadlier than typhoid fever or malaria. Last year alone they affected more than 10,000 adults, according to hospital reports to the CDC, and nearly 1,700 children, according to an analysis of hospital discharge records. The infections also cost an average of nearly $46,000 per patient to treat, adding up to billions of dollars yearly.
At one time, CLABSIs were thought to be largely unavoidable. But in 2001, Dr. Peter Pronovost, a critical care medicine specialist at Johns Hopkins, simplified existing guidelines into an easy five-step checklist with items like “wash hands” and “clean patient’s skin with an antibacterial agent.” Hopkins’ CLABSI rate plunged.
Given what is now known about how the case of Thomas Eric Duncan at Texas Health Presbyterian was handled, the attempt to blame the hospital’s electronic health record for the missed diagnosis sounds pretty lame.
But people are still doing it:
Critics of electronic medical records have found a case they will be talking about for years.
Consider this argument from Ross Koppel and Suzanne Gordon:
While it is too early to determine what precisely happened in this case, it is not too early to consider the critical issues it highlights. One is our health care system’s reliance on computerized technology that is too often unfriendly to clinicians, especially those who work in stressful situations like a crowded emergency room. Then there are physicians’ long-standing failure to pay attention to nurses’ notes. Finally, there is the fact that hospitals often discourage nurses from assertively challenging physicians.
Long promised as the panacea for patient safety errors, electronic health records, in fact, have fragmented information, too often making critical data difficult to find. Often, doctors or nurses must log out of the system they are on and log into another system just to access data needed to treat their patients (with, of course, additional passwords required). Worse, data is frequently labeled in odd ways. For example, the results of a potassium test might be found under “potassium,” “serum potassium level,” “blood tests” or “lab reports.” Frequently, nurses and doctors will see different screen presentations of similar data, making it difficult to collaborate.
A group of nurses at Texas Health Presbyterian has come forward with a very different picture of what happened when Liberian Ebola patient Thomas Duncan arrived at the hospital with Ebola-like symptoms on September 28th. If true, the allegations are certainly unsettling.
In an unusual move, the nurses spoke anonymously to the media, conducting a blind conference call in which none of the participants were identified.
After arriving at the emergency room with a high fever and other symptoms of the disease , the nurses said the patient was kept in a public area, despite the fact that he and a relative informed staff that he had been instructed to go to the hospital after contacting the Centers for Disease Control in Atlanta to report a possible case of Ebola.
The Dallas hospital at the center of the Texas Ebola outbreak has changed its story.
Last Thursday, the hospital blamed a poorly designed electronic medical record for the failure to diagnose Duncan when he arrived at the hospital’s emergency room with symptoms consistent with Ebola, including a fever, stomach cramps and headache. According to the initial story, a badly designed electronic health record workflow made it difficult for doctors to see details of Duncan’s West African travel. Duncan was sent home. Very bad things happened as a result, as we all know by now.
On Friday, the hospital reversed itself without explanation.
The new statement:
Clarification: We would like to clarify a point made in the statement released earlier in the week. As a standard part of the nursing process, the patient’s travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician’s workflow. There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event. [ Full text ]
In other words: The EMR didn’t do it.
When the EMR story came out Thursday, critics jumped all over it. It did sort of make sense to some people, especially people who aren’t fans of electronic medical records. The idea that a piece of key information could get lost in the maze of screens and pop ups and clicks in a complex medical record sounded plausible.
A lot of other people weren’t buying it:
The swiftness of the hasty retreat led some critics to speculate that Texas Health’s statement Thursday provoked the wrath of EPIC, the hospital’s EMR vendor. Industry critics pointed out that many major EMR vendors, EPIC among them, often include strongly worded clauses in contracts that forbids customers from talking publicly about their products.
After this story was posted, EPIC contacted THCB with a response via email. Company spokesman Shawn Kieseau wrote:
We have no gag clauses in our contracts. We had no legal input or participation in our root cause analysis discussions with Texas Health staff on this issue. Texas Health’s correction is appropriate given the facts in this situation.
It was a mistake to send the Liberian national Thomas Eric Duncan home from a Dallas emergency room after he presented with fever and pain, which were early signs of Ebola infection.
It would be a larger mistake to miss an important learning opportunity. This case demonstrates what I believe to be a major threat to patient safety—caregiver distraction.
Doctors and nurses are increasingly prevented from giving full attention to the important things in patient care. The degree of value-added nonsense has reached the point where delivering basic care has gown dangerous. This morning, in Canada, news of a case of deadly drug interaction occurred because of alert fatigue—or distraction.
I am a cardiologist; I am also a patient. I want the Duncan case to be a turning point, a wake up call, a never event that serves as a spark to improve the delivery of medical care. Right now, all that this case has changed are tweaks to EHR protocols and checklists. We need more than tweaks; we need big changes.
An uncomfortable truth is that medical mistakes are normal. Errors, like this one in Texas, have occurred since doctors started treating patients. The good news is that technology has made medical care better. No credible person suggests a return to the paper-chart era. Yet, it is still our duty to face mistakes, learn from them, and in so doing, improve future care. Being honest about root causes is necessary.
Another truth about medical mistakes is the ensuing rush to inoculate against blame–which always comes. In the Duncan case, initial blame was assigned to the electronic health record. The computer software failed to flag the travel history in the physician “workflow.” (Just using the word, workflow, hints of the bureaucracy problem.) And you know there is trouble when hospital administrators use the passive voice. “Protocols were followed by both the physician and the nurse…”