Wednesday, January 7, 2015
Killed by an abundance of caution?
Back in August, I wrote: “Most patients returning from the outbreak area with febrile illness (those meeting the Person Under Investigation (PUI) definition) will not have Ebola, but they may be very sick. If an overly stringent lab protocol prohibits or delays laboratory testing, substandard medical care may lead to adverse outcomes.”
In September, I wrote: “The overwhelming majority of those with febrile illness upon return from the outbreak areas will not have Ebola—but they may well have something requiring urgent attention and appropriate therapy (malaria, typhoid, meningococcemia). Prompt laboratory testing will be essential, and potentially life-saving. … However, many hospitals plan not to let any samples from suspected Ebola patients cross the threshold of their laboratories. [This] could be dangerous for patients presenting with “severe non-Ebola infection” who happen to have been in an outbreak area in the prior 21 days.”
Well, the Centers for Disease Control and Prevention has just released a report on their initial experience with “PUIs” in U.S. hospitals, and there's this disturbing little nugget buried within: “At least 2 persons who tested negative for Ebola died from other causes. Based on reports from health departments and health care providers, in several instances efforts to establish alternative diagnoses were reported to have been hampered or delayed because of infection control concerns. For example, laboratory tests to guide diagnosis or management (e.g., complete blood counts, liver function tests, serum chemistries, and malaria tests) were reportedly deferred in some cases until there were assurances of a negative Ebola virus test result. In other instances, radiologic studies, such as computed tomography and ultrasound scans, or evaluation for noninfectious conditions, such as severe hypertension and tachycardia, were reportedly delayed while a diagnosis of Ebola was under consideration.”
Given the ratio of PUIs to actual Ebola patients presenting to U.S. hospitals, it is quite likely that more patients will die in the U.S. from AOC (“Abundance of Caution”) than die from Ebola.
Back to the CDC now: “… it is important to recognize that the likelihood of Ebola even among symptomatic travelers returning from these countries is very low. In the hospital setting, where policies and procedures should be in place to safeguard health care workers, consideration of Ebola should not delay diagnostic assessments, laboratory testing, and institution of appropriate care for other, more likely medical conditions.”
In other words: diagnose and treat the patient, not your Fear of Ebola.
Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
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Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
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