Discharged ED patient tests positive: Your move
By Patti Grant, RN, BSN, MS, CIC
Infection Preventionist, Dallas, TX
There are obvious challenges that run through the training of an Infection Preventionist (IP) and fortunately many have answers with solid references. However, despite excellent formal training offered by our professional organizations and evidence-based recommendations to tackle basic patient care issues, there remain less obvious topics that can shake the confidence of the novice and make the learning curve a little steeper.
Several of these less evident learning ordeals have been covered in past columns, but this time let's tackle the dreaded "infectious follow-up" of labs from a patient discharged from the emergency department (ED). Actually, based on personal experiences and networking with peers, the post-ED positive infectious lab test can be a sensitive and anxiety-producing follow-up issue regardless of years of experience.
No need to rehash the uniqueness of the ED setting of rapid turnover, assessment, and interventions. Suffice it to say that when the patient is admitted directly via the ED there is no doubt who Laboratory Services will call with a positive lab result: the physician or patient care professional caring for the patient. Where it gets tricky is when the infectious lab result is finalized after the patient has been released. Depending on your internal policies there are definite situations where the IP should be involved when infectious lab results come to light after discharge from the ED to home, another healthcare facility, and/or admitted to the same facility. Various examples include:
- Reporting a communicable disease to the local health authority (i.e., sexually transmitted diseases, enteric pathogens like Salmonella species, vaccine-preventable diseases, etc.) that are mandated by state regulations.
- Following up on a multidrug-resistant organism (MDRO) or Clostridium difficile to verify Contact Precautions have been instituted.
- Review of positive blood, sputum, wound, or urine cultures to determine healthcare-associated (HAI) infection status for your facility (a recent discharge) or something you should report to the transferring facility.
- Checking to see if a public safety worker (fire, police, emergency medical technician, paramedic, etc.) was exposed to a communicable disease listed as "notification required" per your state regulations
- Working with Employee Health Services when Meningococcal meningitis, for example, requires an investigation to determine if prophylaxis is required.
In these examples the IP is not treating anything based on the lab result per se, but is working to directly help prevent the transmission of infectious agents to others within the health care community or public health arena. Most IPs are not medical doctors and do not practice medicine. Ours is a profession that is more transmission-based than treatment-based.
Where the follow-up of positive 'infectious' lab results becomes gray is when treatment is not required because there is not an active infection, but a colonization is present with an MDRO. When an ED patient has been identified with MDRO colonization after discharge who notifies the patient? IPs go into their transmission-based mode and flag the patient record so they are slated for Contact Precautions during their subsequent hospitalizations to the facility. It is often during the next hospitalization that the patient finds out, for the first time, they had an MDRO isolated during their prior ED visit.
This notification responsibility should belong to the ED and not the IP because doing so triggers treatment-based questions from the patient. Most IPs are not qualified and/or not permitted to have treatment-based conversations with the patient because they might be practicing medicine without a license. If written notification is the way your healthcare facility decides to go, again the question/answer contact should be the ED because referring them to infection prevention can quickly turn into a patient "dissatisfier," especially when the IP states "I'm sorry, but I am not qualified to discuss your medical condition, please call..." This is a question you might want to look into before you have a public relations nightmare on your hands from a (rightfully) distraught or baffled MRDO patient.