Measles patient ordered into isolation, but remains in the ED for 12 hours

'Hypervigilance,' clearly defined process can help avoid such incidents

This was the stuff of an ED manager's nightmare: A 36-year-old woman with measles, thought to be the source of an eventual outbreak of measles in February 2008, was kept in the ED of Northwest Medical Center in Tucson, AZ, for more than 12 hours after a physician had ordered that she be placed in isolation. To add insult to injury, she had presented to the same ED a day earlier complaining of flu-like symptoms. She was misdiagnosed, given an antibiotic and discharged.

A state investigation subsequently showed that no isolation precautions were taken at either visit, and the hospital was fined $1,000 for waiting too long to isolate the patient.

The hospital has worked with the state to develop a correction plan, and now has an action plan in place, says spokeswoman Kim Chimene, although she would not provide any details.

Experts say there are several steps ED managers can take to ensure that isolation orders are followed. "There needs to be some clear delineation of responsibility once [isolation is] ordered," says Matt Keadey, MD, the medical director of the ED at Emory University Hospital in Atlanta. "You need to have a process set up, and there needs to be some semblance of early identification; if not, you'll end up with those patients out there [in the waiting room] with everyone else."

James G. Adams, MD, chair of emergency medicine at Northwestern Memorial Hospital in Chicago, agrees. "You need to have hypervigilance, knowing that anything can take an interesting twist," he says. For example, Adams notes, measles initially might resemble a viral infection. "This one was recognized by the doctor, but hypervigilance means that everybody should be alert and aware," Adams says. Sometimes, he says, even the department secretary might recognize something odd or "off" that is not being recognized by the staff. "I've had circumstances where a secretary pointed out that a person looked 'different,'" he recalls. "That prompted me to look at them, and it turned out they had just had a stroke in the waiting room."

Keadey takes a similar approach. "It's the responsibility of everyone," he says. "What this scenario sounds like is they were waiting on an isolation bed upstairs, but the doctor may not have communicated this to his or her own staff."

Information can be communicated electronically, Keadey says, "but if it's critical, face to face and voice to voice is by far the best way to do it." If a doctor wants to isolate a patient, he says, "I would say tell the individual nurse responsible for caring for the person, and then the charge nurse if you do not get the response you need." If necessary, Keadey adds, you could even take it to a person on a higher level.

Your infection control professional also is a key member of the team, says Keadey. "They are not only valuable for developing protocols for identifying patients with infectious diseases, but if there is any uncertainty about whether to isolate a patient, they can be an invaluable resource," he says.

Create a culture of ED teamwork

One of the most effective ways for identifying and responding quickly to an infectious patient is to create a culture of teamwork, Adams says.

"You must have an atmosphere of welcoming everyone's input — avoid an authority gradient, where staff members are reluctant to address those who 'outrank' them," he says. He likens the situation in the ED to flying a ship to the Moon. "If anybody notices something wrong, they'd better bring it up, or it could have bad consequences."

In terms of the isolation order that wasn't followed, "how do these orders get communicated from team to team?" he asks. "Was the order ignored because it was too much trouble, or was the effort needed to get the patient isolated too tough?

Communication, and high recognition of everyone on the front lines, can keep problems such as these from escalating, Adams argues. Meetings will not work, he says. "It's a day-to-day culture," Adams says." If secretaries have a concern, they should be listened to and made to feel they are an important part of the team," he says. "If they feel respected, their performance will go up," Adams says.

At Adams' ED, "we will entertain any comment about anything," he says. "We all have to pitch in." Creating this "ultimate teamwork" takes a lot of on-unit positive communication, Adams says. "Congratulate someone if they pick up an error," he advises. "Don't blame them."

Sources

For more information on improving isolation procedures, contact:

  • James G. Adams, MD, Chair of Emergency Medicine, Northwestern Memorial Hospital, Chicago. Phone: (312) 694-7000.
  • Matt Keadey, MD, ED Medical Director, Emory University Hospital, Atlanta. Phone: (404) 778-5975.