Toolkit guides patient follow-up after breaches
Patients may be anxious, angry and distrustful
It is an unfortunate sign of the times that recurrent injection safety lapses and hepatitis outbreaks have reached the point where public health officials felt it necessary to create a toolkit to guide notification and follow-up of patients potentially exposed to bloodborne pathogens.
Though the infection control breaches that lead to patient exposures are often surprisingly basic — reused needles and/or syringes, improper reentry and subsequent contamination of single and multidose medication vials — outbreaks that were once considered shocking outliers have become the new normal in ambulatory care. Since 2001 more than 150,000 patients have been urged to seek testing for bloodborne infections, according to the Centers for Disease Control and Prevention.
Though exposure incidents have occurred in hospitals, the vast majority of outbreaks were in outpatient clinics, medical offices, long-term care settings and hemodialysis centers. The outbreaks reported to the CDC are almost certainly an undercount, as many infections caused by violations of basic infection control are likely missed due to inadequate surveillance systems and lack of public health resources to investigate hepatitis cases with no traditional risk factors (i.e., IV drug injection).
There were 35 documented hepatitis outbreaks linked to poor infection control practices reported to the CDC during 2008-2012. Of those, 33 (94%) occurred in non-hospital settings. Breaking the numbers down, there were 16 outbreaks of hepatitis C virus (HCV) during the period, resulting in 160 infections and more than 90,000 patients notified to seek testing. In addition, there were 19 outbreaks of hepatitis B virus (HBV) in the same timeframe, resulting in 153 infections and some 10,000 people notified for screening. On top of these ongoing hepatitis outbreaks, there was a nationwide fungal meningitis outbreak due to contaminated injectable steroid solutions last year that led to notification and follow-up of some 14,000 patients.
Given the scale of the problem, the CDC designed a patient notification toolkit that should standardize the process and allow facilities to stop reinventing the wheel every time an outbreak occurs.
Containing a variety of templates, sample patient letters and other resources, the toolkit is designed for public health departments and health care facilities that must notify patients of a potential exposure to infectious agents following a discovery of unsafe infection control practices. At a minimum, patient notification letters should include:
• How/where it happened
• Possible symptoms
• Corrective actions taken
• 24-hour contact number
• Assurance that the correct patients are being contacted
• Plan of action/next steps
A mix of powerful emotions
Patients exposed to possible infections may feel a mix of emotions that include anxiety, anger, and loss of trust, Abbigail Tumpey, MPH, CHES, associate director for communications science in the CDC’s Division of Healthcare Quality Promotion, noted in a recent blog post. (http://ow.ly/lZfpW)
"Given this mix of strong emotions, how does a healthcare facility representative break the bad news to a patient?" she said. "The answer is in proven risk communication concepts that ensure we address patients’ concerns and feelings, while giving them the ability to take back control of the situation — and their health and healthcare."
Crisis communication literature identifies several factors that determine whether the public will perceive a messenger as trusted and credible, she explained. After an exposure incident occurs, health care officials contacting the patients should express empathy and caring, honesty and openness, dedication and commitment, and competence and expertise, Tumpey said.
The CDC toolkit reviews such risk communication principles and includes fact sheets on diseases that can be transmitted by unsafe injection practices and other basic infection control lapses. The kit also includes communication strategies when dealing with the media and explains how to set up a call center hotline for patients and the general public. To create the toolkit, the CDC conducted focus groups with the general public to get feedback on patient notification letters and assess their baseline knowledge of safe injection practices.
Patients think hospitals a higher risk
The CDC released the following summary results on the focus group feedback:
• Participants had a somewhat limited understanding of safe injection practices and the diseases that can be transmitted by unsafe practices.
• Focus group participants thought unsafe injection practices were more common in hospital settings than in a health care provider’s office. However, a review of U.S. outbreaks resulting from unsafe injection practices in the past 10 years indicated that the majority of them took place in outpatient settings.
• Participants had a neutral perception of the risk of getting an infection from an unsafe injection practice. News of an infection may come as a surprise to the patients, because they don’t see themselves as being at risk.
• The cost of exams, treatments, etc. were key concerns to focus group participants if they received a letter.
• All but one participant said they were "very likely" to get tested if they received a letter.
• Focus group participants would continue to seek medical care if they received a letter, and some would even go back to the healthcare provider where the incident occurred.
Editor’ note: The complete CDC toolkit is available at: http://ow.ly/lZfxJ