Dallas doctors apparently never saw a nurse's note that an emergency room patient with fever and pains had recently been in Africa, and he was released into the community while infected with deadly Ebola.
It remains unclear why, despite the hospital's attempt at an explanation Friday. Early in the day, Texas Health Presbyterian Hospital said in a statement that a nurse's notes on the infected patient, Thomas Eric Duncan, were contained in records that a physician wouldn't see. Friday night, a spokesman for the institution said that wasn't so.
"We would like to clarify a point made in the statement released earlier," Wendell Watson, a spokesman for the hospital, wrote in an e-mail. "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," Watson said.
The changing message came after the hospital faced criticism from other medical professionals about the actions taken prior to the patient's release. Ashish Jha, a health policy professor at Harvard University's School of Public Health in Boston, said no matter what, the doctor responsible should have double-checked the man's travel history before he was sent back out into the community.
"There are so many flaws in the logic of ‘The EMR system made us to do it,'" Jha said in a telephone interview Friday, referring to the hospital's initial statement. "When a patient walks in the ER with a fever, the standard question is ‘Have you traveled?' I don't understand why that question wasn't asked by the physician."
Two days after being released, Duncan returned in an ambulance to the Dallas hospital, was placed in isolation and subsequently confirmed as having the deadly disease.
Wendell Watson, a spokesman for the hospital, said earlier Friday that the hospital had wrongly designed its digital record system so not all of a nurse's notes are visible to doctors. Its not clear from the clarification sent to media just before midnight what actually happened.
Watson declined to comment further in a phone interview Saturday.
Early Friday, Watson had said the software, made by Epic Systems Corp., had been reconfigured since the release occurred to bring patient travel history immediately to the physician's screen. It had also been modified "to specifically reference Ebola-endemic regions in Africa," the hospital said in its earlier statement Friday.
Robert Rudin, an associate policy researcher at Rand Corp., a non-profit research center based in Santa Monica, California, who has studied the use of electronic medical records,, said he sympathizes with any doctor and nurse who might have been involved at the Dallas hospital.
Some systems "have an unbelievable number of tabs and pages," Rudin said in a telephone interview Friday. In the case of the Dallas patient, "did the nurse assume — and many people assume this — that when the information was entered, it would be visible and prioritized?"
Monitoring for Symptoms
Health officials have vowed to stop any spread of Ebola in the U.S. There are now 50 people in Dallas being monitored daily for Ebola symptoms, down from 100, officials said. Ten are considered high risk and will be physically checked by health workers twice a day.
The rest are lower risk and will be examined once daily and checked in on by telephone, Texas health commissioner David Lakey said. So far none have developed symptoms.
Epic, based in Verona, Wisconsin, is one of the biggest providers of electronic medical systems in the U.S., with yearly sales of $1.5 billion and 290 customers, a company spokeswoman said last year. Shawn Kiesau, a spokesman for the company, didn't respond to requests for comment on the Dallas case made by e-mail and phone.
The Dallas patient, Duncan, was also asked if he had been around anyone who had been ill, according to a hospital statement. "He said that he had not," the hospital said. Published reports have said that Duncan was exposed to people with Ebola during his time in Liberia.
When Duncan came into the emergency room the first time on the evening of Sept. 25, he had a temperature of 100.1 Fahrenheit, abdominal pain for two days, a sharp headache, and decreased urination, according to the hospital's statement.
"These symptoms could be associated with many communicable diseases, as well as many other types of illness," the hospital said. "When he was asked whether he had nausea, vomiting, or diarrhea, he said no. Additionally, Mr. Duncan's symptoms were not severe at the time."
As a result, he was released early the next morning. Duncan returned on Sept. 28 by ambulance, was placed in an isolation unit and health officials subsequently confirmed that he had the deadly Ebola virus, which has infected about 7,500 people in the West African countries of Liberia, Sierra Leone and Guinea, killing about half. Governments and aid agencies are adding resources to try and stop the virus's deadly spread.
U.S. in Liberia
In Liberia, the U.S. plans to deploy 1,800 more soldiers, up from 1,400 announced on Sept. 30, to support aid workers trying to bring the outbreak under control, Rear Admiral John Kirby, a Pentagon spokesman, said Friday in a news conference in Washington.
As many as 4,000 soldiers may eventually be sent to Liberia, Kirby said, 1,000 more than when President Barack Obama first announced the mission in September.
A U.S.-built hospital for medical workers is scheduled to open by Oct. 18, Kirby said. Aid workers are currently fanning out into Liberian villages to build 10- to 20-bed clinics for Ebola victims to distribute thousands of kits of protective gear to their families, the director of the U.S. Agency for International Development, Raj Shah, said at the White House.
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