Ebola & Systems & Processes: Can We Do Better? Can We Learn?
Yesterday, Thomas Eric Duncan, the first person diagnosed with Ebola in the U.S. died in a Dallas hospital.
As I've been following this story, I keep thinking about bad systems and bad processes. Sometimes, there's a lack of planning and sometimes it's a lack of proper execution, it seems. I'm not spending much time asking “who screwed up?”
Liberia, where Duncan traveled from, had airport checks that relied on voluntary disclosure (Duncan lied) and temperature checks (he was not yet symptomatic).
Cleaning crews (without proper protective gear!) eventually cleaned up Duncan's Ebola-laced vomit from outside an apartment building (it had sat there for days)… see below (and read about it).
The people Duncan stayed with were left in that apartment for days, with armed guard outside (to keep them in and keep them safe), but they complained that nobody was bringing them food. Students who had been exposed to Duncan weren't removed from school for a few days. The CDC didn't send a proper clean up crew for days… the sweat-stained sheets from Duncan were still inside the apartment. The family didn't know what to do with the sheets and mattress. They were cleaning the apartment themselves with bleach. Officials argued about the method needed for disposing and transporting the waste.
Bad systems? Poor planning? It sure seems so. See “Five blunders US made in treating country's first Ebola patient.”
And, at the hospital, there were stories about problems with systems… later retracted by Texas Health Resources.
Initial reports came out about Duncan being discharged from the emergency department, even after telling a nurse he was from Liberia. The doctors supposedly didn't hear about the Liberia connection and thought he was just a guy with stomach pains, decreased urination, and a low-grade fever. They didn't assume Ebola. They sent him home… only to have him get worse, expose a bunch of people, and end up coming back in an ambulance.
I was happy that individuals weren't being blamed and thrown under the bus, for once. It was good to be happy about something related to this case.
In the facility's electronic health record (EHR) system, though, nurse and physician workflows were separate. That means the travel history the nurse entered into the hospital's Epic Systems EHR didn't automatically appear in the physician's standard workflow, the hospital said in a statement summarized by Healthcare IT News.
The hospital statement read, in part:
Protocols were followed by both the physician and the nurses. However, we have identified a flaw in the way the physician and nursing portions of our electronic health records (EHR) interacted in this specific case. In our electronic health records, there are separate physician and nursing workflows.
The documentation of the travel history was located in the nursing workflow portion of the EHR, and was designed to provide a high reliability nursing process to allow for the administration of influenza vaccine under a physician-delegated standing order. As designed, the travel history would not automatically appear in the physician's standard workflow.
As result of this discovery, Texas Health Dallas has relocated the travel history documentation to a portion of the EHR that is part of both workflows. It also has been modified to specifically reference Ebola-endemic regions in Africa. We have made this change to increase the visibility and documentation of the travel question in order to alert all providers. We feel that this change will improve the early identification of patients who may be at risk for communicable diseases, including Ebola.
The hospital said they had corrected or updated the workflows and wanted other hospitals to learn from their problems (I didn't think any EHR/EMR system had ever been updated that quickly before). It's a “teachable moment,” said the CDC head.
In response to questions raised about Mr. Duncan's first visit to the hospital emergency department on the night of September 25th, we have thoroughly reviewed the chain of events. In the interest of transparency, and because we want other U.S. hospitals and providers to learn from our experience, we are, with Mr. Duncan's permission, releasing this information.
But, late Friday, the hospital put out a new statement saying the workflow hadn't been a problem and physicians should have seen the travel information on their screen in the system:
We would like to clarify a point made in the statement released earlier in the week. 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.
So how did this happen? Bad processes? Bad planning? THR had received Ebola information before Duncan arrived. But, they didn't put the pieces together and they sent him home.
What's your take on this situation? Can we get better at anticipating problems and improving workflows, processes, and systems in advance? Can we learn from each other to avoid having to all make the same mistakes? How can we better protect caregivers, first responders, and the public? Or are we just not very good at systems and processes… at being proactive?