Dallas error in releasing Ebola patient puts hospitals on alert

The preparedness of U.S. hospitals to identify potential Ebola cases and check the spread of the often-fatal disease is being called into question after a Dallas hospital released an Ebola-stricken patient despite a nurse knowing he had just been to Africa.

The discharge of Thomas Eric Duncan, the first person diagnosed with Ebola in the U.S., possibly exposed as many as 50 people to the virus. The Centers for Disease Control and Prevention has a team in Texas tracing Duncan's contacts and those who had close proximity to him.

The CDC has been bombarding hospitals in recent months with information on how to prepare for Ebola. But the events at Texas Health Presbyterian Hospital Dallas, owned by Texas Health Resources, are a reminder of the need for heightened vigilance. “This is a wake-up call for all medical providers in the U.S.,” said Dr. Lee Norman, chief medical officer at the University of Kansas Hospital, Kansas City. “We need to be asking patients who present with the symptoms about their recent travel and exposure to others who have traveled to and from infected areas.”

Many providers have implemented infectious-disease protocols with funding from HHS' Hospital Preparedness Program. “A lot of the early work was in preparation for a pandemic in the days when it was the H5N1 avian flu that we were worried about,” said Dr. Melinda Moore, a former CDC official and now a senior scientist at the RAND Corp.

But the Dallas case shows mistakes still can occur because of flawed work processes. On Sept. 19, Duncan left his native Liberia and arrived in the U.S. a day later to visit relatives in Texas. Duncan reportedly had carried a pregnant woman in Paynesville City, near Monrovia, who was sick with Ebola, which has killed more than 3,300 throughout West Africa. It's not clear whether he knew she had Ebola. He reportedly began feeling sick around Sept. 24 and visited the emergency department at Texas Health on the night of Sept. 25, the hospital said.

Texas Health Resources officials said a communication lapse associated with the electronic health record resulted in a physician not seeing the nurse's note about Duncan's recent travels. That led to the doctor discharging him even though he showed symptoms that included fever, abdominal pain and headache—early warning signs of Ebola. Two days later, Duncan was admitted to the hospital and placed in an isolation unit, where he has remained.

Hospital officials said they had a staff checklist to identify possible Ebola carriers, and acknowledged that Duncan told the nurse about his traveling to Africa. “Unfortunately, connections weren't made related to travel history and his symptoms,” Dr. David Lakey, commissioner of the Texas Department of State Health Services, said last week during a call with reporters. “The individuals caring for this individual did not think about the possibility of Ebola.”

Hospital officials said the staff had followed proper protocols, but the miscommunication was caused by a flaw in EHR software that did not allow the physician to see the nurse's note about the patient's recent travel history. “The documentation of the travel history was located in the nursing workflow portion of the EHR,” the hospital said in a written statement. “As designed, the travel history would not automatically appear in the physician's standard workflow.”

Since the incident, the hospital said it has modified the EHR's travel history section so that information is displayed in both nurse and physician records. A special reference to Ebola-endemic regions has been added.

Many hospitals are reassessing their emergency procedures to ensure staffers consistently follow guidelines when evaluating patients suspected of having an infectious disease. “It's really important that hospitals in all their practice settings, not just the emergency department, train their clinicians to take an appropriate travel history,” said Dr. Paul Biddinger, chief of the Division of Emergency Preparedness at Massachusetts General Hospital. At Massachusetts General, all clinicians, including nurses and physician assistants, have the authority to put a patient into isolation if the patient meets the criteria.

At the New York City Health and Hospitals Corp., which runs 11 EDs, the system has used surprise practice drills with actors pretending to be patients showing symptoms that could be early signs of Ebola, said Dr. Ross Wilson, HHC's chief medical officer. These drills are done to see how quickly staffers recognize potential Ebola risk and act to correct any problems.

Follow Steven Ross Johnson on Twitter: @MHsjohnson