In diagnosing potential causes of infectious diseases like Ebola, Texas Health Dallas care teams are trained to look for multiple indicators, including the following:
· Mr. Duncan presented with a temperature of 100.1F, abdominal pain for two days, a sharp headache, and decreased urination. These symptoms could be associated with many communicable diseases, as well as many other types of illness. 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 he first visited the hospital emergency department.
2. Has the patient been around anyone who has been ill?
· When Mr. Duncan was asked if he had been around anyone who had been ill, he said that he had not.
3. Has the patient traveled outside the United States in the last four weeks?
· Mr. Duncan was asked if he had traveled outside the United States in the last four weeks, and he said that he had been in Africa. The nurse entered that information in the nursing portion of the electronic medical record.
When patients visit the emergency department, they are first assessed by a triage nurse. Then an intake nurse conducts a more thorough screening process that includes:
· vital signs;
· general clinical assessment;
· a neurological assessment; and
· questions about major risk factors:
o domestic violence;
o tetanus status;
o tuberculosis risk;
o travel history outside the United States in the previous 4 weeks;
o suicide risk assessment; and
o falls risk assessment.
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.
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