Balancing patient safety with patient safety

Mike has already pointed out the degree of uncertainty surrounding how to prepare for (and respond to) the spread of novel H1N1. One of the challenges is maintaining a focus on overall patient safety and the potential unintended consequences of our H1N1 response.

One example that comes to mind is the question of how long to keep ill health care workers (HCWs) at home after their symptoms improve. The current CDC guidance suggests HCWs stay at home for at least 7 days after onset of “febrile respiratory illness” (temp greater than 37.8 C and cough or sore throat).

This may not be a problem now, but soon there will be a multitude of circulating respiratory viruses (see here for a partial list). If it is a bad “respiratory virus season”, even if H1N1 represents a minority of the circulating viruses, then a very large number of HCWs will be staying home from work for at least a week. And we know that understaffing is a problem for patient safety.

What are the alternatives? Three that come immediately to mind include: (1) sending HCWs back to work once they are afebrile for 24 hours, as the CDC is now recommending for schools and other workplaces, (2) sending HCWs back to work once afebrile, but making them wear a mask until the 7 day point is reached , or (3) screening all sick HCWs with a test that has a rapid turnaround time and high negative predictive value, and sending those that are negative for influenza A back to work once symptom-free and afebrile. Investigators from Beth Israel-Deaconess in Boston recently reported a negative predictive value of 96% for the rapid DFA test.

As Mike alludes to in his post, the most important thing is to remain flexible, and nimble, realizing that the response to novel H1N1 will evolve with the pandemic. Many hospitals will try initially to adhere to CDC guidance, but must be willing to modify their approach if they begin to experience staffing shortages that threaten patient care.


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