Sunday, July 17, 2005

Why we have protocols.

I've said it before, and I'll say it again: "A policy does not exist to inconvenience you. There is a reason for it."

That was brought home to me last week in a big way.

A patient had come in, had a bad surgical outcome, and had spent the better part of eight weeks bouncing from unit to unit. At one point, some bright person had noticed that the patient was coughing up a lot of junk (sorry for the technical term) and decided to do an acid-fast smear and culture on that junk.

Acid-fast bacteria are a big family. Most of 'em you don't really need to worry about, but one you do: tuberculosis. Our hospital policy says this: if a patient has an acid-fast bacillus positive smear or culture, that person is put into respiratory isolation in a negative-pressure room until it can be determined that they do or do not have TB. It sounds draconian to do that, but it's really quite sensible; the treatment for TB is nasty beyond description and takes a very long time.

So this patient had a negative AFB smear and a positive AFB culture. The micro lab called the floor where the patient was at the time and gave the results to a physician's assistant who had been following the case.

Here's where the system breaks down. The PA, being a Quasi-Important Person with an inflated sense of his own authority, decided that the culture didn't matter, that the patient didn't have TB. How he determined that without psychic abilities escapes me, but the point remains: he didn't notify the infection control folks or put the patient into isolation. In other words, he carefully ignored the protocol that the hospital has put into place for the protection of everyone.

Micro also screwed up. They're supposed to call report, with a read-back, to two people: the resident in charge of the case and the nurse caring for the patient. They didn't. They ignored the protocol that was put into place for the protection of everyone.

So. Fast-forward four weeks. The patient's been on our floor for two weeks. Another bright person, this one from the pulmonology staff, takes a walk through the patient's chart and finds the old AFB positive culture result. The patient is slapped into isolation, where I find them after I come back from a three-day weekend.

I'd taken care of that patient for two weeks solid. Several times I had gotten coughed on and sprayed with mucus (no matter how careful you are, this will sometimes happen). I was told that an AFB-positive culture had *just come back* from micro, hence the sudden isolation.

Which struck me as fine, until I read the chart and noticed that the AFB culture had actually been done back at the end of May. And that it had been positive. And that the patient had been un-isolated and coughing on yours truly, as well as other nurses, techs, support staff, and doctors all that time.

My hair caught fire. I started making phone calls. I found the record of an order for a PPD (purified protein derivative test for tuberculosis), but no record of its having been done on the patient. (Protocol again, this time a failure of a nurse to chart properly.) I wandered into the room and inspected both arms--yep, there's the permanent-marker circle that defines a PPD placement. Okay. It's negative. Back on the phone, I paged the infection control team leader and told her about what had just happened. She paged the PA in question and the chief attending physician of that service. The attending called me, so I had to tell her the same story I'd told everybody from IC to ICU.

The upshot of all of this drama? The patient got some super-duper DNA screening widget test that involves turning urine into gold, or some such, which determined that there was no tuberculosis bacillus present. Period.

(Of course, we'll all have to be tested again in twelve weeks, just to be sure.)

The test costs not-a-little-money. It has to be sent out, and the results in this case were statted, which costs more. The hospital is going to eat that cost. There were also a number of us who'd cared for this patient who'd had to go home and inform our families that we might've been exposed to a particularly icky bacillus. (That was a fun one; Chef Boy was coming down off of having his smoker explode when I told him.)

Yes, TB is hard to catch. Yes, it's treatable. Yes, the chances of my having caught it, even with direct exposure to infective goop, were quite slim.

But the point remains: at least two people in this little drama didn't follow protocol. One didn't follow it because he just knew he was right; the other didn't follow it because they were just plain lazy. As it turns out, everything was fine--and the PA in question really *was* right this time.

Still, it cost us 24 hours of worry and cost me quite a lot of time to clear up.

The worst bit? The PA, since he doesn't work for the hospital itself, can't be written up or otherwise go through our disciplinary--sorry, "counselling"-- process. And the lime pit in my back yard is already full.


Special Sauce said...

Stupid PA.

I've got a lime pit in my backyard that's just going begging for morons. I'd gladly take one off your hands, in exchange for all the fun reading you've given me.

Anonymous said...

After 50 years on this earth I finally, a few years ago, started getting positive PPDs. It is just coincidental, I suppose, that this occured after the hospital sent us a patient (I work in a SNF) WITHOUT a complete H&P and Discharge Summary to let us know that she was supposed to be continued on Rifampin and INH for 3 more months.

Infectious Disease Doc doesn't feel I am a great candidate for the 6 month INH thing since I have had 3+ years of negative sputums and clear CXR's.

Just one of Nursing's little "gifts" that you'd rather not get. Maybe I am paranoid, but I am DEEPLY suspicious that the "oversight" was deliberate; the hospiital wanted this patient GONE because her medicare days were almost up, and disclosing the TB would have made SNF placement problematical. Of note, also, is the fact that no nurse from the hospital called us about this patient to give us report. Of course, in report they would have been obligated to list all DX's - but this, too, was SURELY just a "coincidental" oversight.

may said...

how about making the protocols more reader friendly? like a comic book perhaps? with drawings and a little bit of entertainment, the PA will surely be interested :)

The new Third Degree Nurse said...

Are the protocols discussed at orientation and then never addressed again?

Anonymous said...

I had the converse - a patient with red snappers in her sputum that turned out to be MAI colonoization - again (she has CF.). She was *quite put out* to be in isolation because of a silly thing like protocol, when she *knew* she only had MAI. But, having seen TB in action, I still support the protocols wholeheartedly. They're there for a reason.