Emergency Situations

To ensure a successful quality control effort, there should be an analysis of the antibiotic used for each type of infection, the patterns of antibiotic resistance, the geographic patterns of infections, time sequence for multiple infections, and the current location and diagnosis for all contagious disease patients in the hospital. While many of these data are used for establishing antibiotic usage guidelines, they are also needed for emergency situations that must identified and investigated.

There are three classes of situations that demand prompt action. The first is the identification of a case of a highly contagious or very virulent disease. The committee should establish a list of diseases that automatically trigger review, including such diseases as typhoid, measles, cholera, and any other diseases of public health significance. An investigation should also be triggered by any severe infectious process that cannot be clearly diagnosed.

The second class that demands prompt investigation is any geographic or temporal clustering of cases of an infection. This may represent a common source of contamination, a carrier staff member, or the beginnings of a community epidemic. In any case, it represents a potential liability situation for the hospital and must be properly investigated.

The third class is the emergence of antibiotic-resistant diseases. This is potentially the most dangerous situation because there may be no safe way to treat the infected patients. Whenever a strain of bacteria is identified that is resistant to the usual therapy, the patient must be carefully isolated while an effective treatment is sought. The medical staff must be alerted to the danger that such resistant diseases pose. They should be cautioned to prescribe antibiotics carefully whenever bacteria become resistant to all but a few drugs. The physician must be careful not to contribute to this problem by inadequate antibiotic therapy that may lead to the emergence of resistance to a new class of antibiotics. A periodic review of the antibiotic prescribing habits of each physician (which could be computerized) would be useful in detecting nonrational antibiotic usage.

The interface between the infection control/antibiotic usage review committees and the medical staff review committees occurs when a medical staff member does not comply with the guidelines established by the committees. The staff members may threaten patient welfare either directly by subjecting the patient to a source of infection or indirectly by contributing to the indiscriminate use of antibiotics.

The direct threat are the most serious an must be dealt with promptly. The common problem is the treatment of a contagious-disease patient without proper isolation techniques, thereby exposing both hospital employees and fellow patients to the risk of infection. This should be grounds for suspension of hospital privileges.

A more difficult problem arises when the physician is the source of the infection. This must be investigated whenever several patients treated by a common physician become infected by a common agent. The infection may be due to improper sterile technique (failure to wash hands between patients), or it may be caused by a subclinical infection carried by the physician. The physician must have proper tests performed to detect the presence of infection; and, if the potential risk of infection is great, the physician's privileges may be limited pending the outcome of the tests. If the physician is found to be infected, staff privileges should be limited until it can be shown that the physician is no longer infectious.

The hospital must be extremely careful to ensure that the physician does not come into contact with vulnerable patients, such as immunosuppressed patients or newborn babies. If the physician has an incurable infection, such as hepatitis, there must be a provision to limit the physician's patient contact to situations that have a low probability of spreading the infection. This will involve different limits depending upon the nature of the physician's practice and the nature of the illness. For instance, a physician with hepatitis should not have any close physical contact with patients. This would not interfere with history taking, decision making, or the direction of nurses or residents. It would require, however, that another staff member do any physical examinations or procedures and would rule out any participation in the call system or emergency room that could require the physician the physician to act alone. While these types of restrictions may be difficult to implement, it should be emphasized that both the hospital and the medical staff member will be liable for any patient infected by the staff member.