Issue: October 2020
Disclosures: The authors report no relevant financial disclosures.
September 05, 2020
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‘Just one missed case’: Study underscores importance of full travel screening

Issue: October 2020
Disclosures: The authors report no relevant financial disclosures.
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An analysis of records from more than 156,000 patient encounters in the Massachusetts General Hospital ED revealed that most included a general travel screening, but records rarely included documentation of where the patient traveled.

During the study, researchers learned of 62 traveler encounters missed by a MERS best practice advisory that was added to the hospital’s EHR in August 2018.

Sarimer Sánchez

“Universal travel and symptom screening is a standard of care that allows for frontline staff and clinicians to rapidly identify patients presenting with possible high-consequence infectious diseases, including MERS and Ebola virus disease, as well as other communicable diseases such as measles,” Sarimer Sánchez, MD, a research fellow at Harvard T.H. Chan School of Public Health, told Healio.

Sánchez explained that the best practice advisory (BPA) at Massachusetts General Hospital (MGH) was triggered when clinicians documented relevant travel and symptom history in the EHR.

“The BPA alerted them to consider MERS in the differential and provided instructions regarding immediate isolation of the patient and who to inform within our institution for next steps in the management,” Sánchez said.

Sánchez and colleagues assessed travel screening adherence and functionality of this clinical decision support tool through a retrospective automated record abstraction of all adult and pediatric patient encounters in the MGH ED from August 2018 through December 2019. According to the study, if a patient encounter had multiple travel screens documented, researchers assessed only the first one and they categorized the encounters as adherent to the screening protocol if providers had answered “foreign,” “domestic” or “no travel” and if the care department at the time of initial travel screening was within the ED.

Overall, 156,276 patient encounters were included in the analysis, of which 121,080 (77%) were adherent to general travel screening. According to the study, among the encounters with documented foreign travel during the study period (n = 5,143), 3,290 (64%) specified the region of travel and only 846 (16%) selected a country of travel with use of the travel screening tool.

Analysis of these encounters showed that travel to the Middle East was documented in 238 patient encounters with use of the travel screening tool and symptom screening was performed in 164 encounters (69%) of which, 113 documented absence of fever and cough, 20 documented fever and cough, 13 documented a cough alone and 18 documented a fever alone.

The MERS BPA was prompted in 43 encounters. According to the study, using BPA guidance, clinicians ordered isolation precautions for 12 patients. Following review of these patients, five patients met the CDC criteria for MERS and were tested, although all tests were negative. However, the researchers found an additional 62 encounters of travel to the Middle East that were not documented through the travel screening tool. “To our knowledge, there were no missed cases of MERS in this cohort,” they wrote.

Sánchez said comprehensive travel and symptom screening can aid COVID-19 mitigation efforts.

“Given widespread community transmission of COVID-19, as well as asymptomatic and presymptomatic infection, the travel component for COVID-19 is not as relevant now as we are operating under the assumption that any patient presenting to our facilities could have COVID-19,” she said, adding that the symptom screening component of travelers continues to play an important role and will do so in the future, beyond COVID-19, “as it provides the flexibility to build in automated prompts to frontline clinicians based on combinations of symptoms with or without travel.”

She said this provides a level of flexibility that can be hyperlocalized.

“As we’ve seen with COVID-19, just one missed case can contribute to significant spread of disease and dramatically shape the course of an early pandemic,” Sánchez said. “This is why we need to evaluate our current screening processes and work with frontline clinicians and staff to design and implement innovative systems that make it easy for them to ask the right questions related to travel and symptoms, document this information consistently in the EMR, and build clinical decision support to guide them on next steps based on the answers to those questions.”