32. CASE: To Report or Not

Dr. B is the epidemiologist and director of infection control for an academic health centre. The reportable disease statutes and regulations in Dr. B’s province specify that hospitals and other health care facilities throughout the province are required to track nosocomial infections (infections not present in patients prior to their admission to the hospital) and to “rapidly report outbreaks” to the local health department. What constitutes an “outbreak” is not specifically defined in the statute or in the regulations. This determination is left to the discretion of each facility’s epidemiologist.

As the hospital’s epidemiologist, Dr. B is charged with collecting data on all reportable diseases. He is responsible for determining when the threshold for an outbreak has been met. His staff provides him with data indicating that the rate of several nosocomial infections has been increasing steadily. The increases have been sustained over a period of three and a half months and are statistically significant. Although Dr. B’s data lag behind by approximately one month due to data collection limitations, all indications are that the rates will remain at their current elevated levels or may even escalate. In Dr. B’s opinion, these increases constitute a nosocomial outbreak and should be reported to the local health authorities.

The hospital is still reeling from the political fallout resulting from intense media attention on a young patient with epilepsy who was left unattended and who suffered a serious fall during a grand mal seizure. The patient is now in a persistent vegetative state. The hospital administration, risk management, and the legal counsel for the medical centre and the university are highly sensitive about the incident. The situation has upset the provincial health minister as well, who has expressed his concern about its reflection on him and his chances for re-election. He is said to have told those close to him that he will “make heads roll” in order to appear to have dealt adequately with the situation.

Dr. B’s infection control staff believes that they have identified the probable cause of the outbreak. They have found that healthcare providers are frequently not adhering to basic hand-washing regimens that are required by standard infection control procedures. Observers on the units report that only 30% of healthcare workers wash their hands between patient contacts. The situation is even worse in the ICUs where only 10% of physicians wash their hands between patient contacts. The welfare of every patient on every unit of the hospital is jeopardized by this situation. Dr. B plans an aggressive internal communications campaign to increase awareness of the current low levels of hand washing and to emphasize the importance of infection control in the care of patients.

Dr. B relays his findings to the hospital leadership and maps out his plans for an aggressive communications campaign. He receives a less than lukewarm response. He is questioned about the provincial reporting requirements. He is told that, since the parameters defining “outbreak” are not specifically defined, it is highly doubtful that the institution is experiencing an outbreak. Hospital administrators agree that the situation must be monitored closely. However, they instruct Dr. B not to report the nosocomial outbreak to the local health agency. In addition, they advise him not to disseminate data on the levels of hand washing observed on the units and instruct him to limit his campaign to a general message emphasizing the importance of hand washing in any successful infection control effort. He is told to monitor the situation closely. In response, Dr. B calls the ethics committee for assistance.

[Case modified from: Ann E. Mills, Edward M. Spencer, and Patricia H. Werhane, Developing Organization Ethics in Healthcare: A Case-Based Approach to Policy, Practice, and Compliance, Hagerstown, Maryland: University Publishing Group, 2001, Case #11 by Margaret Skelley, pp. 41-42]

  • What is your gut feeling as you read through this case?
  • What values are at play for Dr. B? For the hospital administrators?
  • Would a decision-making framework be relevant or helpful in this situation?
  • How would you approach this situation when Dr. B. called for an ethics consult?


Some Values and Ethics Issues to Consider

  • Accountability
  • Transparency
  • Medical error
  • Patient safety
  • Compliance with policy
  • Duty to provide care
  • Risk
  • Honesty, trust and truth-telling
  • Respect for professional integrity

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