The coronavirus (COVID-19) epidemic and patient safety
Authors: Dirk M. Elston
Journal: Journal of the American Academy of Dermatology (2020)

In this issue of the JAAD, Chen et al1Chen Y. Pradhan S. Xue S. What are we doing in the dermatology outpatient department amidst the raging of the 2019 novel coronavirus?.J Am Acad Dermatol. 2020; 82: 1034Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar discuss patient safety measures in a Chinese dermatology clinic during the coronavirus outbreak (2019-nCoV acute respiratory disease), including patient screening, respiratory precautions, and telemedicine consultations. The steps they enacted serve as a reminder that we should have policies in place for infection control in every dermatology clinic. Patients with varicella, measles, and other viral exanthems present to the dermatologist and may pose a risk to patients and office staff. Employees should receive all appropriate vaccinations, and testing should be available for employees to determine their immune status. This is especially important for women of child-bearing age who may be exposed to diseases such as varicella and erythema infectiosum. If available, a negative pressure room should be designated as an isolation room for patients with respiratory pathogens, and exposed susceptible individuals should be furloughed during the incubation period.2Herwaldt L. Smith S. Carter C. Infection control in the outpatient setting.Infect Control Hosp Epidemiol. 1998; 19: 41-74Crossref PubMed Scopus (47) Google Scholar,3Preblud S.R. Nosocomial varicella. Worth preventing, but how?.Am J Public Health. 1988; 78: 13-15Crossref PubMed Scopus (13) Google Scholar Large health care organizations often address these issues during in-processing of employees, but many dermatologists practice in private clinics and should review existing policies to prepare for the inevitability of contagious patients entering the clinic. This is not the first outbreak of a severe coronavirus. Prior outbreaks of virulent coronavirus strains have also been associated with severe respiratory syndromes and patient deaths. Individuals who are asymptomatic or who have only mild symptoms may spread the virus. However, superspreading events—instances where an index patient transmitted disease to ≥5 subsequent patients—were typically associated with patients who were severely ill, initially not recognized as severe respiratory syndrome-coronavirus cases, and subsequently died. Delays in implementation of control measures contributed to secondary transmission, but contact tracing, testing, employee furloughing, and implementation of recommended transmission-based precautions for suspected cases ultimately halted transmission.4Alanazi K.H. Killerby M.E. Biggs H.M. et al.Scope and extent of healthcare-associated Middle East respiratory syndrome coronavirus transmission during two contemporaneous outbreaks in Riyadh, Saudi Arabia, 2017.Infect Control Hosp Epidemiol. 2019; 40: 79-88Crossref PubMed Scopus (18) Google Scholar Our responsibility for patient and employee safety is not limited to respiratory pathogens. Virulent streptococcal infections associated with necrotizing fasciitis and death have been spread during liposuction in outpatient facilities.5Beaudoin A.L. Torso L. Richards K. et al.Invasive group A Streptococcus infections associated with liposuction surgery at outpatient facilities not subject to state or federal regulation.JAMA Intern Med. 2014; 174: 1136-1142Crossref PubMed Scopus (15) Google Scholar The procedures were performed by a single surgical team that traveled between locations, and 2 team members were colonized by the organism. Substandard infection control, including errors in equipment sterilization and standard precautions, contributed to the outbreak. Prevention of transmission of blood-borne infections deserves special mention, and readers should review the JAAD continuing medical education articles that focused on patient safety and blood-borne pathogens (https://www.jaad.org/article/S0190-9622(09)00603-3/fulltext and https://www.jaad.org/article/S0190-9622(09)00602-1/fulltext).6Elston D.M. Stratman E. Johnson-Jahangir H. Watson A. Swiggum S. Hanke C.W. Patient safety: part II. Opportunities for improvement in patient safety.J Am Acad Dermatol. 2009; 61: 193-205Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 7Elston D.M. Taylor J.S. Coldiron B. et al.Patient safety: part I. Patient safety and the dermatologist.J Am Acad Dermatol. 2009; 61: 179-190Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 8Brewer J.D. Elston D.M. Vidimos A.T. Rizza S.A. Miller S.J. Managing sharps injuries and other occupational exposures to HIV, HBV, and HCV in the dermatology office.J Am Acad Dermatol. 2017; 77: 946-951.e6Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Standard precautions should be enforced, and policies should be in place for postexposure prophylaxis. As captains of our individual ships, it falls to us to put policies in place to prevent the spread of disease and prepare for the needle-stick injuries and transmissible diseases that are part of the practice of medicine. What are we doing in the dermatology outpatient department amidst the raging of the 2019 novel coronavirus?Journal of the American Academy of DermatologyVol. 82Issue 4PreviewIn late December 2019, several individuals with unexplained pneumonia were reported in Wuhan, China. A novel coronavirus was subsequently identified as the causative pathogen and provisionally designated 2019 novel coronavirus (2019-nCoV).1 As of February 10, 2020, 42,638 cases of 2019-nCoV infection have been confirmed in China, with 21,675 suspected cases and 1016 deaths. There are still more than 3000 confirmed cases every day, involving people living in or visiting Wuhan, as a subsequent characteristic of human-to-human transmission. Full-Text PDF