Ebola: Are We Prepared?

The latest developments in the Ebola outbreak continue to flood news reports and stir controversy. A series of what appeared to be errors in managing the first case of Ebola on U.S. soil has set off a firestorm of questions. Are U.S. hospitals really prepared to manage Ebola patients?

A Revised Protocol
Just a few days after the death of Thomas Eric Duncan, the first Ebola patient diagnosed at Texas Health Presbyterian Hospital in Dallas, an announcement was made that two nurses who cared for him had contracted the disease. Then, a national nurses union conducted a survey that cast doubt on whether hospitals throughout the country were up to the Ebola challenge. All eyes turned to the Centers for Disease Control (CDC) and other government agencies for guidance and action.

In response to questions that arose surrounding its original protocol, the CDC has issued a revised protocol that spells out specific infection control measures for health care workers who treat Ebola patients. Among the guidelines are instructions to wear personal protective equipment (PPE) that leaves no skin exposed. Several professional organizations, including the American Nurses Association, had requested clearer guidelines, specifically regarding the proper type of PPE and how to put it on and take it off. The revised protocol calls for all health care providers to receive in-depth training with the proper PPE and to be supervised by a trained monitor when putting on any PPE and taking it off.

All of the health care providers who treated the Ebola patients at Emory University Hospital, Nebraska Medical Center, and the National Institutes of Health Clinical Center followed these guidelines and none have become infected to date.

Help on the Way
The Pentagon has announced that it is forming a 30-person expeditionary medical support team to provide immediate assistance to civilian health professionals in the U.S. should additional cases of Ebola be diagnosed here. The team will include 20 critical care nurses, five doctors trained in infectious diseases, and five trainers in infectious disease protocols. The team will receive special training in infection control and PPE before it deploys.

The CDC is also sending more resources to Texas Health Presbyterian Hospital in addition to a team of 10 public health professionals that was sent last month. The original team is supporting the highest standards of infection control and assisting with contact tracing efforts. The new 16-member team will be assisting the Dallas hospital in infection control techniques and monitoring health care workers who had contact with the Ebola patient. The team includes experts who have successfully controlled outbreaks of Ebola in Africa over the past 20 years. Two infection control nurses from Emory University Hospital who cared for Ebola patients without becoming infected are part of the team and will provide peer-to-peer training and support.

What Nurses Had to Say
After two nurses who cared for the Ebola patient at Texas Health Presbyterian Hospital became infected, National Nurses United, a nurses’ union, surveyed more than 1,900 nurses in more than 750 facilities in 46 states. Survey results showed that:

  • more than 80% of the nurses responding felt that they do not have adequate training to care for an Ebola patient
  • 76% said their hospital had not issued an official policy on admitting potential patients with Ebola
  • 75% responded that their hospital policies are not adequate
  • 36% said that their hospitals do not have sufficient supplies, including critical PPE such as face shields and fluid-resistant gowns.

The union also spoke to nurses from Texas Health Presbyterian Hospital and reported that nurses there felt unprepared and ill-equipped to deal with Ebola. Statements made by these nurses, along with the hospital’s explanations, include:

  • The Ebola patient who entered the emergency department at Texas Health Presbyterian Hospital wasn’t isolated for several hours. When a nursing supervisor demanded that he be moved to an isolation unit, she said that hospital management resisted. The hospital responded that the Ebola patient was “moved to a private room and placed in isolation.”
  • The nurses were provided with PPE that left their necks exposed. When they expressed concern, they were told to wrap their necks with medical tape. The hospital said that the nurses were given PPE that was consistent with CDC guidelines.
  • Nurses complained about hazardous waste piling up in the hallways. The hospital replied that it went “above and beyond the CDC recommendations” and that waste was contained according to standards.

Some nurses also charged that they had not received any hands-on training and that training on Ebola was not required by the hospital. They also reported that lab specimens drawn from the Ebola patient were sent through the hospital’s tube system, potentially contaminating the entire system.

Texas Health Presbyterian has issued a letter of apology, regretting the hospital’s failure to diagnose Thomas Eric Duncan when he first visited the emergency department. The hospital admitted it had “made mistakes in handling this very difficult challenge” and blamed a failure to fully deploy training and education programs. The letter also said that Texas Health Presbyterian is working with the CDC to improve its protocols.

What’s Next?
The decision to transfer two Ebola-infected nurses from the Dallas hospital to specialized biocontainment units suggests a departure from the CDC’s earlier position that Ebola patients could successfully be treated at hospitals around the country. Going forward, to be able to deliver care at properly equipped facilities with trained care providers, experts suggest that regional Ebola centers —similar to regional trauma centers—be created. William Jarvis, former chief of the CDC division that monitors infection control at hospitals, is one who believes that the care of Ebola patients should be delivered at regional centers. Even with these centers, however, all hospital emergency departments and urgent care centers still need to be prepared to properly identify potential Ebola patients and handle them safely in the event that one walks through their doors. Some centers for Ebola care have already been designated. New York’s Bellevue Hospital Center, for example, will receive any confirmed Ebola patients from within the city’s 11 public hospitals. Hopefully, that won’t be necessary.

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