Thursday, October 9, 2014

A Lesson Learned from the First Ebola Death in the U.S.

It is with great sadness that I write about the Ebola patient case at a hospital in Dallas, Texas. The patient has now died. All healthcare providers would be well served by studying what happened in this case. In late September a man walked into a hospital with a fever, complaining of abdominal pain and a sharp headache.  When the patient was asked whether he had nausea, vomiting, or diarrhea, he said “No.”  At that time his symptoms, which were not severe, could have been associated with many infectious diseases, as well as many other types of illness.  He was also asked if he had been around anyone who had been ill, to which he said “No” and if he had traveled outside the United States within the last four weeks. He responded that he had been in Africa.  A nurse entered that information in the electronic medical record. From what we know it appears that he was sent home with antibiotics.  The patient returned two days later saying he was worse and this time he was admitted to the hospital and placed into isolation with possible Ebola.  Ultimately, the U.S. Centers for Disease Control released the information that this individual tested positive for Ebola and has now died of that disease.

Ebola scares us because it has a high mortality rate and its initial signs and symptoms are not unique. The current outbreak can and will be contained and extinguished but this will require a well-designed and executed international plan.

Is our current health care delivery system capable of creating and executing this plan? Well, everyone knows that we don’t have an international health care system. We have many national health systems of varying capabilities.  A country like Sierra Leone, for example, doesn’t have a well-developed public health infrastructure or primary care system. In our own country our healthcare system has more capacity, but, the events in Dallas show that you can have extensive financial resources deployed in a healthcare system, but, have it poorly designed to meet a need of the community it serves. 

In this case, the hospital in Dallas appears to have had a major “latent” error (hole in the Swiss Cheese) that was waiting to be part of a trajectory that would lead to the catastrophe of putting a patient with Ebola back out on the street. I am afraid that the very same latent error is present in many healthcare organizations throughout our country. That latent error is the absence of direct concise communication between members of the healthcare team. I should be cautious commenting on this case without all of the facts, but it appears that at least one team member knew that the patient had recently traveled from Africa and yet the patient was discharged from the emergency department only to be admitted later with Ebola, thereby having potentially spread the disease to multiple other individuals.

The knowledge of what happened in Dallas is a potential treasure for the rest of us in the US healthcare system. We must learn from this and redouble our efforts to operate as a high-functioning team with freely flowing information and people not afraid to speak up if they have a safety concern.









Physician Assistants WeekPlease join me in celebrating all GBMC physician assistants (PAs). This week is National PA week (Oct. 6-12) and is a time when PAs celebrate their profession and showcase the value they bring to today’s healthcare team.

A physician assistant (PA) is a nationally certified and state-licensed medical professional who begin their careers with rigorous education in a highly competitive field.  Upon completion of a bachelor’s degree, prospective students must then attend an intense three year PA program and complete at least 2,000 hours of supervised clinical practice.  They then must pass the Physician Assistant National Certifying Exam (PANCE), which is administered by the National Commission on Certification of Physician Assistants (NCCPA). 

The PA staff at GBMC practice in many areas from the outpatient offices to the inpatient units in a wide variety of specialties. Please join me in thanking our PA’s for their hard work and for their important role in caring for our patients.

22 comments:

  1. John, I completely agree with your assessment of the ebola communication but I would like to add another observation. One account I heard on national news was that the nurse entered the information in the nurses' section of the EMR but since physicians document in another section, the information was not picked up. Whether this account is accurate or not, I do not know but I think it does indicate how important it is that disciplines read other parts of the EMR to see the patient's whole story if it is not an integrated EMR.....no matter what the diagnosis of the patient.
    Donna Lewis

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    1. Thanks, Anonymous. If all that members of a team do is put their findings in the chart, but, never communicate directly, these catastrophes will occur whether the documentation is electronic or on paper because there will always be someone who didn't read someone else's note. The Team must communicate directly and frequently when there are important issues that if they are missed could create harm. I think that the commentary about the record is a distraction. It is true however that designers of the record should work to make it hard to miss critical issues.

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    2. Dr. Chessare, just as you note above that electronic and paper communication is not enough, being referred to the info web on ebola updates by our manager is not enough to prepare us to care for patients with a potentially deadly infectious disease. We need interactive, on-site training and adequate supplies on our unit.
      - another nurse

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    3. Thanks, Anonymous. We are acutely aware of the potential for employees to contract illnesses and we are deeply invested in continuously refining protocols and training, in collaboration with all levels of staff, to minimize that risk. Our designated Ebola Task Force has created a training schedule, which is already underway, and involves drills on the correct use of PPE, as recommended by the CDC, and adherence to strict infection control procedures. Also, videos of GBMC HealthCare training sessions are available on the Infoweb.

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  2. How is it possible to be safe with just using standard, contact, and droplet precautions if we have to care for Ebola patients? Does our hospital carry the hazmat suits? I would like one of those suits if I am assigned to such patients for my own safety, the safety of my coworkers, my family, my community.... The blue isolation gown is pretty but it is not enough.
    One Nurse

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    1. Again, both the CDC and DHMH in conference calls attended by GBMC personnel this week state that tyvek suits are not protocol in the United States and could potentially contribute to more contamination risk for the healthcare worker due the difficult nature of removing the suits. Emory University and Nebraska both have specialized units to handle chemical, radiological, and biohazard events. Their staff have been trained for years in the donning and doffing of the suits and it has been part of those specialized facilities standard operating procedures. The guidance from the CDC for acute care facilities has been "more PPE is NOT better and presents increased risk for exposure of healthcare workers during the removal process"

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  3. Should there be a mandatory screening of employees who recently returned from Africa? I'm very concerned about a co-worked scheduled to return next week and the safety of our staff.

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    1. All employees should be assessed the same way that a patient is assessed if they are returning from an area that the CDC considers high risk for exposure. If you have a concern, you should discuss this with your boss who can then consult Infection Control and Employee Health if there are remaining questions.

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  4. Is GBMC equipped to handle an ebola patient? The two YOU TUBE videos posted for us to watch were for standard droplet isolation patients. Do you think this is enough to protect us from contracting the disease, God forbid that Ebola reaches our workplace? Do you have a plan in place, as to where to admit the patient to, or should you consider transporting the patient to a better equipped hospital? The PPE we see on TV being worn by people that come in contact with ebola patients covers the whole surface of the body, not the PPE on the videos from YOU TUBE dating back 2012.

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    1. GBMC is in the midst of preparations to ensure we have the necessary supplies, protocols and equipment to provide care to a patient with Ebola Virus Disease (EVD). The situation is evolving rapidly, and we must be ready to adapt to any additional guidance from the CDC or change in plan as it occurs. The Emergency Department, Pediatric ED, Labor and Delivery have been provided triage tools and call trees to ensure prompt isolation and communication if a patient meeting the criteria of a "Patient Under Investigation" (PUI) arrives. The communication from the CDC and DHMH is consistent that a PUI will not likely be transferred to another acute care facility and that all hospitals should be able to isolate and manage the patient with standard, contact and droplet precautions. The reality is that patients with EVD will need critical care. Therefore, the patient would be placed in a location with critical care capabilities. GBMC is actively engaged with our state and federal partners to ensure we are providing our healthcare teams necessary protections and will make any necessary amendments as the guidance changes.

      Both the CDC and DHMH in conference calls attended by GBMC personnel this week state that tyvek suits are not protocol in the United States and could potentially contribute to more contamination risk for the healthcare worker due the difficult nature of removing the suits. Emory University and Nebraska both have specialized units to handle chemical, radiological, and biohazard events. Their staff have been trained for years in the donning and doffing of the suits and it has been part of those specialized facilities standard operating procedures. The guidance from the CDC for acute care facilities has been "more PPE is NOT better and presents increased risk for exposure of healthcare workers during the removal process"

      Please consult the infoweb ebola page regularly to find updated case definitions, algorithms, isolation guidance and contact information.

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  5. What does GBMC have in place in case of an ebola outbreak in our community or if a patient walks in and meets the checklist for it?

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  6. Thanks, Anonymous. Our infection control department is taking the lead with our leaders to make sure that we are ready. They are sending out regular updates to our plan. Have you seen our Ebola updates on the home page of the Infoweb. Your manager should be discussing your department's readiness at your department meetings.

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  7. Thank you for the updates and information. I understand from both your responses and the guidance from CDC that the Tyvek suits and enhanced PPE are not part of our protocol at this time. Would it be possible to look into training in use of those suits/PPE for the employees at GBMC? As soon as possible? In light of the case of the nurse who has contracted Ebola from a patient, many heatlhcare workers are rightfully terrified. It seems that many of the staff here fear that both they and the facilities that employ them are unprepared to care for an Ebola patient. This was clearly the case in Dallas. To be fair, it is apparent that this feeling of lack of preparedness is prevalent at many hospitals in the United States. It seems that enhanced PPE and increased, appropriate training have worked for the facilites in Georgia and Nebraska. So the ultimate question is, shouldn't GBMC be concerned enough for it's staff to at least investigate the possibility of employing such precautions and training here? In order for us to meet our vision of providing the care to each patient every time that we would want for our own loved ones, patient care staff need to be healthy, safe, and feel that their employer has their best interests at heart. As we all are well aware, without healthcare workers, there can be no health in the community at large!

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    1. Thanks Anonymous. The CDC provided updated guidance on proper PPE equipment on Monday, Oct. 20. This includes impervious gowns that go to mid-leg, shoe coverings and hoods. Staff expected to care for EVD patients are the priority group to receive this training.

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  8. We have a plan, but has there been or will there be hands-on training for donning/removing protective gear and following the CDC protocols? Has GBMC considered creating a dedicated team to treat possible Ebola patients?

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    1. Yes hands on training will be provided to those identified as the care team. We are in the process of filming videos to reinforce PPE training sessions. An EVD patient will require critical care intervention and the critical care team will be providing care.

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  9. http://www.telegraph.co.uk/news/worldnews/ebola/11155840/Ebola-medics-better-trained-in-Sierra-Leone-than-Spain.html

    Seem to me that we will need to consider doing hands-on training rather than just emailed diagrams and instructional videos to stop this infection.Now that a second health care worker is infected, we need to stop pointing fingers and get serious.

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    1. Thanks Anonymous. Hands on training is underway for those at GBMC that will be in direct contact with suspected Ebola patients. We are in the process of filming videos to reinforce PPE training sessions.

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  10. What about protective gear for our shoes? I hear the pt in Texas had copious amounts of diarrhea and vomiting which could potentially be on the floor.

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    1. As stated in the above question, shoe and leg covers are being supplies and the donning and doffing of the covers is being provided in the PPE education sessions to include staff from critical care, ED, NICU and L&D.

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  11. This is a copy of what GBMC has posted for PPE
    PPE for all staff entering the room:
    fluid-resistant, long-sleeved, cuffed gown
    gloves
    full face protection (face shield)
    surgical or procedure mask
    What about covering for shoes? Something not pores is needed like the blue gowns. Is that being supplied?
    Also what about direct admit patients? How are they being screened prior to entering the hospital?
    What if they have the S/S, but have not traveled? Why are we not asking about realtives friends that they be in contact with that could be potential carries, but are not showing S/S yet?

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  12. Thanks Anonymouos. Yes. Shoe and leg covers are being supplies and the donning and doffing of the covers is being provided in the PPE education sessions to include staff from critical care, ED, NICU and L&D. We have put into place a universal screening policy across the GBMC Healthcare system complying with CDC guidelines.

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