Thursday, October 16, 2014
MedPage: Ebola and Hospitals: How Great Is the Threat?
As events unfold, many healthcare workers, especially nurses, have expressed concern about their safety when treating Ebola patients.
Participants in a webcast sponsored by National Nurses United vented about their frustrations, concerns, and fears involving inadequacy of hospitals' response to the Ebola situation. Nurses from throughout the U.S. told consistent stories of their hospitals' lack of planning, training/education, and protective clothing for nurses and other healthcare workers.
A nurse from Florida claimed that she was suspended from her job after officials at her hospital learned she had contacted the CDC to request information about preparations and precautions for Ebola.
The Nurses' Story
Typical of that concern is this statement from Patricia Mungovan, an RN and regular MedPage Today reader who works in Chicago.
"Today yet another healthcare worker has been diagnosed. Dr. Tom Frieden has lost the confidence of the healthcare workers in the country with his blame the victim statements," Mungovan told MedPage Today.
She noted that the CDC has now initiated more detailed protocols but worried that action is coming too late. "But look at all the harm and ill will his self-serving statements produced. We deserve better in this country."
Vernon Dutton, RN, who has 35 years' experience as an acute care specialty nurse, said issues surrounding Ebola isolation are symptomatic of a much larger problem that has "been a long time coming."
The key, according to Dutton, who divides his time between two New Orleans hospitals, is symptomatic of system-wide failure.
"The nurses were pressed into taking that patient before they were ready," Dutton said. "No hospital is ready for Ebola. There's no continuity of care.
"The problem in Texas would have happened anywhere in the country. Isolation isn't the problem in and of itself. It's the hospital. [And] there's no standardization in isolation protocol," Dutton added.
In an interview with Brian Short, RN, president and founder of allnurses.com, he said his organization surveyed 3,000 members and 74% said they didn't feel safe or prepared to deal with a potential Ebola outbreak or patient, and 73% said their hospital hadn't provided them with training to handle a patient infected with Ebola.
Short, who had an allnurses.com public relations person present during his interview with MedPage Today, said the organization conducted the survey before it was known that the first infected healthcare worker was a nurse.
"I'm sure that's going to raise the anxiety of the healthcare workers now. All this level of awareness of the nurses not feeling safe and prepared," Short said.
Short said allnurses.com plans a follow-up survey for next week. "It's a great way to get a pulse on what nurses are feeling."
"The main thing that we can take away: nurses understand the risks that come with their job. They're willing to do their job, but they need the proper equipment and proper training to do the job effectively and safely," Short added.
Indeed, the ability to care for an Ebola patient is far from simple, according to nurses from Emory Hospital, which was the first U.S. hospital to treat Ebola patients.
In an article in NURSE.com, Carolyn Hill, MSN, RN-BC, nursing director of the serious communicable disease unit at Emory, detailed the experience she and 20 of her nurses shared while treating two U.S. aid workers who were flown to Emory from Sierra Leone.
This excerpt from that article stands in stark contrast to the simple personal protective equipment (PPE) and private room advice that the CDC has been offering:
"While treating the first two patients simultaneously, there were three nurses on duty at all times wearing PPE -- one in each room with a patient, and one in the adjoining anteroom. Instead of 12-hour nursing shifts, the team switched to 8-hour shifts with one break, Hill says. After 4 hours in one of the three rooms, nurses would doff their PPE, take a shower, and then break for 30 to 45 minutes while physicians relieved them, Hill said. Then the nurses returned for the 18-step process of donning the Tyvek suit -- a 25-minute task that included putting on eye protection, two pairs of gloves, a plastic apron and protective booties. Another critical step included checking the gauge for the powered air purifying respirator, which cleans air before it is inhaled."
In the ED
Seth Trueger, MD, MPH, an emergency medicine physician at the University of Chicago, put it this way, "Everyone has made the assumption that there was a protocol violation that comes with the assumption that if you self-contaminate, you did something wrong. But no matter how good you are, there's an inherent failure rate."
Corey Slovis, MD, chairman of emergency medicine, Vanderbilt Emergency Medicine, voiced what many have been saying in comments sent to MedPage Today: "I'm disappointed that the CDC did not get to Dallas quickly, and disappointed that they are not clear enough on what and how is best to prevent disease -- including why we are not going to disinfect our hands like Doctors Without Borders."
But, Eric J. Adkins, MD, MSc, medical director of emergency services, Wexner Medical Center at The Ohio State University, had high praise for the CDC. "In my opinion, the CDC has been very out in front on this initiative. It appears that they are doing everything possible to respond appropriately to the Ebola outbreak," he said.
Adkins said that, at his hospital, they have had "dedicated sessions to practice use of PPE. We have worked to secure adequate supplies of the appropriate equipment and are ensuring it is readily available in our emergency department. We have recently performed simulated 'mock' patients with Ebola viral disease to test our response and have had much success with identifying how we can improve the readiness of our staff."
Ednan Bajwa, MD, director of the infection control unit at Massachusetts General Hospital, noted that information now being shared by Emory has been very helpful but more information from Texas Health Presbyterian would be "most informative. They had the sickest patient. They have not shared their experience."
Bajwa speculated that concerns about possible lack of protocols at the Texas hospital has been a barrier to that information sharing.
From his perspective he said the concept of early treatment, like what was done in Nebraska and Emory, was most interesting."They showed that early treatment was critical. Every patient treated early has done well. If you pay attention to early aspects of Ebola this is not a lethal illness. It is clear Dallas made mistakes ... Emory and Nebraska had protocols in place," Bajwa said.
North of our borders, Canadians are running their own preparedness drills.
Niranjan Kissoon, MB, vice president for medical affairs at BC Children's Hospital and Sunny Hill Health Centre for Children in Vancouver, B.C., told MedPage Today, "Key departments have been advised to purchase a minimum of 24 hours of Hemorrhagic Fever PPE (different than the Decontamination PPE) and have been provided the list of equipment necessary."
The British Columbia health service "has been working with us to ensure that the warehouse will be consistently stocking of all of these items and after-hour contacts with HSSBC are in place for departments to rush order."
Moreover, Kissoon said, "Infection Control has been working diligently to ensure training is available to all staff on proper PPE donning and doffing procedures. They have recently finished a training video they are making available as well."
The Eyes of Texas
Meanwhile, across Texas major cities are responding with their own Ebola plans.
The Houston Chronicle reported that during a City Council meeting "health and first responders have taken inventory of what equipment they would need in the case Ebola came to Houston and have a plan in place. The key, Persse said, is to assume the city will see an Ebola case and prepare accordingly."
Similar scenes have played out in media reports from Austin and San Antonio, which, along with Dallas and Houston, make up the four largest cities in the state. All four are within 250 miles of one another, and the state's fifth largest city, Fort Worth, is just 30 miles west of Dallas.
Telephones have been busier than usual at the Texas Biomedical Research Institute (TBRI) in San Antonio, which has conducted Ebola vaccine studies for the past 10 years. According to the San Antonio Express-News, TBRI officials have fielded calls from health officials and media representatives throughout the world.
At the University of Texas Medical Branch (UTMB) at Galveston, a statewide referral center, President David Callender, MD, said in a statement that UTMB does not anticipate receiving any Ebola patients but nonetheless has a contingency plan.
UTMB houses one of the two National Biocontainment Laboratories in the nation (the other being at Boston University Medical Center), charged with conducting high-level studies of infectious organisms and diseases. Work at the two national centers is supplemented and complemented by a dozen regional biocontainment laboratories, all under the auspices of the National Institute of Allergy and Infectious Diseases.
And, Gov. Rick Perry established a statewide infectious disease task force charged with developing recommendations and a strategic plan for responding to infectious disease threats, such as Ebola. The task force has scheduled its initial meeting Oct. 23 in Austin.