Although months have passed since the most recent Ebola epidemic—the deadliest in history—has dominated headlines, the virus is still at the forefront of discussions among US public health institutions attempting to improve preparedness efforts before another public health crisis strikes.
Earlier this month, Texas Health Resources (THR)—one of the largest faith-based, nonprofit health systems in the United States—announced the findings of an independent panel that reviewed the treatment of the first patient diagnosed with Ebola Virus Disease (EVD) in the US, as well as the two nurses who contracted the disease during his treatment.
The patients were treated at Texas Health Presbyterian Hospital Dallas (THD), one of Texas Health’s largest hospitals. Based on the findings in the panel’s report, Texas Health has implemented several steps to improve the quality of care provided to patients at the Dallas hospital and the system’s other North Texas facilities.
The panel convened in February at the behest of THR, and with the authorization and support of the hospital’s board of trustees, to review the facts of the events surrounding the care and ultimate death of the EVD patient and the transmission of the virus to two nurses, and to make recommendations aimed at improving performance and preparedness for similar unforeseen events.
“While specifically directed toward the future operations of (Texas Health Dallas) and Texas Health Resources, these recommendations also present an opportunity for other hospitals and health systems to review and learn so that they also may prepare for unanticipated and potentially catastrophic events,” the panel wrote.
In addition, the report stated, “Hospitals and health systems throughout the United States were (and continue to be) at various states of readiness for a similar event. Accordingly, an important outcome of the work of the panel is to inform hospitals, health systems and public health authorities as they develop processes for implementing and verifying continuous quality improvement and safety to address novel clinical events like the experience with Ebola in Dallas.”
Dr. Denis Cortes, the Emeritus President and CEO of the Mayo Clinic, chaired the panel. Joining him were Patricia Abbott, a registered nurse and director of the Hillman Scholars Program at the University of Michigan School of Nursing; Dr. Mark Chassin, CEO of the Joint Commission; G. Marshal Lyon III, associate professor of medicine in the Division of Infectious Diseases at Emory University School of Medicine, where Vinson emerged virus free; and Wayne J. Riley, clinical professor of internal medicine at Vanderbilt University.
“We welcome this panel report and believe that it will lead us to better diagnoses of diseases in our emergency rooms, better care for our patients overall, and better coordination with local, state and federal officials in the event another rare event like this unfolds,” said Barclay Berdan CEO of Texas Health Resources. “We’re hopeful that these findings will also help hospitals and health systems across the country be better prepared for future novel events.”
On September 25, 2014, Thomas Eric Duncan, a Liberian émigré, arrived at the emergency department of the hospital complaining of dizziness, abdominal pain, nausea, and headache. He was evaluated first by a nurse and then a physician. Although the nurse noted that he had recently traveled to Africa and entered his travel history into the electronic health record system (EHR), it was not verbally communicated to the physician.
While undergoing several diagnostic tests and receiving intravenous fluids, his temperature jumped from 100.1 to 103.0 and then dropped to 101.2 after being given Tylenol. His heart rate also increased, and the automatically calculated Systemic Inflammatory Response Syndrome (sepsis) Score rose from 0 on admission to 3 (out of 4) at discharge. However, Duncan was discharged with a diagnosis of sinusitis and given prescriptions and instructions to return to the emergency department if symptoms worsened.
The report noted, “It is not clear that the physician was aware or reviewed information that the patient’s temperature had risen to 103 at one point in the visit, or that the SIRS score went to level 3 out of 4.”
The experts emphasized a number of significant lessons to be learned from this first visit. First, the hospital needs to have a protocol or system in place that reviews or re-asks about critical travel information. The experts also cautioned against an over-reliance on the EHR for communication of important clinical information between the key members of the patient’s clinical care team.
“We agree with the panel’s recommendation that we take a look at the roles the different members of the ER team play and how they work,” said Dr. Daniel Varga, chief clinical officer and senior executive vice president for Texas Health. “The electronic health record is a wonderful tool, but we need to have a high-reliability system in place that doesn’t over-rely on that technology and empowers team members to speak up about the condition of a patient.”
The report explained that the panel’s findings associated with the misdiagnosis and discharge of Duncan raise a number of issues:
- Lack of inter-professional teamwork
- Inadequate communication processes and over reliance on the EHR to convey critical information
- Inadequate review and reevaluation of relevant clinical information before disposition
- Lack of thorough physician oversight during the ED stay
- Overemphasis on patient satisfaction versus safety and outcomes
- Dissemination of information on EVD patient treatment was not treated as a priority.
Three days after Duncan’s initial visit, Dallas Fire & Rescue paramedics picked him up at his apartment. While en route to the hospital, the paramedics communicated that they had an inbound patient recently arrived from Liberia with nausea, vomiting, diarrhea and an elevated temperature.
On arrival at the hospital for his second ED visit, he was taken immediately to isolation. THR made a presumptive diagnosis of Ebola Virus Disease, which they conveyed to Dallas County Health and Human Services and then the Centers for Disease Control and Prevention (CDC) within 2-3 hours of Duncan’s arrival.
Duncan was cared for in the emergency department in a separate, isolated area for approximately 30 hours as the Medical Intensive Care Unit (ICU) was prepared for his admission. During that time, none of the staff became infected who participated in the care of Duncan.
The panel determined that, “Mr. Duncan’s care throughout his stay in the Emergency Department was appropriate for a person with symptoms consistent with EVD.” Once transferred to the ICU, Duncan was cared for in a vacated 24-bed unit by several nurses following CDC-directed procedures. However, healthcare workers had areas of exposed skin that were not fully covered or shielded by the CDC-prescribed level of protective equipment.
Despite the hospital’s efforts, Duncan died on October 8.
The panel of experts determined that the hospital could have been better prepared in advance of the admission of a patient with EVD; however, the healthcare workers performed well in caring for Duncan on his second visit. The panel did, however, fault the CDC for failing to prepare the hospital in the use of personal protective equipment, waste management and "other challenges that would emerge as critical."
In fact, the report emerged amid a lawsuit by Nina Pham, one of two nurses who contracted Ebola while caring for Duncan, alleging that THR failed to provide training and proper protective gear.
The panel concluded that the death of Duncan andthe infection of two nurses emerged from three distinct, but overlapping issues:
- THD and RHR was not prepared to diagnosis and manage a patient who came to their facility without a preexisting diagnosis of EVD, putting the entire health system and community at risk.
- CDC and others were learning alongside the actual providers. The responsibilities of all parties were not clearly outlined in advance of the Ebola event; and
- Hospitals need to understand in the future that CDC serves on in an advisory role, so it is up to the hospital to ensure the “quality, safety and high reliability of clinical operations.”
Moving forward, THR has learned that preparedness requires both preparing a community hospital for the arrival and diagnosis of a patient infected with EVD or any other emerging infectious disease, and making sure the staff and the facility are ready to treat a patient who is infected.
“The fact that CDC and the hospital staff were learning together as circumstances evolved demonstrates a misunderstanding by both partners for the need to drill and train together in a comprehensive way prior to a public health event like Ebola,” the report concluded. “These learnings are now relevant in that they have helped shape the standard operating procedures for how personal protective equipment must be used for an infection such as EVD.”
With these lessons learned from the tragic death of Duncan, THR has begun implementing a system wide approach to emergency preparedness that establishes clear definitions of command roles and hasexpanded the scope of emergency preparedness to address clinical scenarios and public health emergencies.
Additionally, Texas Health is involving all levels of its system in a comprehensive drill twice a year with direct participation of system leaders, including a clinical disaster involving multiple entities.
“We recognize the importance of strengthening our preparedness for public health emergencies, whether they involve the rare occurrence of a serious infectious disease or the more frequent disastrous weather events that we experience in North Texas,” said Dr. Jeffrey Canose, chief operating officer and senior executive vice president for Texas Health. “We’re committed to improving how we prepare, rehearse and respond to these events and have undertaken the necessary work to implement national best practices at Texas Health.”
The panel’s report is being shared with local, state and federal health officials so that public health partners at all levels are better prepared for a potentially catastrophic event.
Texas Hospital’s handling of Ebola Crisis: Not an Isolated Incident of US Lack of Preparedness of Major Public Health Crisis
Although the report is the first independent review of the incident, this is not the first time the United States’ preparedness has been called into questions. Last year, the Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation (RWJF) released the report, 2014 Outbreaks: Protecting Americans from Infectious Diseases examining the country’s policies for responding to ongoing and emerging infectious disease threats.
According to the report, the Ebola outbreak highlighted serious underlying gaps in the country’s ability to handle severe infectious disease threats and control their spread. Although the US has made significant strides in preparing for public health emergencies since 9/11, competing priorities and initiatives, as well as fewer dollars, significantly challenge national public health preparedness.
In fact, previous TFAH/RWJF reports have noted a decline in emergency and public health preparedness since 9/11, and the Ebola outbreak demonstrated that the nation’s ability to contain a novel emerging infectious disease threat is fundamentally flawed.
“Quite simply, after the series of emerging infectious disease threats that the county has faced in the last 10 years, it is unacceptable that we don’t have adequate, dedicated and consistent funding to support the development pipeline,” said Dr. Tom Inglesby, chief executive officer and director of the University of Pittsburgh Medical Center’s Center for Health Security.
“Ebola has the potential to substantially degrade a healthcare system,” Inglesby said. “It even has the potential to destabilize countries. So, while at times, the specific nature of the media coverage of Ebola has been extreme, the level of attention it has received has been well deserved.”
Continuing, he added, “We know what happens when Ebola gets out of control — entire countries and regions are ground to a halt with serious ramifications from disrupted or destructed trade to extreme starvation and stigma to restricted travel. For those reasons, Ebola must be stopped at its source, otherwise it can spread to other nations and wreak havoc on a broader scale with the world’s health, economy, commerce and travel.”
In addition, at the height of the Ebola crisis, Homeland Security Today reported on a hearing revealing that Department of Homeland (DHS) has not effectively managed and overseen its inventory of pandemic preparedness supplies, including protective equipment and antiviral drugs, calling into question the ability of DHS personnel to effectively respond to a pandemic.
Testifying at a House Committee on Oversight and Government Reform hearing, DHS Inspector General John Roth referenced an August 2014 audit that concluded DHS did not adequately assess its needs before purchasing pandemic preparedness supplies, and then did not adequately manage the purchased supplies.
"We spent millions of dollars for a pandemic … We don’t know the inventory, we don’t know who’s got it, and we don’t know who’s gonna get it," Rep. John Mica (R-Fla.) said during the hearing.
Roth responded: "You are correct."
Homeland Security Today recently reported that the post-9/11 Commission’s Blue Ribbon Study Panel on Biodefense has determined there is a lack of leadership in biodefense. For example, the White House appointed an Ebola czar during the Ebola epidemic when there were already people who could have taken charge during the crisis.
The panel said the government should lay out clearly-defined roles and responsibilities in case of a future epidemic or terrorist attack, since a leadership vacuum could significantly hinder response efforts.
“If we try to go forward without a leader, without somebody who has a vision for what needs to happen, without somebody who has a good understanding of all the different pieces and parts that should be coming together to establish good biodefense for this country, then we’re going to continue to have just what we have, which is a sort of mish-mash of stuff, which seems like it might be doing something, but we’re not sure if it is,” Asha George, the panel’s co-director and one of the authors of the report, said.
The panel also found that the Ebola outbreak exposed serious deficiencies in US public health preparedness, and could have been handled better by having proper protocols in place for the spread of infectious diseases, which require special treatment of patients and handling ofspecimens. Hospitals must be prepared for what could happen if a deadly or antibiotic resistant disease spread to the United States.
The Ebola outbreak needs to serve as a serious wake-up call for public health institutions and personnel. Although the Ebola outbreak is not currently a major headline, it is only a matter of time before another infectious disease strikes. And next time, the nation needs to be ready.