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The first U.S. Ebola patient who walked into an emergency room last month posed a major test for the chosen hospital, Texas Health Presbyterian Hospital Dallas. The hospital made some now-notorious missteps, including failing to diagnose Ebola virus the first time the patient, Thomas Eric Duncan, arrived as well as allowing two nurses who treated him to become infected.
In the aftermath of the case the U.S. Centers for Disease Control and Prevention (CDC) has updated its guidelines for health care workers’ protective gear, called personal protective equipment (PPE), which was probably at fault for the nurses’ infections. Hospitals around the country are on alert for more cases of the Ebola virus, which has ravaged west Africa but so far left the U.S. relatively unscathed.
Scientific American spoke to health care emergency management expert Kristin Stevens about the lessons learned from Dallas and what other U.S. hospitals can do to be prepared. Stevens is the former director of emergency management at New York University Langone Medical Center in Manhattan and now runs the Stevens Research & Consulting firm.
[An edited transcript of the conversation follows.]
Based on what we’ve seen at Dallas Presbyterian, do you think the average U.S. hospital is prepared for Ebola?
[CDC director Thomas] Frieden was on the news saying any hospital in the U.S. should be able to manage an Ebola patient. That struck me as odd, because managing an infectious disease in a hospital is not as straightforward as it may seem. Infectious diseases like C. diff [Clostridium difficile] and MRSA [methicillin-resistant Staphylococcus aureus] have presented significant challenges for hospitals for years. Why did the CDC think that managing Ebola would be straightforward?
From the beginning we underestimated how difficult it was going to be. Someone had to go first. Now everybody is more ready than they were. If somebody comes in with symptoms consistent with Ebola, hospitals are going to take it much more seriously now.
Is it likely that any other hospital would have fared better as the first to deal with an Ebola patient coming into the emergency room?
Even with all the blame being hurled towards Dallas Presbyterian, I’m still honestly not sure that most hospitals would have done much better, and I could easily see other hospitals doing far worse.
Judging them on whether they did a good job or a bad job feels like [asking]: How’s the view from the cheap seats? The bigger lesson is that all of this is much harder than we anticipated. I don’t think it was really solid in people’s minds that this could actually happen here.
One of the biggest missteps in the Texas situation was that the initial safety protocols and protective gear turned out not to be enough to protect nurses from catching Ebola. What does that tell us about our preparedness for future disease outbreaks?
What we’ve seen is the lack of flexibility in our preparedness. The notion that the PPE we thought was appropriate turned out to not be enough really caught everybody by surprise, and changing direction has been time-consuming and challenging. That is dangerous for future outbreaks because emergencies are inherently changeable—there are surprises.
We also need to look at how we plan to allow for more variability in the diseases that we’re facing. Everybody spent so much time planning for pandemic flu, and then Ebola came up and hit us from behind. We need to be thinking there might be a vaccine, there might not; there might be treatment, there might not; it might require isolation, it might not. There are things out there that are far more infectious than Ebola and new diseases are always emerging.
Besides the issue of proper protective gear protocols, what else went wrong in the Dallas case?
I don’t think we’ve really done well by our health care workers. When the first nurse in Texas got sick, the statement was, “There was a breach in protocol but we don’t know what the breach was.” How do you know there was a breach in protocol and that the protocol isn’t bad? Then we moved on to the nurse that got on the plane. She had the okay from the CDC to fly, but the statement was, “She shouldn’t have gotten on the plane.” So I’m getting concerned that we’re now not only asking health care workers to assume the risk of getting sick but also to assume the risk of getting blamed for getting sick and getting blamed for exposing others, even when they’re following guidelines. If this is how we’re treating our health care workers, who’s going to want to take care of Ebola patients?
You need to create an environment where staff feel supported by their institutions. By managing staff concerns, providing appropriate training, and making sure there are enough supplies, that’s going to give you your best chance to be successful in managing an outbreak.
What lessons would you tell other hospitals to take from the Texas case?
Once a potential patient is identified, we need to make sure that the current PPE protocols are followed. Have the up-to-date guidance on PPE protocols and on isolating patients quickly. Be prepared to do staff tracking and contact tracing. Make sure your records are all in shape, so you can quickly figure out who in your hospital could have potentially been exposed. Make sure your contacts are up to date and that you have the ability to safely manage hazardous waste. Have open forums where staff can raise concerns. Get your leadership out on the floor and talking to staff. It would be a great time to have a town hall and tell them what you’re doing to prepare and let them ask questions. This is a time for open communication. You want to hear from all levels of the organization. If people don’t feel safe doing their job, they can't work effectively.
Does it make sense to have designated hospitals to treat Ebola patients, rather than having them stay at local hospitals?
Every hospital needs to be prepared for a patient arriving with Ebola—patients are still going to go to the hospital that they normally go to if they’re sick. But I do think designated Ebola hospitals make some sense when you look at the bigger picture. There’s a lot at stake for health care institutions. If you’re an Ebola hospital and you get a patient and everything goes well, it’s a real feather in your cap. But if anything goes wrong, it can be devastating for your institution.
Look at Dallas. They’re taking a hit by reputation but they’re also taking a financial hit. The patient census at Presbyterian has been down because of this incident.
