Ebola Outbreak Places Spotlight on Healthcare Worker Concerns, Protocols

October 21st, 2014

By CHHS Research Assistant Laura Merkey

While the Ebola outbreak is a global concern and has sparked collective fear and apprehension, it is undisputed that healthcare workers have suffered great losses and still face the greatest amount of risk.  In the United States (US), two nurses who helped treat Ebola patient Thomas Eric Duncan at Texas Health Presbyterian Hospital in Dallas have contracted the virus. One of those nurses, Nina Pham, was transferred to the Special Clinical Studies Unit at the National Institutes of Health Clinical Center in Bethesda, Maryland. The facility has one of four biocontainment units in the US, which is designed to provide high-level isolation and is staffed by infectious disease and critical care specialists. The second nurse, Amber Joy Vinson, was transferred to a biohazard infection disease center at Emory University Hospital in Atlanta, the same facility where two missionaries were successfully treated for Ebola. Over 800 passengers who were linked to flights that Vinson took prior to her hospitalization—but during a period where she may have been infected—have been notified.

The transfers and potential exposures beg the question of what went wrong at Texas Health Presbyterian and what can be done to fix the problem. A Congressional hearing last week probed the handling of the Ebola cases. Dr. Thomas R. Frieden, the director of the Centers for Disease Control and Prevention (CDC), emphasized the number of potential exposures and the strain that this has put on the facility. CDC investigators have hypothesized that the nurses became infected during the first few days of Duncan’s treatment, during which the nurses were wearing protective gear but had not yet been upgraded to full biohazard suits. Evidence presented also suggested that workers were not initially wearing shoe covers.

Another nurse involved in Duncan’s treatment has decided to speak out about what she claims was “inadequate training and infection control” at the hospital.  Briana Aguirre says that it took three hours after Duncan arrived at the emergency room for him to be placed in isolation, despite clear indicators that he had been infected with the virus, and the fact that he had been in the emergency room three days earlier with similar symptoms, but was misdiagnosed and sent home.

Aguirre also criticized the protocols in place at the hospital, which included only instructing the healthcare workers once about the proper use of protective equipment such as masks and gloves before entering the Ebola patient’s room, and that the equipment left a patch of her skin exposed.  She also said that the hospital had offered only one, non-mandatory lecture on treating Ebola patients about a month prior to Duncan’s arrival, which she did not attend.

Allegations such as these have prompted discussions of what can be done to improve the safety of healthcare workers.  Federal and state health officials are trying to determine how best to keep healthcare workers safe, and have focused on personal protective equipment (PPE).  The CDC has tightened its guidance for PPE, adding to its August guidance the recommendation that workers wear coveralls and single-use hoods.  “Donning and doffing” procedures for the PPE is also recommended, including the addition of a monitor to watch for possible mistakes. Their new guidance is more in line with the World Health Organization’s recommendations.

Other facilities, such as Emory Hospital, upped protections prior to the CDC’s recent release. The most important part of the protection, experts explain, is making sure that that the PPE fits properly, which can be a challenge: most employees are only fit-tested when they begin at a place of employment, and if they lose or gain weight, or grow facial hair, the equipment may no longer fit correctly.

The errors and missteps made by Texas Health Presbyterian and those that will likely be made in the future by others could open up a multitude of potential liability issues and legal concerns. In addition to potential medical malpractice claims, hospitals that fail to meet certain standards could be liable for corporate negligence. In 1991 the Pennsylvania Supreme Court in Thompson v. Nason held that a hospital can be held liable if it “fails to uphold the proper standard of care owed to the patient, which is to ensure the patient’s safety and well-being while at the hospital.” This is a non-delegable duty which includes, among other duties, maintaining safe and adequate facilities and equipment, and most crucially for this situation, “a duty to formulate, adopt and enforce adequate rules and policies to ensure quality care for the patients.”

Undoubtedly, there is some question as to what the proper standard of care is for hospitals and healthcare workers in situations like this, in which they are faced with a previously unseen or potentially unknown infectious virus.  However, as more and more allegations of substandard procedures surface, this will likely be an important question moving forward, and likely have to be addressed by both the courts and federal agencies.



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