A tragedy of errors: Expert panel cites problems, lessons learned in death of U.S. Ebola patient
Healthcare, CDC response undercut by confusion, poor communication
November 1, 2015
Reprints
As with many individual tragedies and even major disasters, hindsight reveals key moments and near misses where a single action may have changed the outcome.
Such is the case with the late Thomas Eric Duncan, a Liberian man who traveled to the U.S. last year with Ebola incubating in his system. He became the index case in what is almost certainly the only hospital outbreak of Ebola in U.S. history. Before he died on Oct. 8, 2014, at Texas Health Presbyterian Hospital in Dallas, Duncan transmitted the virus to two of his nurses — both of whom survived.
How different the entire outcome might have been had Duncan been admitted when he first presented to the hospital for care on Sept. 26 but was sent home with a misdiagnosis of sinusitis. As previously reported in Hospital Infection Control & Prevention, Duncan returned to the hospital via ambulance two days later, raising the painful and inevitable question whether he might have survived Ebola if he had been admitted on the first visit. The hospital was roundly criticized and duly apologized, but some wonder if other U.S. hospitals that have never seen a case of Ebola would have suffered a similar fate, particularly in the practice of infection control when a single breach could lead to transmission. (See our award-winning report, “Ebola in America,” in the Dec. 2014 issue of Hospital Infection Control & Prevention.)
Thus, infection preventionists and other clinicians should take note of some of the breakdowns and lapses detailed in a report of an independent expert panel convened by Texas Health Resources — the parent company of Texas Health Presbyterian — to investigate the incident. In releasing the report on Sept. 5, 2015, THR stated it 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.
“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,” THR CEO Barclay Berdan, FACHE, said in a statement. “We’re hopeful that these findings will also help hospitals and health systems across the country be better prepared for future novel events.”
In that regard, the expert panel report concluded that “in retrospect, THR learned that reaching an appropriate level of preparedness requires addressing two important issues: preparing a community hospital for the arrival and diagnosis of a patient infected with Ebola or any other emerging infectious disease, and making sure the staff and the facility are ready to treat a patient who is infected. These are two distinct dimensions of preparedness that community hospitals must drill for to ensure their staff is ready to diagnose, stabilize and treat a patient [with a novel infection].”
The expert panel’s key findings and recommendations are summarized as follows.
First ED visit
On Sept. 25, 2014, Duncan went to the emergency department of Texas Health Presbyterian complaining of dizziness, abdominal pain, nausea, and headache. Later, an ED physician added symptoms of rhinorrhea and nasal congestion following a physical exam.
“After a wait of approximately an hour, the patient was taken back to the treatment area and assessed separately, first by a nurse and then by a physician,” the investigators reported. “During the nursing assessment, when questioned as part of the influenza screening process, the patient identified that he had recently travelled from Africa. This information was documented in the patient record; however, it was not communicated verbally to the physician as directed by a prompt in the electronic health record (EHR). According to the record, the physician or scribe noted in a separate area of the EHR that the patient stated that he was from the Dallas area.”
Though entered into the EHR, Duncan’s information was not verbally communicated among the staff and the electronic record was not configured to provide for automatic alerts on questions related to travel history. “Once the information was entered, there were no systems in place that would trigger a review or re-asking of critical travel information,” the panel found.
In addition, a recently implemented patient diagnostic tool called the Systemic Inflammatory Response Syndrome Score (SIRSS) should have raised a red flag but was missed or ignored by clinical staff. The SIRSS can range from 0 to 4, with a higher score indicating a possible need for further diagnostic work to determine if the patient is septic. When the SIRSS is 2 or above, an electronic board visible to ED staff is highlighted in red, indicating a need for further intervention. The care team responsible for Mr. Duncan did not take action, though the score had increased to 3.
“The nurse who noted the increase did not verbally communicate that increased score to the physician or the discharge nurse,” investigators found. “In addition, although displayed on an electronic board visible to all members of the care team, the alert related to the increase of the SIRSS was not acknowledged by the discharging physician or others involved in the discharge of the patient. This indicates the physician’s and clinical teams’ potential unfamiliarity with the electronic board and SIRSS score display and in retrospect appears to show a limited focus on the entire care encounter by the clinical team.”
Other report findings that contributed to the misdiagnosis and discharge of Duncan included:
- Lack of inter-professional teamwork.
- Inadequate review and reevaluation of relevant clinical information before disposition.
- Lack of thorough physician oversight during the ED stay.
- Dissemination of information on Ebola patient treatment was not treated as a priority. Training for Ebola preparedness had not been fully implemented in the ED and the awareness of risk factors for Ebola across the entire clinical team had not been sufficiently stressed.
- Instead, the ED was highly focused on the launch of a Level II Trauma Program and was trying to improve “patient satisfaction workflow” with an abbreviated triage process.
CDC took to task
Emergency medical workers brought the rapidly deteriorating Duncan back to the hospital by ambulance two days later on Sept. 28, informing the hospital of his Ebola symptoms in route. He was cared for in a separate, isolated area of the ED for approximately 30 hours and then transferred to a medical ICU. The 24-bed unit was vacated and dedicated solely for the care of this single patient.
“Nurses there cared for him following the CDC-directed procedures for use of personal protective equipment; however, healthcare workers had areas of exposed skin that were not fully covered or shielded by the CDC-prescribed level of protective equipment,” investigators found. “In Mr. Duncan’s case, the volume of liquid gastrointestinal efflux was massive, and these fluids were known to be highly infectious.”
As a result of this concern, nursing staff and hospital leadership decided to upgrade to more rigorous PPE that include Powered Air Purifying Respirators (PAPRs) and Tyvek suits.
“Based on a review of the timeline of events, it is clear that the CDC’s focus in early conversations with the hospital was on contact-tracing and notification,” the panel reported. “It does not appear that issues such as personal protective equipment, waste management, and other challenges that would emerge as critical were addressed by CDC at the onset of this event. The first representative of the CDC did not arrive on-site until three days after Mr. Duncan entered the emergency department the second time, and only after there was a confirmed positive Ebola test.”
Although this was not included in the report, CDC Director Tom Frieden, MD, stated at the time — after the first nurse was reported infected — that, “I wish we had put a team like this on the ground the day the first patient was diagnosed. That might have prevented this infection. But we will do that from today onward with any case, anywhere in the U.S.”
However, even when CDC was on site at the Dallas hospital, there was confusion among staff about the role of the various federal advisors. This misunderstanding led to some uncertainty about what standards to follow and who would provide the most up-to-date guidance on managing infection control and personal protective equipment, the expert panel said.
“This challenge was most evident as noted by the clinicians and their leadership concerning the evolving standards in the use of personal protective equipment,” the panel found. “Consistent with published CDC guidelines, the staff used contact and droplet precautions at the onset, and evolved to the use of PAPRs. On arrival of CDC and following the initiation of PAPRs, the team worked with CDC to continue to evolve the approach to personal protective equipment. The sequence of new PPE and training meant that staff had to adapt, train, and relearn PPE donning and doffing from shift to shift. This constant learning and relearning eroded the staff’s confidence that they were fully up-to-date and competent on the latest modifications that were being developed in real-time. The doffing process was particularly difficult and required more training to build efficacy.”
The removal of contaminated PPE has been theorized as the source of transmission to the two nurses, but the expert panel did not draw any conclusions on what specific exposures may have led to the infections.
Factors cited by the panel regarding the patient death and the transmission to the nurses include:
- It was evident during this process that the CDC and others were learning alongside the actual providers. In retrospect, it appears that there was a lack of effective and efficient collaboration prior to the event between the hospital, THR, the CDC, HHS, and the Department of Transportation as well as city and state public health resources.
- When preparing for future disease outbreaks, hospital administrators, doctors, and nurses must understand that the CDC serves only in an advisory role and it is up to the institution to take care of individual patients and ensure quality, safety, and high reliability of clinical operations. It is also critical for CDC to better communicate its role and to work collaboratively with health systems prior to, during, and after an event like Ebola.
Editor’s note: “The Expert Panel Report to Texas Health Resources Leadership on the 2014 Ebola Events” is available at the THR website: http://bit.ly/1R7j0oP.
As with many individual tragedies and even major disasters, hindsight reveals key moments and near misses where a single action may have changed the outcome.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.