Ebola in America

2014-10-16-NYT-lax-us-guidelines-on-ebola-led-to-poor-hospital-training

Lax U.S. Guidelines on Ebola Led to Poor Hospital Training, Experts Say
By DONALD G. McNEIL Jr.
New York Times, 2014-10-16

Many American hospitals have improperly trained their staffs to deal with Ebola patients because they were following federal guidelines that were too lax, infection control experts said on Wednesday.

Federal health officials effectively acknowledged the problems with their procedures for protecting health care workers by abruptly changing them. At 8 p.m. Tuesday, the Centers for Disease Control and Prevention issued stricter guidelines for American hospitals with Ebola patients.

They are now closer to the procedures of Doctors Without Borders, which has decades of experience in fighting Ebola in Africa. In issuing the new guidelines, the C.D.C. acknowledged that its experts had learned by working alongside that medical charity.

The agency’s new voluntary guidelines include full-body suits covering the head and neck, supervision of the risky process of taking off protective gear, and the use of hand disinfectant as each item is removed.

Sean G. Kaufman, who oversaw infection control at Emory University Hospital while it treated Dr. Kent Brantly and Nancy Writebol, the first two American Ebola patients, called the earlier C.D.C. guidelines “absolutely irresponsible and dead wrong.”

Speaking by phone from Liberia, where he was training workers for Samaritan’s Purse, the medical charity that Dr. Brantly and Ms. Writebol worked for, Mr. Kaufman said he had warned the agency as recently as a week ago that its guidelines were lax.

“They kind of blew me off,” he said. “I’m happy to see they’re changing them, but it’s late.”

Melissa Brower, a C.D.C. spokeswoman, said the agency was “taking a hard look at our recommendations and may be making changes.”

Dr. Thomas R. Frieden, the director of the C.D.C., expressed regret about his agency’s initial response to the first Ebola case in Dallas.

“In retrospect, with 20/20 hindsight,” he said a few hours before his agency tightened its guidelines, “we could have sent a more robust hospital infection control team and been more hands-on with the hospital from Day 1.”

Some major hospitals, aware of the inadequacy of the older C.D.C. guidelines, have followed more stringent standards in training their staff. But many — including Texas Health Presbyterian Hospital in Dallas, where two nurses were infected by a dying patient — have not.

The Doctors Without Borders guidelines are even stricter than the new C.D.C. directives in that they require full coverage of the torso, head and legs with fabrics that blood or vomit cannot soak through, along with rubber aprons, goggles or face shields, sealed wrists and rubber boots. Doctors and nurses wear two sets of gloves, including long outer ones that strap or are taped to the gown; janitors wear three sets.

As they undress in choreographed steps, Doctors Without Borders workers wash their hands with chlorine solution eight times and are sprayed with a chlorine mist. Most important, all personnel disrobe only under the eyes of a supervisor whose job is to prevent even a single misstep.

Risky procedures like blood sampling are kept to a minimum.

“I’ve seen the C.D.C. poster,” said a Doctors Without Borders representative who spoke on the condition of anonymity because she did not want to be named criticizing the agency, and who was referring to C.D.C. guidelines before they were changed on Tuesday. “It doesn’t say anywhere that it’s for Ebola. I was surprised that it was only one set of gloves, and the rest bare hands. It seems to be for general cases of infectious disease.”

National Nurses United, the country’s largest union and professional association of nurses, with 185,000 members, criticized the C.D.C. on Wednesday for taking so long. Worse, the union said, many hospitals ignored even the lax guidelines because they were voluntary.

For example, the union said, nurses at the Texas hospital complained that the protective gear the hospital issued left their necks exposed — and they were told to wrap their necks with medical tape.

“They were learning infection control on the fly,” said DeAnn McEwen, chief of infection control for the union. “That’s no substitute for planning.”

Nurses United called for federal and state laws making C.D.C. guidelines mandatory.

While Dr. Frieden has been criticized for arguing that almost any American hospital can handle Ebola patients and critics have demanded that all Ebola patients go to special isolation units, that debate is somewhat misguided, experts said.

The isolation units — which have filtered air, double doors and negative pressure — were built to prevent the spread of airborne diseases like SARS and tuberculosis.

The greater Ebola danger is large amounts of blood, vomit or diarrhea splashing caregivers. That is prevented by training, proper protective gear, rigorous cleaning and close supervision, specialists said.

Ebola victims resemble cholera victims in some ways.

In Bangladesh, which trains doctors all over the world in cholera treatment, hospitals do not place cholera patients on padded mattresses with bedpans. They usually lie on rubber sheets stretched across bed frames with holes cut so diarrhea can run out into buckets.

Doctors Without Borders personnel place buckets or chamber pots under patients. Its protocols require cleaning pools of fluid not by mopping, but by spraying them with chlorine and then throwing large absorbent cloths over them. Like doctors, janitors work in pairs, watching over each other.

All infected materials are immediately burned, sometimes in a field right behind the hospital. Reusable rubber items like aprons and boots are cleaned with detergent and bleach. One important Doctors Without Borders step — chlorine sprays — could be dangerous inside hospitals because it would make corridors slippery.

A step considered vital — which the new C.D.C. guidelines now include — is having a sharp-eyed “site supervisor” constantly watching for errors.

“The buddy system works for getting dressed, but not for getting undressed,” said Dr. William Fisher II, a critical care specialist from the University of North Carolina who worked in a Doctors Without Borders center in Guinea this summer and said he was now designing training for the C.D.C.
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Doctors go into wards feeling fresh, he explained. But they emerge an hour later exhausted, sweating and sometimes shaking from a close call, like one he had when a patient grabbed his mask.

In the exit area, he said, “there was someone in charge whose sole focus was helping you get undressed safely.”

“You stood in front of them and did nothing until they said so,” he said. “They didn’t care if it was your first time or your 800th time. I was exhausted and emotionally drained. I looked forward to it.”

Initial Doctors Without Borders training takes two to five days, followed by three to six weeks of supervised work.

The nurses’ group, which is unfamiliar with those protocols, sent a letter to the White House on Wednesday demanding the adoption of the standards used by the University of Nebraska Medical Center with some enhancements.

That hospital is a designated isolation center, and its guidelines resemble those of Doctors Without Borders in some ways. A recent update to them called for head and neck hoods and the wiping of rubber clogs with bleach. The nurses’ union also demanded hazardous materials suits and powered air-purifying respirators.

Those can be cumbersome and claustrophobic, and the Nebraska guidelines treat them as recommended, not as standard.

2014-10-17-NYT-obama-may-name-ebola-czar-after-amber-joy-vinson-flight-causes-concern

Obama May Name ‘Czar’ to Oversee Ebola Response
By JACK HEALY, SABRINA TAVERNISE and ABBY GOODNOUGH
New York Times, 2014-10-17

...

A federal official said that the Centers for Disease Control and Prevention had broadened its search for contacts of Amber Joy Vinson, the second nurse infected with Ebola at Texas Health Presbyterian Hospital here, after interviewing family members who gave a different version of events from Ms. Vinson’s. The nurse had said she had a slight fever before boarding a flight from Cleveland to Dallas on Monday. But family members said she had appeared remote and unwell during her trip to Ohio over the weekend.

The C.D.C. said it was now tracking down passengers on Frontier Airlines Flight 1142 from Dallas to Cleveland, which Ms. Vinson took last Friday. It had already been tracing passengers on her Monday flight.

Ms. Vinson’s case raised flags for investigators because the day after she arrived home in Dallas, she reported substantial symptoms. Health experts say those would be unlikely to develop in just one day.
...

Mr. Obama spoke Thursday night
after meeting with several top aides working on the Ebola issue.
The president praised their work
but said they were also responsible for other tasks,
including national security matters and other health care concerns.

“It may be appropriate for me to appoint an additional person,
not because they haven’t been doing an outstanding job,
really working hard on this issue,
but they are also responsible for a whole bunch of other stuff,”
Mr. Obama told reporters.

He added that appointing an Ebola chief would make sense
“just to make sure that we are crossing all the t’s
and dotting all the i’s going forward.”

[Obama seems really, really clueless here.
The point of having a czar is to have one person responsible for the effort,
who has no other responsibilities other than this one.
The next step is to give that person authority commensurate with their responsibility.
Will Obama give them that authority?
We shall see.]

...

Another line of questioning dealt with why Ms. Vinson had been allowed to fly even after she called the C.D.C. from the Cleveland airport on Monday and told officials she had a slight fever. It was not known then that she had contracted the virus.

“Were you part of those conversations?” Representative Tim Murphy, Republican of Pennsylvania, asked Dr. Frieden.

“No, I was not,” Dr. Frieden responded.

The hearing thrust the Ebola virus and the government’s halting management of it into the realm of politics in the midst of a national election season.

“Errors in judgment have been made,” Mr. Murphy said. “We have been told, ‘Virtually any hospital in the country that can do isolation can do isolation for Ebola.’ The events in Dallas have proven otherwise.”

2014-10-17-NYT-controls-poor-at-hospital-nurse-says

Controls Poor in Dallas, Nurse Says
By KEVIN SACK
New York Times, 2014-10-17

DALLAS — A nurse who observed and participated in the care of Ebola patients at Texas Health Presbyterian Hospital spoke out publicly on Thursday about what she characterized as inadequate training and infection control there.

The nurse, Briana Aguirre, 30, who has worked at the hospital for three years,
...

2014-10-17-NYT-Fineberg

Ebola in America: The Crisis Widens
New York Times Letters to the Editor, 2014-10-17

To the Editor:

I have been teaching health care classes professionally for nearly 30 years.
In that time, it has become clear that
many health care administrators are more concerned about
saving time and money
than they are about saving and protecting lives.
Especially for low-paying, low-level jobs,
administrators sometimes look the other way,
even when it should be obvious that
applicants lack the medical aptitude to perform their job safely.
And with more and more recent immigrants entering the field,
there are many people who simply do not understand
what physicians, co-workers and patients are saying.

Containing Ebola means setting and enforcing strict protocols.
Just one weak link in the chain is a recipe for disaster.
So administrators need to be vigilant in
their hiring, training and supervision of health care workers,
to ensure that patients — as well as the community at large — are safe.

JOHN FINEBERG
St. Paul, Oct. 16, 2014

The writer is an emergency medical technician.