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Texas hospital error shows need for better Ebola training

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The Texas Health Presbyterian Hospital in Dallas. AP photo The Texas Health Presbyterian Hospital in Dallas. AP photo
BY ELIZABETH CHUCK, NBC News

(NBC News) - American hospitals may need to step up their training for potential Ebola patients, some advocates say, after a Texas incident raised fears about the virus not being properly contained.

The case of the Dallas hospital that initially sent home a man sickened with Ebola highlights an urgent need for better training — not only for the nurses who are the front-line defense against stopping the spread of any disease, but for all health care personnel, some experts say.

It was not necessarily human error that caused the hospital staff to mistakenly send home Liberian national Thomas Eric Duncan, Texas Health Presbyterian Hospital says. It says it has updated software that appears to have made doctors miss a nurse's note flagging that Duncan came from Liberia.

Duncan was sent home after showing up on Sept. 26 with a fever and abdominal pain. The hospital had recently held a drill for Ebola and Duncan told a nurse he had recently returned from West Africa, yet he was not isolated. He returned two days later in an ambulance at the urging of his nephew, who called the Centers for Disease Control and Prevention after Duncan was admitted.

Duncan's initial "overall clinical presentation" did not imply he had Ebola, Dr. Mark Lester, a vice president for the hospital system, told NBC News. And the hospital says he denied he'd been in contact with anyone who was sick. Still, the response to the first person diagnosed with Ebola in the U.S. wasn't comforting to many.

The California Nurses Association, the largest union of registered nurses in the country, is particularly disturbed by the incident. While many other nurses' associations do not yet have data on how much Ebola training hospitals are offering, the California Nurses Association warned about Ebola preparedness this week.

A small survey the group conducted of 400 nurses across 25 states found that 85 percent of nurses hadn't received training on dealing with Ebola and more than 60 percent felt their hospital wasn't ready to treat Ebola cases.

"The hospitals right now should be doing 24/7, ongoing education and training, including sessions where all health care workers can ask questions and have demonstrations of appropriate 'donning and doffing,' which is essentially putting on the equipment and taking off the equipment," said Bonnie Castillo, a registered nurse with the California Nurses Association.

While the survey percentages sound alarming, the president of another nurses' group points out that infection prevention — for Ebola or any other contagious disease — is standard nursing education.

"What everybody needs to remember is that we have infection control procedures for a lot of patients, not just Ebola, and all of us receive that training, some of us on an annual basis," said Deena Brecher, president of the Emergency Nurses Association.

Hospitals are alert to the risk of someone coming in with many different infectious diseases, not just Ebola but also tuberculosis, influenza, measles. They know to quickly isolate or at least segregate patients who are coughing, sneezing, vomiting or who have diarrhea. Health care workers examining such patients wear gloves, masks and often gowns.

The California Nurses Association survey numbers may be deceptive if they included nurses who don't routinely use isolation procedures, such as outpatient nurses, Brecher said.

Without knowing precisely what happened at the Dallas hospital that allowed Duncan to walk out, Brecher said the onus to identify Ebola falls on everyone who interacts with the patient, not just one nurse.

"It's like bacterial meningitis. It starts like any other illness. In the early stages of that illness, it could be hard to identify," she said. "As emergency care providers, both physicians and nurses, we need to work together. It's multiple levels of screening. All of us need to be diligent in asking the questions of our patients and families to identify patients that are at risk."

The Texas Nurses Association issued a similar call.

"There is a tremendous amount of information sharing that goes into screening, treating, and following patients throughout their care," Cindy Zolnierek, the executive director, said in a statement. "Blaming individuals is counterproductive."

"Blaming individuals is counterproductive."


On Thursday, National Nurses United — the umbrella organization for the California Nurses Association — called on hospitals to immediately increase emergency preparations for Ebola in the U.S.

"We warned that it was just a matter of time in an interconnected world that we would see Ebola in the U.S. Everyone should recognize that Texas is not an island either, and as we've heard from nurses across the U.S., hospitals here are not ready to confront this deadly disease,” said National Nurses United executive director RoseAnn DeMoro.

The president of another group, the American Nurses Association, echoed the call.

"Now that the first travel-related case of the disease in the United States has been reported in Dallas, Texas, it is critical that all members of the health care team have appropriate knowledge, education and personal protective equipment to effectively provide care to patients," Pam Cipriano said in a statement emailed to NBC News.

Linda Greene, a member of the Association for Professionals in Infection Control and Epidemiology and an infection prevention manager at Highland Hospital in Rochester, New York, said she expects to see an increase in Ebola training at hospitals now that it's "on our soil."

"Hospitals are certainly in the process of doing the training. To some extent, perhaps, it wasn't close enough to home," Greene said. If they haven't already, hospitals are now likely thinking of "the next level" of intensive training.

That training should include assessing hospital equipment and purchasing tools and materials necessary for proper treatment, assessing isolation capacity, demonstrating how to wear protective gear and holding information sessions where hospital staff can ask questions, to name a few, she said.

And it shouldn't just be limited to hospitals.

"Rather than speculate on what they did, I like to speculate on the lessons learned."


Asking about symptoms and travel history should happen "first and foremost in your triages, particularly in your emergency departments, but even in your outpatient facilities," she said. "That initial screening is so important. And really, aside from Ebola, that should be part and parcel of how we conduct business."

As for the Dallas hospital slip, Greene said, "We're all human beings, and despite our best efforts, particularly in emergency departments where it is extremely busy and you might have multiple priorities — they may have had a code at the same time. Rather than speculate on what they did, I like to speculate on the lessons learned."

The main lesson from Dallas: Hospitals need to drill their policies and procedures into their employees through reinforcement. "They have to see, do we really do what we say we do?"


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