We're going to be analyzing what happened in Dallas, for a long time, and from here in Kathmandu, I can already see that the doctors and the administrators are "circling up the wagons."
Some how a twentytwo or twentythree year old Registered Nurse, a BSN graduate of Texas Christian University, has become a national figure. Today from Kathmandu I prayed for her. It's bad enough that she now faces the fear that her own personal trajectory through this illness will be worse before it gets better; it's even worse that somehow she is blamed for contracting it.
If you hear any speculation that it was her own fault in any way, be advised that this is probably some kind of cover-your-okole move from an administrator. I guarantee you that it's much more complicated.
To read what I mean, follow me beyond the little orange smear of unknown body fluid.....
Okay, so we start with a short link to the L.A. Times, which tells about things that needed to be done at the hospital in Dallas, but weren't. The nursing staff wanted to share, but they were afraid of being fired if they went public. This is one more example of the value of unions. The leader of the collective bargaining group used her position to pass on this feedback and potentially to enhance the safety of - all of us. Here's a positive example of the value of unions in improving working conditions. It's a shame that the nurses would feel pressure to not be honest about the gaps in planning - but that's the way it is these days.
The article quoted the press release from Presbyterian Hospital:
“Patient and employee safety is our greatest priority and we take compliance very seriously. We have numerous measures in place to provide a safe working environment, including mandatory annual training and a 24-7 hotline and other mechanisms that allow for anonymous reporting. Our nursing staff is committed to providing quality, compassionate care, as we have always known, and as the world has seen firsthand in recent days. We will continue to review and respond to any concerns raised by our nurses and all employees.”
Hmmmm... adminis-speak if you ask me.
Start with the list of things the nurses shared. To that I will add some logical things that should have been done.
To begin with, the hospital administration should have known that this was going to be a case with a national profile, especially since the initial triage was somehow delayed. Did they or did they not keep a log of training for every person that went in the room? did they review the training of everyone - the housekeepers? the phlebotomists?
They could have arranged just-in-time review for everyone.
What the average DailyKos reader may not know is that every hospital already has special positive-pressure rooms for use when a patient with active TB is admitted, as well as a system for isolation and infection control.
When they are saying the nurse got infected through a mistake, but they can't pinpoint what her mistake may have been, that causes me to wonder about the role of "fomites" in this transmission. When fomites are involved, the mistake that caused the infection can be one made by somebody else, and we'll never know who.
time for a definition: a fomite is an inanimate object upon which infectious material resides. In the famous historical case of Lord Jeffrey Amherst during the French and Indian Wars, he distributed blankets that had been used by small pox victims, to the Indians. They all developed small pox from handling the blankets. In his case the fomites provided a way to wage biological warfare. In the case of Ebola virus, it's any object that was handled by the victim with the active infection.
As an aside, one of the things that makes norovirus (also known as "cruise ship virus") so persistent, is that it persists on room surfaces, and can be transmitted by touching the surface, even if you did not touch the victim.
Here's some speculation
I know it's speculation, but here is one possible scenario: the nurse from the previous shift used a pen, touching it with her gloved hand that was contaminated. Then took the pen outside the room, and laid it down somewhere without decontaminating it. Then the soon-to-be-infected nurses picked it up, not knowing it was contaminated.
Or another scenario: maybe there was a computer in the room for patient charting, and the previous nurse touched the keyboard with her gloved hands that were contaminated; then the new nurse used the keyboard with her bare hands,thinking it was okay, and touched her mouth. For me, I was a pen-chewer ever since childhood and one thing I had to learn is not to put the end of the Bic pen into my mouth. I think the hospital in Dallas, and all other hospitals, need to consider the procedures to enforce a secondary zone around any room with an Ebola patient.
Or another scenario: They were changing the linen but the receptacle for linen was down the hall, and not just outside the door, which would have meant that linen contaminated with infectious fluids like diarrhea, was carried down the hall. Or that the wet linen dripped onto the person's shoes, and maybe they were not wearing booties over their laces. when they untie the shoes, that's when they come into contact.
This is the kind of level of procedure that we are talking about. Bordering on obsessive. And some people dislike it and rebel against it. (which is not a good thing). Oh, and of course, meticulous handwashing, not just using the wall-mounted hand sanitizer ( a per peeve of mine. I don't think they are as effective as claimed).
I read somewhere that CDC is conducting a 3-day workshop here in USA to train volunteers in techniques like this. This is good. Here are my suggestions:
First, hospitals are regulated and inspected by as many as two dozen different state and federal agencies for safety compliance. The biggest and most prestigious is known as the Join Commission. The Joint Commission needs to be working to develop a compliance standard and making sure that every one has it. Every hospital, everywhere.
This Ebola transmission qualifies as a "sentinel event." From now on, all future acquired infections with Ebola now need to be scrutinized as thoroughly as possible, and the results shared nationwide. This will prevent any given individual administrator from spinning the events. When the administrator is covering their Okole or trying to salvage the hospital's reputation, they are preventing the rest of us from learning from the event.
Next, we now have a nationwide network of Universities and Medical Centers that use sophisticated simulation modeling techniques. Such things as a mockup of a patient room complete with all equipment the room would have. Each of these places could be used for very realistic training. Why not? Along these lines, the CDC needs to share a standard Ebola simulation scenario that focuses on dealing with the actual symptoms, using PPE and prevention of fomites.
A hospital housekeeping department will usually have a specific list of cleaning steps, similar to what a hotel would have. The managers need to monitor this by actual observation, not just reviewing the list at a meeting while the housekeeping staff sits there passively.
I am sure the readers will think of more (and I am sure that the same guy who thinks every Ebola victim needs an enema will also throw in his two cents). The bottom line is - until you can prove to me that all these steps were in place, you can't blame the individual nurse. she was "the tip of the spear"
Oh, and by the way. I have been a nurse for many victims of infectious disease, both in USA and in a mission setting in Asia. If you want to read one of my books, go to The Sacrament of the Goddess on Amazon.