Is the country’s healthcare infrastructure better prepared to confront an infectious disease crisis than it was early last fall when Thomas Eric Duncan presented to the ED at Texas Health Presbyterian Hospital in Dallas, eventually becoming the first patient in this country to be diagnosed with the deadly and highly contagious Ebola Virus Disease (EVD)? Duncan eventually died from EVD, and two nurses who were caring for him contracted EVD, prompting hospitals across the country to ramp up preventive and protective measures, and try to play catch-up on the training of frontline providers on what is known about identifying and managing patients with EVD.
Most healthcare experts believe public health authorities and frontline providers all learned valuable lessons as they scrambled to absorb the evolving guidance — both on how to most effectively manage EVD patients and optimally protect staff. However, while the knowledge base has expanded and most frontline providers have received at least some new training on dealing with infectious disease threats, there is also wide agreement that there is still more to do.
To facilitate this process, an independent, expert panel convened by Texas Health Resources, the parent company of Texas Health Presbyterian Hospital, has unveiled a detailed review of how the Duncan case was managed, what went wrong, and what steps need to be taken to strengthen the hospital’s and the community’s response to future infectious disease threats. Further, the panel’s recommendations are sure to resonate with frontline providers across the country, as most fully realize that their hospital or ED could be the index site of the next emerging infectious disease.
Avoid relying on the EMR
The panel examined the circumstances surrounding Duncan’s first visit to the ED on Sept. 25, 2014, after which he was discharged with a diagnosis of sinusitis. The panel found that while a nurse noted in Duncan’s electronic medical record (EMR) that the patient was from Africa — a key point for consideration of EVD — this information was not highlighted or prioritized within the EMR, and it would have required the physician to look beyond the standard patient assessment screen to see the patient’s travel history. This problem, and a general lack of awareness of the risk factors for EVD, led ED staff to miss an opportunity to correctly diagnose Duncan, isolate him, and begin treatment at an earlier stage of the disease, according to the panel’s report.
The panel recommended the hospital develop and implement a plan for improving collaborative interaction between ED nurses and physicians, and it also pointed out the danger of overrelying on the EMR for communication. Jon Mark Hirshon, MD, MPH, PhD, a professor in the Department of Emergency Medicine and in the Department of Epidemiology and Public Health at the University of Maryland School of Medicine in Baltimore, agrees that over-reliance on EMRs can be a problem throughout the healthcare system, and that more attention needs to be paid to making sure that these records are designed and leveraged to promote patient safety.
“It is a federal mandate for us to go to EMRs, and there are reasons and rationales behind this, but there is a challenge to it as well,” notes Hirshon, who also serves on a group focused on Ebola preparedness for the American College of Emergency Physicians (ACEP). “What has changed in the last year is that people are much more aware of asking those [appropriate screening] questions, and the communication has improved. At the same time, it is a challenge to make sure there is good communication between the providers and that the EMR is reinforcing that communication and not fragmenting it.”
Deena Brecher, MSN, RN, APRN, ACNS-BC, CEN, CPEN, the immediate past president of the Emergency Nurses Association, clinical director for Emergency Services at Cincinnati Children’s Hospital in Ohio and a member of the ACEP Ebola Expert Panel, agrees with Hirshon, noting that it is very important for EMRs to be truly multidisciplinary.
“I am sure every organization has an opportunity to really look at that,” she says. “The other piece to remember is that nothing replaces face-to-face communication, and if anyone has a concern at any point in time or recognizes something that doesn’t seem right, it needs to be escalated, and a computer probably isn’t the best way to do that.”
Promote culture of safety
The expert panel noted that leadership in the ED at the time that Duncan presented seemed to be more focused on preparing for the launch of a new trauma program and an effort to improve patient satisfaction than on patient safety and outcomes. It recommended that the health system examine how metrics and goals are created, and establish that patient safety and outcomes must always come first. It is a message that likely touches a nerve in other EDs.
With patient satisfaction now tied to reimbursement, ED administrators need to strive to strike the right balance, Brecher acknowledges.
“That continued focus on safety is really paramount, and I challenge all of the team members in the ED to remember that this is most important. Providing quality care in a safe environment has to be our most important focus,” she says. “If we can do that, that will help our patient and family experience [scores], but there has to be a balance, and the focus needs to be on safety.”
Hirshon concurs, noting that patient satisfaction is always important to ED directors.
“I understand the rationale,” he says. “You want to provide good patient satisfaction, but the right balance between patient satisfaction and high-quality care is something in flux right now — trying to figure out how best to make sure that people are satisfied but that they also get the best care possible.”
Be alert to clinical changes
The expert panel noted that even with the earlier missteps on Duncan’s initial visit to the ED, staff still might have been able to notice signs that the patient was deteriorating if staff had fully understood and been trained in how to make use of the Systemic Inflammatory Response Syndrome Score (SIRS). The panel observed that Duncan’s SIRS increased to three (out of four) by the time he was discharged, indicating that he was at high risk; however, while a nurse noted the increase, she did not communicate it verbally to a physician. Further, even though Duncan’s SIRS was posted on an electronic display board that was visible to the entire care team, the individual team members did not seem aware of the alert.
The panel also noted Duncan’s 103 F temperature should have prompted a re-evaluation prior to discharge, but panel members said it was unclear whether the physician was even aware of the patient’s rising temperature.
Hirshon suggests the concept of checking on a patient’s vital signs before he or she leaves the ED is valid, and that processes should be in place to ensure the physician is aware of the data before he signs off on the discharge.
“This is critically important, and it goes back to the whole issue of communication to make sure the different providers — the nurses and the physicians — are communicating important components of the care,” he explains.
Brecher adds that it is important for ED personnel to recognize when something is different.
“If something is out of the ordinary or not as expected, then that is usually what would trigger another evaluation,” she says, noting that the ED in Dallas had a SIRS system that should have alerted providers to take another look at the patient. However, Brecher points out that this was a systems breakdown.
“There was not enough training or competence in how to use the [SIRS] system or how to recognize what to do [when it was triggered], so that was the root cause of not having that second evaluation.”
In reviewing the care of Duncan on his second trip to the ED, this time arriving by ambulance on September 28, the expert panel observed that the patient was quickly placed in isolation, and his care was consistent with recommendations for someone with EVD. The panel also noted that none of the healthcare workers involved with Duncan’s care during this 30-hour period became infected.
However, as the event continued to unfold and federal agencies such as the CDC became involved in an advisory capacity, the expert panel reported that hospital leaders were unclear of the role of the federal advisors. This led to confusion over what standards to follow — both in managing Duncan’s case as well as the cases of the two nurses who later became infected with EVD after Duncan was transferred to the ICU.
Further, the panel noted there wasn’t effective collaboration among the hospital, federal health authorities, and regional and state agencies, and that the lack of clarity on the roles of each of these entities led to many of the problems that ensued. To improve preparedness for future infectious disease events, the expert panel noted that partnering agencies need to train and drill together in a comprehensive way, and that such drills need to include infectious disease scenarios.
It’s a directive that all hospitals and EDs should be taking seriously, observes Kristi Koenig, MD, FACEP, FIFEM, the director of the Center for Disaster Medical Sciences at the University of California at Irvine, and a professor of Emergency Medicine and Public Health in the UC Irvine School of Medicine.
“In the past we weren’t used to dealing with emerging infectious diseases in such a rapid manner where knowledge was evolving, the situation was evolving, we had risks that were happening fairly rapidly, and we had to get just-in-time training in place,” she says. “We had conflicting information sometimes in terms of something as basic as what protective equipment we should use.”
Koenig stresses that hospitals and communities need to provide education and training, and have exercises that deal with infectious diseases.
“It is very important,” she says. “It is one of my biggest concerns in terms of novel disasters that we may face in the future.”
Prioritize planning, preparedness
Koenig adds that the media play a big role when such threats are in the news, but she is concerned about when media attention wanes.
“We still need to be aware because in addition to the current diseases such as Ebola, MERS [Middle East Respiratory Syndrome], measles, or things that we already know, there will be something novel, something new, so we need to constantly be on the lookout,” she stresses.
Brecher shares Koenig’s concern about remaining prepared.
“One of the challenges is it costs money to have the [personal protective] equipment (PPE) in order to practice,” she says. “Nurses and providers should be allowed, encouraged, and mandated to have what they need to put on and take off [equipment] exactly how they would be doing it if they were taking care of a patient with Ebola or any other serious infectious disease that could potentially harm them.”
Brecher observes that while hospitals were clamoring to obtain the proper PPE during the EVD outbreak last year, such demand has eased considerably, and she is worried that budgetary concerns may be playing a role. However, as far as overall preparedness is concerned, Brecher contends that communities and hospitals have made strides in the past year, although the improvement is uneven.
“There are some communities who have figured it out and do it well. They regularly meet and discuss these kinds of issues. I know there are communities that haven’t even thought through the entire process yet,” Brecher says. “The standard should be that we know [what everyone’s role] is, and we know what to do if a situation arises, and if we are not sure we know who to call, we know what our resources are, and we have open communication.”
One concept that healthcare authorities across the country moved to very quickly as events evolved during the EVD crisis is the idea that facilities and healthcare teams should be designated in each region to care for patients diagnosed with EVD. Hirshon believes this is a good approach that is likely here to stay.
“The idea of regionalization of care is very important, not just for emergency infections and disaster preparedness, but in general,” he says. “There has been an acknowledgement and understanding of the importance of regionalization of care, and this is one of the things that prompted that.”
Trauma systems and stroke centers are other examples of regionalization, Hirshon observes. “This just rein-forces the importance of good communication within a regional basis as well.”
Prepare for next event
Texas Health Resources declined to speak with ED Management about the expert panel’s findings, but noted in writing that it is moving on a systemwide basis to act on the panel’s recommendations. Brecher commended the organization for sharing the findings publicly.
“For them to release this report is incredibly valuable because it gives everyone the opportunity to learn from what didn’t go well … and to move forward, change, and be ready for the next patient,” she says. “There are always opportunities to improve. It is a journey, so every time [an event like this occurs] we learn something.”
(Editor’s note: Links to the expert panel’s findings and recommendations are available here.)
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Deena Brecher, MSN, RN, APRN,ACNS-BC, CEN, CPEN, Immediate Past President, Emergency Nurses Association, and Clinical Director, Emergency Services, Cincinnati Children’s Hospital, Cincinnati. E-mail: [email protected].
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Jon Mark Hirshon, MD, MPH, PhD, Professor, Department of Emergency Medicine and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore. E-mail: [email protected].
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Kristi Koenig, MD, MD, FACEP, FIFEM, Director, Center for Disaster Medical Sciences, University of California, Irvine, and Professor, Emergency Medicine and Public Health, School of Medicine, University of California, Irvine. E-mail: [email protected].
Sidebar: Preplanning, HIC structure facilitate response
Like most hospitals, Texas Health Presbyterian Hospital relies on a Hospital Incident Command (HIC) structure to manage its emergency response to disasters and other threats. The hospital activated the system when an ambulance brought Thomas Eric Duncan to the ED with symptoms of Ebola in 2014. However, an expert panel found several deficiencies in the way the health system approached the crisis. The panel noted that the hospital historically has outsourced the HIC function to a vendor for education and event management. However, when the hospital activated the vendor, this was not formally communicated to staff. Further, the panel noted that when it became apparent the initial HIC response plan was not sufficient, the hospital set up a separate clinical incident command system. Later, when communication between various community, state, and federal stakeholders broke down, a third communications command center opened. The panel said these evolving add-ons demonstrate that the various functions of the HIC system were not adequately defined or carried out early enough.
Kristi Koenig, MD, is a big proponent of having hospitals utilize a HIC system, but she notes that the decision-making around activation should be a key component.
“You have to have processes, policies, and procedures in place in your hospital to determine when to activate,” she explains.
Further, Koenig notes that all the key roles and functions need to be well-defined during planning. The expert panel found that the response in Dallas was, in fact, hampered by roles and responsibilities that were not clearly outlined and understood in advance of the Ebola event.
Koenig says that a well-planned and constructed HIC structure should be able to adjust to changing circumstances as needed.
“The one thing we can be sure of is that things won’t go according to plan, and disasters are often going to be evolving and have unknown components,” she says. “But if you have this basic command and control structure, then you have the ability to get access to information and make decisions … so that you can manage any event.”
However, Koenig acknowledges hospitals have not traditionally thought of the HIC system as much in the case of an emerging infectious disease.
“They would think of it more for an earthquake, a hurricane, a plane crash, or something like that, but it works very well for emerging infectious diseases,” she advises.
A well-devised HIC system should be able to oversee everything from waste management to communication with media and local health authorities.
“It is flexible so that it can expand or contract depending on the needs of the situation, and there is incident action planning so that you can make rapid decisions based on incomplete information, which was the situation we were dealing with,” she explains.
Koenig also says to prepare for no-show staff who are afraid, ill, or have ill relatives, and to implement just-in-time training so procedures can be modified on the fly, if necessary.
