"They threw the nurses under the bus. And when they admitted that it was not the nurses' fault, there was no apology."
That assessment of the Texas Health Presbyterian Hospital's handling of the Thomas E. Duncan case comes from a nurse who supervises the emergency department at another community hospital in the Dallas-Fort Worth metroplex.
The nurse, who spoke with MedPage Today on condition of anonymity, said she and other nurses were very familiar with the electronic health record system used at Texas Health Presbyterian since it is used by several hospitals in the region. They all knew the statement about separate workflows was false.
Equally false, she said, is the the suggestion that Duncan was initially discharged by the ED because he had no insurance.
"That is ludicrous," she said. "In the first place, neither the doctor, nor the nurse knows if the patient has insurance -- and don't want to know. All we know is that the patient doesn't have a primary care doctor, so the patient is admitted under the care of a hospitalist."
Typical practice, she said, is for a "registration person" to handle insurance information after a decision to admit is made.
"Hindsight is great, but really none of us here in the metroplex had ever seen an Ebola patient. Clearly the doctor didn't connect the dots, but I'm not surprised. It would not surprise me if the doctor looked at the travel note and thought, 'Liberia. I wonder where that is.' And against that mindset, why wouldn't you discharge a patient with flu-like symptoms and stable vital signs. To say that a nurse or a doctor would knowingly discharge a patient and put the whole community at risk, is ludicrous," she added.
Although she and others now have a heightened index of suspicion for Ebola, she said there is still a disconnect between what "the CDC is telling us, and what we see from the CDC on TV."
For example, she said she received two to three emails daily, as well as mandatory daily staff briefing sessions, in which "we are told that standard measures -- gowns, masks, and gloves and a private room -- are what is needed and on TV we see the CDC in hazmat suits."
The CDC director Thomas Frieden, MD, said Sunday that the newly diagnosed nurse most likely was exposed to Ebola by a protocol violation, but has not offered details.
Asked to speculate about what type of possible protocol violation could have exposed a nurse to Ebola, the ED supervisor had an answer: "there is a very specific way to take off the gown etc., folding inside to outside so that the 'dirty' area never touches skin. We're taught this in school and we practice it in school, but after that we don't practice it. The only staff who routinely follow that procedure are operating room staff and infectious disease unit staff. In ED units or medical units, it is not practiced."
Moreover, she said that the CDC is not requiring hospitals to reteach that sterile technique.
On Monday, Frieden said he regretted that his comment had been interpreted by some as "finding fault" with the nurse or with the hospital. He said that was not his intention and that he understood that flawless adherence to the strict infection controls needed with respect to Ebola is very difficult to achieve.
Nurse Associations React
The Texas Nurses Association said the following in a press statement:
"The facts are not known about how the nurse in Dallas was exposed. It is incorrect to assume that the nurse failed to follow protocols. Nurses work collaboratively within a complex healthcare environment. Just like in the case of Mr. Duncan, it is critical that we approach these cases objectively and learn from a full account of what happened. Only this way will nurses and all healthcare workers be equipped to safely care for patients and themselves."
"There is no standard short of optimal in protective equipment and hands-on-training that is acceptable," RoseAnn DeMoro, executive director of National Nurses United, said in a statement.
When National Nurses United, the largest organization of nurses in the U.S., surveyed members about Ebola protocols across America, 85% said their hospital did not provide adequate education, 37% reported their hospital did not have sufficient protective gear for staff onhand, and only 8% said their hospital had a plan to properly equip an isolation room.
Nurses Band Together
"Nurses are educated about reverse and regular isolation in their basic training program. However, most nurses do not do that as a regular part of their work unless they work on a hematology/oncology floor or an infectious disease floor," Victoria Erickson, PhD, PNP-BC, program director of graduate nursing programs at the University of Colorado Denver, told MedPage Today in an email. "Thus individuals who are not used to the very strict isolation procedures would clearly need a refresher."
Erickson said that she discussed the issue of whether the nurse was 'at fault' for not telling members of the team that the patient had travelled from Liberia with several of her colleagues, some of whom are familiar with the hospital in Texas.
"I am told that it is a very physician-centric institution, and it was not surprising that: the MD's did not read the nurses note, and when there was a problem a press conference held by the hospital blamed the nurse for the lack of communication. This approach is what is going horribly wrong in healthcare today," Erickson said.
"She put her life in jeopardy to help another. She is a warrior and a hero," Gina Nelson, DNP, founder and CEO of Primary Care Nurse Practitioners of New York in Staten Island, told MedPage Today in an email.
"I have been tweeting my upset about the CDC blaming the nurse by saying she broke protocol. I think we are still learning how to protect ourselves against this monster as evidenced by our medical missionaries in Africa contracting it as well," Nelson said.
"We have more to discover in our quest to care for those afflicted and protect those that are caring for them. We need to build on what we already know and learn from what has been ineffective as opposed to blaming the brave Nurse on the front line," Nelson added.