A year ago this month, the first patient diagnosed with Ebola on U.S. soil entered Texas Health Presbyterian in Dallas. On Friday, the hospital is releasing findings from an independent panel that reviewed what happened and what went wrong.
Last October, speaking to a U.S. House committee, the hospital’s chief clinical officer, Dr. Daniel Varga, admitted that the staff of Texas Health Resources made mistakes when Thomas Eric Duncan first arrived at the hospital’s emergency room.
"We did not correctly diagnose his symptoms as those of Ebola and we are deeply sorry," Varga said.
Now an independent panel has had a chance to look over the misdiagnosis of Duncan, his care, as well as the care of the two nurses who became infected with Ebola and survived. CEO Barclay Berdan says none of the five panel members received payment, only reimbursements for travel.
So what did they find?
“Texas Health Dallas and THR were not prepared to diagnose and manage a patient who came without a preexisting diagnosis of Ebola," says Berdan.
A lack of communication and oversight
The report says the hospital was not prepared for several reasons. First, there was a lack of communication, teamwork, and physician oversight during Duncan’s original stay in the Emergency Department. Also of concern: Health care workers may have put patient satisfaction over safety and tried to rapidly diagnose and move on to the next patient, Berdan says.
"There may be an over-emphasis on patient satisfaction," Berdan says. "Much of that historically has been spurred by overcrowding in emergency rooms and complaints about overcrowding.”
The report also points out the role of the various federal advisors was unclear for the hospital – and this misunderstanding led to confusion about which infection control standards to follow. As a result, nurses were improvising with their personal protective equipment and then forced to learn conflicting methods of donning and doffing the suits.
Confusion at national, state and local levels
In addition, the report determines CDC guidance on waste management was not clear and led to delays in obtaining the permits from the Department of Transportation to transport the bagged trash.
Confusion at the national, state and local level was a major stumbling block, Berdan says.
“A key takeaway from this review, is we had not in Dallas, Texas, focused on how to we work together as a team with public health departments, county, state officials, and the federal folks from the CDC," Berdan says. "There wasn’t a clear understanding of the role that each played in that. We hadn’t practiced it together.”
Texas Health Resources came up with an action plan that outlines lessons learned and improvements so far. Among them: reorganizing the emergency department into team-based pods of care, establishing a chain of command, and redesigning workflow to make sure a patient’s travel history is shared.
Drills, threat evaluations
But chief operating officer Dr. Jeffrey Canose admits problems weren’t limited to the emergency room.
"This was a systems of care issue we needed to address very broadly,” he says.
Which is why Canose notes they’ve focused on involving multiple levels of staff in drills twice a year, and pulled together a group to proactively evaluate threats related to emerging infectious diseases.
“This event taught the entire country that we are much more vulnerable to those kinds of biological and medical situations that will require a full scale emergency response by a hospital and a health system," Canose said.
Canose hopes these lessons will help hospitals prepare for future infectious diseases across the country.
About the independent panel
The independent panel included Denis Cortese of the Mayo Clinic, Patricia Abbott with the University of Michigan School of Nursing, Mark Chassin with the Joint Commission, G. Marshall Lyon III with Emory University School of Medicine and Wayne J. Riley with Vanderbilt University School of Medicine.
Ebola in Dallas: KERA Special Coverage
Ebola in Dallas: A Timeline