A year after a Texas hospital admitted a man who was diagnosed with the Ebola Virus and infected two nurses, an independent review board has completed a report spotlighting both the shortfalls in response and the lessons learned that could improve preparedness and performance in the event of a future outbreak.
Texas Health Resources released the report, which analyzed the treatment of Thomas Eric Duncan, a Liberian man who was admitted to Texas Health Presbyterian Hospital Dallas late last September with symptoms that were confirmed as Ebola. The report panel found that the hospital and the Centers for Disease Control, learning on the fly, provided inadequate protective gear to healthcare workers.
Three key areas that affected the handling of the case:
- failure to identify Duncan as a potential Ebola patient when he first showed up at the emergency room three days before being admitted
- the care provided to Duncan and the infection of the two nurses, and
- communications and emergency management throughout the situation.
That said, the hospital has learned from these mistakes and offers recommendations to other healthcare facilities that may take on a potential Ebola patient. In particular, it encourages hospitals to consider transferring patients promptly to one of the specialized centers with experience handling Ebola cases, such as the National Institutes of Health in Maryland or the University of Nebraska Medical Center.
Texas Health has also implemented:
- team strategies and tools to enhance performance and safety
- a comprehensive deployment of the SIRS score, which monitors patient symptoms and calculates risk of an infection being present, as well as sepsis order sets across its entities.
- a systemwide approach to emergency preparedness that establishes clear definitions of command roles that flex with changing situations and expanding the scope of its emergency preparedness measures, and
- a comprehensive drill twice a year with direct participation of system leaders, including a clinical disaster involving multiple entities.