By Cathryn Domrose
Glen Cove (N.Y.) Hospital’s new $3.2 million infectious-disease unit, named last December as one of 55 designated regional Ebola treatment centers in the U.S., has sophisticated isolation equipment, the latest in telemedicine technology and even living quarters for staff who may need it. It’s managed by a team that includes nurses from all specialty areas of the North Shore-LIJ Health System in New York — pediatrics, ob/gyn, ED, med/surg, critical care.
The team conducts drills for putting on and taking off personal protective equipment every month, holds quarterly simulations and keeps up on the latest infectious disease news. Team members meet regularly, both professionally and socially. They have even designed team T-shirts. But they have yet to be deployed and the unit has never had a patient. With any luck, its two beds will remain empty for a long time — but its nurses will be prepared.
“Emory didn’t have anybody for many years,” said Darlene Parmentier, MSN, RN, MBA, CNML, Glen Cove’s director of critical care, telemetry and emergency. She was referring to Emory University Hospital in Atlanta, where the first American diagnosed with Ebola, a physician infected in West Africa, was treated last year. At the time, Emory was one of four biocontainment centers in the U.S. designated to treat people with dangerous infectious diseases. Glen Cove’s new unit was created and designed according to lessons learned from the Ebola crisis in West Africa — lessons that have reverberated in healthcare facilities across the country, from community hospitals to large healthcare systems like North Shore-LIJ.
Up close and personal
The complexities of caring for someone with a deadly infectious disease hit close to home after Thomas Eric Duncan, traveling from Liberia, was diagnosed with Ebola in the U.S. last September. Duncan had visited the ED at Presbyterian Hospital Dallas with a high fever. Although he told a triage nurse he had been traveling in Africa and she noted the information in an electronic record, the attending physician did not see it and sent Duncan home.
Four days later Duncan returned in an ambulance, vomiting and very ill. The staff immediately isolated and cared for him, but he eventually died from the disease. Two nurses who cared for him in the later and most contagious stages of his illness also contracted Ebola. They were taken to facilities designed to care for people with highly infectious diseases and recovered.
The response at Presbyterian Hospital Dallas could have happened at almost any hospital in the country, said Patricia Abbott, PhD, RN, FAAN, FACMI, associate professor and director of the Hillman Scholars program at the University of Michigan School of Nursing in Ann Arbor. Abbott was the only nurse on an expert panel convened to review the incident by the hospital’s parent company, Texas Health Resources. The panel issued its report in September, including recommendations to improve preparation for similar events at healthcare facilities nationwide.
When Duncan was diagnosed, health officials believed any U.S. hospital could care for an Ebola patient, Abbott said. “Based on what happened in Dallas, they found that wasn’t the case.” Most facilities did not have the resources or capacity to handle an Ebola patient in addition to providing regular care. As a result, the national protocol for caring for patients with suspected Ebola or other highly infectious illnesses such as MERS has changed. Now, according to guidelines from the CDC in Atlanta, patients suspected of having Ebola are isolated until they can be transferred to an assessment center for testing.
If they have Ebola, they are transferred to a specialized regional treatment center, such as the one at Glen Cove. Some hospitals may serve as both assessment and treatment centers.
If a person with Ebola symptoms arrived at any hospital today, Abbott said, she expected workers would immediately ask about travel history and follow procedures if the patient had been to a country with Ebola. But the Presbyterian Hospital Dallas case also offers some timeless lessons for all facilities beyond drilling with personal protective equipment and following CDC guidelines, she said. These include:
• The need for everyone in a healthcare facility, from unit clerks to the chief of surgery to have situational awareness of what is going on in the community and the healthcare arena, including newsworthy epidemics. For instance, she said, if there were rioting in the area, a facility would need to monitor the situation and prepare for possible injuries. Because Dallas has a large Liberian community and an international airport, the possibility of someone who had been exposed to Ebola in Liberia flying in to visit family was higher than in other areas, she said. Duncan’s travel history should have immediately raised a red flag among all care providers.
• Understanding that while electronic health records are useful tools, they should not be over-relied upon as the sole means of communication of crucial information among healthcare team members. Good face-to-face communication is important in making sure information is received.
• The importance of true team-based care, in which team members communicate with, trust and respect one another and involve each other in making care decisions. When physicians at Presbyterian Hospital Dallas first talked to colleagues at Emory for advice on Duncan’s care, nurses were not included in the discussions, according to the report. While this may not have made a difference in what happened, it created resentment and mistrust among the team, Abbott said.
• The need for practiced coordination with players outside the hospital, including first responders, state and local health departments and the CDC. According to the report, the hospital expected the CDC to take over care for Duncan rather than act as an adviser, and the CDC did not properly communicate its role to the hospital. “Nobody knew who was in control,” Abbott said. The confusion demonstrated the need to have protocols in place outlining the roles of each organization and to drill and train together before a public health crisis occurs, the report stated.
Preparation pays off
Extensive preparation paid off at the biocontainment centers that cared for other Ebola patients in the U.S. Before the first person with Ebola arrived at the Nebraska Biocontainment Patient Care Unit in Omaha, — Richard Sacra, MD, a physician who had treated patients at a missionary hospital in Liberia — nurses were excited but also a little fearful, said Angela Vasa, BSN, RN, CCRN, lead nurse at the unit.
Shelly Schwedhelm, MSN, RN, director of the Nebraska Medical Center’s ED, trauma and preparedness services, wondered if she’d made the right decision in agreeing to care for patients with the disease, and worried about the risks to her team.
But when Sacra arrived, the nurses realized he was like any other critical care patient, Vasa said. “It really allowed us to get back into our old routine.”
The constant drilling with personal protective equipment paid off, Schwedhelm said. “We learned that our focus on PPE for the past nine years was pivotal in the success and safety of caring for patients with a highly infectious disease.” They also learned, and have shared with other hospitals, the importance of using volunteers with different areas of expertise. The team is about half ICU-ED-based, but also includes nurses from med/surg, perioperative, labor and delivery and other units. “When you put all our skill sets together you get a rich environment for problem solving and trouble shooting,” Schwedhelm said.
Glen Cove used the same formula to recruit volunteers from across the health system to be on call to work in the infectious disease unit, said Susan Kwiatek, DNP, MBA, RN, the hospital’s executive director. “If we went to one unit and said, ‘You’re the Ebola unit,’ we would have scared off a lot of nurses.” Most nurses are very willing to care for patients with Ebola with the right equipment and training, she said, but the decision to do so must be theirs.
Just as epidemics like HIV-AIDS helped prepare hospitals and healthcare workers for the appearance of Ebola in the U.S., the Ebola experience has provided valuable lessons for the response to the next infectious disease crisis, said nurses involved in Ebola preparedness. “I don’t think it’s going to be perfect,” Abbott said, “but it will be different.”
Cathryn Domrose is a staff writer.
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