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As I've written about (here and here) poor systems, a lack of protocols, and not adhering to protocols and standard practices are almost always “system problems.” A lack of proper training about protocols is a system problem.
System problems are the responsibility of hospital management, plain and simple.
National Nurses United is right to call for better planning and better protection of nurses and other caregivers. See their release: “Ebola-RNs Call for Highest Standards for Protective Equipment, including Hazmat Suits and Training.”
However, I think it's a bit of a straw man argument to say that recent news stories about the Dallas nurse, Nina Pham, who contracted Ebola through the treatment of Thomas Eric Duncan is “being blamed” for not following protocols.
I haven't read anything that said the nurse is anything other than a victim. I don't see blaming taking place. Maybe the general public reacts that way (ah, she's a bad nurse and she screwed up), but you can't control people's reactions.
If the nurse wasn't trained properly on Ebola protocols, including how to properly de-gown, she was a victim.
If the nurse was tired at the end of a long shift and wasn't properly supervised in how she worked or de-gowned (to prevent an inadvertent infection caused by touching her face with a dirty glove, as happened in Spain), she was a victim.
I guess the media can re-emphasize the systems component here.
From the NNU release (from what appears to be an unscientific survey):
Current findings show:
- 76 percent still say their hospital has not communicated to them any policy regarding potential admission of patients infected by Ebola
- 85 percent say their hospital has not provided education on Ebola with the ability for the nurses to interact and ask questions
- 37 percent say their hospital has insufficient current supplies of eye protection (face shields or side shields with goggles) for daily use on their unit; 36 percent say there are insufficient supplies of fluid resistant/impermeable gowns in their hospital
- 39 percent say their hospital does not have plans to equip isolation rooms with plastic covered mattresses and pillows and discard all linens after use; only 8 percent said they were aware their hospital does have such a plan in place
Lack of planning, lack of education, lack of communication — system problems.
Not having enough supplies and not having the right equipment — system problems.
Hospitals need to step up and prepare. It would have been better if this was already happening, but the wake up call has hopefully taken place.
The CDC says existing protocols are sufficient:
Frieden said investigators have yet to determine how Pham was infected. He stood by the protocols — including the use of masks, gloves and other equipment — saying they have proven safe for health care workers for decades.
Yet, officials want to establish an “official Ebola hospital” in each state.
“We'd like to have at least one hospital in every state that does feel they could manage a patient from start to finish.”
Maybe that doesn't speak well to the level of planning, or lack thereof that has already taken place.
Officials seem to be contradicting each other, with some saying things like “most American hospitals can safely treat Ebola” but others say “I don't think every hospital has the facilities or the wherewithal, or for that matter the desire, to care for Ebola patients.” Hmmm. We have to sort this out.
Nebraska Medical Center and Emory Medical Center are two of the existing Ebola centers. Maybe it's no surprise that they have both treated Ebola patients without any reported infections of staff. Do they have better processes and better training? Better supplies and equipment?
As the WSJ reports:
“The people at Emory have been training for, get this, 12 years,” said Trish Perl, a professor of medicine and a senior epidemiologist at Johns Hopkins Health System in Baltimore. “They have teams that are well-formed and well-developed.”
The news stories and recent actions paint a picture, to me, of a lack of planning. You could blame the CDC. You could blame hospital management. But don't blame the nurses and individual caregivers. We need to protect them as they serve and care for others. That's also a key step, it seems, in protecting the public.
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I think there is a certain amount of personal responsibility required in order for one to achieve self preservation. You can’t have someone there 24/7 to monitor every move you make. You make it sound like no matter how she got it it was the companies fault.
If there was a lack of training or a lack of supervision (such as not having a buddy system during a dangerous operation like removing protective clothing that’s potentially contaminated), yeah that’s primarily the hospital’s fault. To blame the individual would show a poor understanding of human factors.
A second nurse at THR has gotten Ebola:
http://www.theguardian.com/world/2014/oct/15/ebola-texas-healthcare-worker-virus?CMP=twt_gu
To me, this speaks to it being a systemic problem. To Jreau’s question above, I guess this goes to show that “self preservation” instinct is not enough to defeat what might be bad systems. If multiple nurses are indeed not following protocols properly, that’s a system problem.
Don’t blame the nurses.
This does NOT surprise me one bit:
Dallas nurses allege ‘no protocol, no system’ in treatment of Ebola patient
In normal circumstances, hospitals do a poor job of managing protocols and a poor job of training and supervising people properly.
The hospital here was apparently caught completely unprepared. Do you blame the CDC? Hospital leadership?
That’s shameful.
More from that article:
The word “should” is harmful in hospitals. There is no “should” — there is “do” or “not do” (credit Yoda).
The shoe covers should have been mandatory.
As cited above, “Triple gloving is a violation of CDC protocol and could make things worse.”
UGH.
Yet, the happy talk from the hospital spokesperson says: “Patient and employee safety is our greatest priority.”
Those words are far too often not backed up by action.
Another article:
“Dallas nurses describe Ebola hospital care: ‘There was no protocol’“
Having an Ebola-specialized hospital designated in each state could give a false sense of security. Other hospitals may not have a sense of urgency to prepare themselves and their staff because the patients will just be shipped off to this other place. In fact, there’s a pretty good chance the first health care providers to care for that patient (and be at risk for exposure) won’t be the Ebola-specialized one. When people are that sick, they’re going to go to the closest hospital to them not the specialized one that may be hours away.
EVERY hospital needs to take steps be prepared, make sure their staff is ready, and have what they need to protect themselves. This includes proper (easily accessible) PPE, training, protocols, and a culture that supports them voicing their concerns with any of it. This country’s health care system is sorely ill-prepared for a disease like this.
I loved the obvious denial of the Texas hospital. The chief clinical officer stated, “I don’t think we have a systematic institutional problem.” How about that river in Egypt?
Comment from a nurse on LinkedIn:
Properly using PPE is like any skill. If you don’t use it, you’ll lose it. I’ve gone through many sets of sterile gloves practicing how to put them on and take them off for the rare occasion that I needed to wear them… and that process is far less complicated than what’s needed for a patient on isolation.
I just hope hospitals actually let their nurses practice this process so it becomes second nature for them before they have to actually use it. I suspect most of them will just offer training videos and posters, though.
Or say “here is the CDC website.” THR should have never allowed their staff to treat Duncan for two days without hazmat suits. What colossally bad judgment.
As shared by a doctor on Twitter… the evolving standards for Ebola protective clothing. The old standard was deemed insufficient, so it was updated. Maybe it should have been sooner.
So the THR nurses might have been wearing gear that adhered to standard. They might have violated protocols in how they took dirty gear off.
LINK
A nurse from THR has spoken out on the Today Show:
Visit NBCNews.com for breaking news, world news, and news about the economy
See a statement from THR denying many of the allegations.
It’s strange to me that they say:
In the NBC interview, Briana claims she talked to a VP (directly in her chain of command, I presume) who did not follow up with her about her questions and concerns.
An open letter from THR:
http://www.texashealth.org/images/letter-to-the-community-101914.jpg
They admit failings in training and preparation, but they also claim to have followed CDC guidelines and that stories and allegations in the news are not true.
However, the CDC itself said (or speculated) that there were breaches in protocol.
I still don’t really understand how “breach of protocol” could somehow be interpreted as “the nurse did it intentionally” yet the Texas Nurses Association seems to be clarifying about something I never heard.
See video:
> I still don’t really understand how “breach of protocol” could somehow be
> interpreted as “the nurse did it intentionally
Interpretation depends on logic and psychology. Fear and blame based cultures predispose people to think blame and take things as blame. Even when the words don’t say that people take it that way.
This is one of the many reasons why the management system is so important. Even the exact same statement is taken very differently by people. A good management system the statement ‘breach of protocol” can by most employees as fine – an indication of yet again seeing a systemic issue and raising it to be dealt with. In a blame based management system it is taken as threatening and maybe even disrespectful.
Good point, John. People bring their past experiences and, sometimes, wounds with them to the workplace.
Here is a great 60 Minutes piece that highlights the nurses and how brave, caring, and compassionate they are:
The strength and performance of individual nurses was never in doubt, in my mind. The bigger questions, largely untouched on 60 Minutes, are about leadership, communication, and training…
Here is an interview with nurse Nina Pham:
http://res.dallasnews.com/interactives/nina-pham/
“In her 90-minute interview, Pham described working in chaotic surroundings at the hospital with ill-prepared nurses who received little guidance on how to treat Ebola and protect themselves.”
“Nina Pham claims the extent of her Ebola training was a printout of guidelines her supervisor found on the web.”