Ebola Control Training Lags With Gap in Federal Oversight

Hospital staff need better training, more funding and sharper oversight to handle Ebola patients, nurses and doctors said after a caregiver in Dallas was confirmed to have caught the deadly virus.

The unidentified worker, who cared for Ebola patient Thomas Eric Duncan at Texas Health Presbyterian Hospital, was infected after a “breach in protocol,” said Thomas Frieden, director of the U.S. Centers for Disease Control and Prevention. It’s the first time someone has contracted Ebola inside U.S. borders.

Even as the CDC has hastened to reassure the public that the virus won’t spread in the U.S., the agency doesn’t monitor hospitals and has no authority to make sure they comply with official guidelines, according to Abbigail Tumpey, a CDC spokeswoman who is leading the education outreach to hospitals.

“There are 5,000 hospitals in the U.S. and I would say probably the number of them that have actually done drills or put plans in place is small,” she said.

It’s up to each hospital to enforce infection control, and standards vary depending on funding for infection experts and time devoted to training.

“We have been screaming for the past three months that hospitals are not prepared,” said Deborah Burger, co-president of National Nurses United, which represents 185,000 nurses across the country.

Complex Protocols

The American Hospital Association was instructing its members “to meet the latest CDC guidance and best practices to protect health care workers,” Ken Anderson, chief operating officer of the AHA’s research and educational trust, said in a statement.

“The CDC is investigating how to improve these plans and processes so all hospitals can learn from what has happened in Dallas,” Anderson said. “These are complex systems and procedures. We urge hospitals to review and update them as appropriate for their community.”

Following the guidelines for protective gear is easier said than done, according to Eli Perencevich, professor of epidemiology at the University of Iowa Carver College of Medicine.

Full protection against Ebola involves special gowns, gloves, a face shield and a mask, and putting on and taking off the various parts is “a slow, deliberate process with lots of steps” which takes about six minutes each way, Perencevich said in a telephone interview.

Training Gap

“The thing that’s most concerning is that people just don’t have experience with this and they may accidentally put a dirty glove to their face or touch something with their hands, and eventually the hand goes to the mouth,” he said.

The CDC has told Texas Health Presbyterian Hospital to assign someone whose sole job is to make sure Ebola caregivers follow protocol, Frieden said yesterday. Doctors Without Borders, the medical aid agency at the outbreak’s front lines in West Africa, uses a “buddy system,” where health workers watch each other dress and undress to make sure there are no slips.

The only way to ensure hospital workers correctly follow procedure is with training and drills, Perencevich said. Some caregivers feel they aren’t adequately prepared.

About 85 percent of nurses haven’t received interactive education on how to take care of Ebola patients, according to the association’s survey of 1,900 nurses in the past few weeks, and 76 percent of the nurses surveyed said their hospital hasn’t communicated any policy on potential admission of patients with Ebola.

Heads in the Sand

Hospital administrators “are like ostriches with their heads in the sand, they keep telling our nurses there is a plan and the nurses say there is no plan,” Burger said in a telephone interview.

Many nurses have been directed to look up the recommendations on the CDC website or they are handed one sheet of paper and given a kit with Ebola equipment in it, but they haven’t received training on how to use it, Burger said.

Funding is another obstacle, as budget cuts are hurting hospitals’ ability to hire experts and equipment, according to some physicians.

“Infection control budgets have been slashed,” said Judy Stone, an infectious disease expert who works at various hospitals in Pennsylvania.

At one hospital she visited, she was alarmed that each room didn’t have its own stethoscope, which meant physicians could be carrying drug-resistant bacteria from room to room. When Stone protested, she was told there wasn’t enough funding to buy more stethoscopes.

Better Training

Health workers should be training with products like Glo Germ, which can only be seen under black light, Stone said. The substance can be spread over surfaces like bed rails, then workers can see where they’ve picked it up and how they could have potentially been contaminated.

The government doesn’t require hospitals to have infection control specialists, and Medicare, the federal insurance program for the elderly, doesn’t reimburse hospitals for hiring such staff, which are essential to training and enforcing standards, said Perencevich of the University of Iowa.

“We pay for procedures -- we give hospitals a lot of money for bypass surgery, but no money to prevent a surgical infection,” he said. “Every dollar the CEO spends on infection control must come out of the budget.”

Better Hospitals

Until hospitals can demonstrate they are adequately prepared, patients may need to be transferred to other institutions that have demonstrated competency, say some physicians.

Ebola “isn’t pixie dust, it doesn’t just jump from one place to another,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

The newly infected health worker “begs the question of whether there should be a limited number of hospitals caring for these patients,” he said.

The CDC doesn’t have the authority to determine whether hospitals are qualified or not, Tumpey, the agency spokeswoman, said. “Sometimes moving patients is not possible if they are too ill,” she said in an e-mail. “We are looking into this issue further.”

Asked in a conference call yesterday if the Dallas health worker might be moved, CDC director Frieden said the agency is exploring all options.

For now, it may be up to individual hospitals to ask for help.

“Any hospital of any size needs to be prepared,” said Phil Smith, medical director of the biocontainment unit at the Nebraska Medical Center in Omaha, which has treated a U.S. missionary worker and television cameraman infected with the virus in West Africa. More Americans infected with Ebola are likely to be repatriated, he said. “It looks like this is something that’s going to be going on for a long time.”

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