EBOLA: Bottom Up, Top Down Neglect, Incompetence And Mismanagement

Ebola reared its ugly head in America when news surfaced that a nurse who provided direct care for Ebola patient zero in Dallas, Texas, had contracted the disease. Subsequent news that a second nurse was infected and who had also cared for patient zero laid waste to official assertions that Ebola would be contained as a Third World problem and did not pose a serious threat to Americans at home. Setting aside the serious missteps committed when patient zero first presented for care, or his presence in America to begin with, the fact that two of his providers became infected while working in what was assumed to be a controlled environment, was a serious blow to the confidence Americans have in the Centers for Disease Control and Prevention (CDC) in particular, public policy makers at the highest level and the public health system in general.

In hindsight, as the first American Ebola patient arrived from West Africa for treatment at Emory Hospital on August 2, 2014, the photos and video taken as he emerged from the ambulance showed him and his attendants covered head-to-toe with personal protective equipment, including one attendant with a respiration devise (1), as if it was a scene from the movie OUTBREAK. Whether the display was, in part, staged to reassure viewers that extraordinary precautions were being taken to protect the general public and the attendants from the virus, it did effectively demonstrate that Ebola was a serious contagion for which equally serious safety measures had to be observed.

Ebola Emory 002 (1) http://ireport.cnn.com/docs/DOC-1157861

Today however, it appears that events on the 2nd of August in Atlanta were a patronizing act and as fictitious as the movie when compared to circumstances as they unfolded at the hospital in Dallas. Evidence rapidly accumulated from the day Ebola patient zero was admitted demonstrating that there was considerable individual incompetence, severe institutional mismanagement and some apparent willful neglect by many individuals and institutions that are responsible for the nation’s public health, the hospital, and those who provide direct patient care. Ebola patient zero was admitted on September 28, 2014, nearly two months after the first patient arrived in Atlanta for treatment in a Level 4 isolation unit.

Hospital administrators, including middle managers, were not by any reasonable standard innocent bystanders to this event, nor, one can easily suspect, were their colleagues in virtually every community and regional hospital across the nation. The other hospitals should thank their lucky stars that patient zero did not present for care at their facility, since they too were likely dependent on the Centers for Disease Control and Prevention (CDC) recommendations for the safe treatment of any patient suspected of having Ebola.

The CDC is foremost amongst the worst reprobates in this calamity of errors as concerns of an impending Ebola outbreak spiked due to the unexpected infections of the two nurses. Although the CDC is not necessarily culpable for patient zero, it does bear a substantial amount of responsibility for the infections of the two nurses who are now epidemiologically identified as Ebola Outbreak patients 1 and 2. CDC is not totally responsible for patients 1 and 2 however, since hospitals and individual providers, in particular professional nurses, share some of the responsibility for reasons that will be addressed.

Meanwhile, hospital administrators insist on casting blame on the CDC while the CDC indignantly blamed the nurses for breaking protocols, and the nurses cast blame on both the CDC and hospital administrators. The nurses’ claim, through their unions and professional associations, that there wasn’t adequate equipment and training in the lead up to the event, thus endangering them as direct care providers as the event began to unfold. Training, they say, was non-existent and the safety equipment substandard.

First question for the nurses: Did you ask for the proper equipment and training? Second question: Did you demand proper personal protective equipment and training? And last, but not least, did you seek to educate yourself about Ebola and its nursing implications? Remember that the outbreak in West Africa had already been raging for several months and, more importantly, it was August 2nd when the media provided dramatic coverage of the first Ebola patient’s arrival in Atlanta, more than two months before patient zero presented for care.

In short, nurses bear some responsibility to keep current with patient care standards and patient/personal safety issues. As the horrific pictures from West Africa and video of the first patient’s arrival at Emory Hospital were broadcast, even a lay person had to realize this disease required much more than gloves, a gown and a mask to prevent cross infection. Common sense was clearly absent, not only long before patient zero first presented, but far after he presented a second time and was admitted. The providers failed themselves and each other, while the hospital administrators failed everyone, including the community they serve. As for the CDC, it appears common sense is not necessarily an integral part of the organization’s thinking process, since it clearly neglected to do what its name clearly implies — control and prevent disease.

Unfortunately for the two Dallas nurses, the CDC is now in control mode, due to its failure to update its 2007 recommendations to prevent Ebola transmission in the hospital environment. While an undated update alerts viewers to recommendations specific for Ebola via a new cover page for the 2007 document and a link to the updated recommendations, the original 2007 recommendations suggested, “Single room preferred…” and to “see Table 3 for Ebola as a bioterrorism agent.” At the link to the updated document however, the Ebola recommendation now read, “Single patient room with door closed” and that “facilities should keep a log of all persons entering the patient’s room.” Since the new cover page was undated, it is impossible to determine if the update was made before or after the first nurse was infected, but recent news reports indicate that as many as three revisions have been recently made, none of which compare seriously to those prescribed by the Department of Defense.

At the risk of blaming the victim, none of the information above completely absolves nurses of responsibility in this morass of incompetence, neglect, and mismanagement. Historically, individual nurses have been relatively unimportant to hospital administrators who placed and replaced them at will. Collectively however, nurses were able to demonstrate that they are a vital factor in the business of health care delivery, forcing administrators to recognize that hospitals can not function unless they can provide nursing care for patients who can not care for themselves. Clearly, the lack of individual respect for professional nurses by hospital administrators forced nurses into unions, who in turn became their advocates and quite possibly the hospital administrators’ worst nightmare.

As a consequence of collective bargaining, however, nurses ceded some degree of their individual authority to the unions and professional associations (unions with a fancy title). While common communications in regard to working conditions continued between nurses and their middle managers, serious concerns or considerations were likely directed to the bargaining unit. Thus, as the Ebola tragedy unfolds, nurses may be bearing some unexpected costs of their decision to rely on someone else to determine their fate, rather than on their own individual efforts, abilities and professional standing.

It is important to stress at this point that nurses unionized because the profession, although highly regarded, is not regarded highly enough to be fully recognized as the primary reason why hospitals exist in the first place. Again, hospitals exist to provide nursing care and supervision to patients who can not care for themselves.

As a result of collective bargaining agreements, nurses are parties to contracts that address their working conditions. Where safety measures are concerned, the working conditions are designed to meet standards set or recommended by government agencies, such as the CDC and OSHA, and accrediting institutions, such as the Joint Commission on Accreditation of Health Care Organizations. Hence, the individual professional nurse relies on those standards and recommendations, while hospital administrators, as evidenced by recent events, are content to cite that a specific box was checked next to an expected standard to indicate conclusively that the institution met the minimum standards required by agency X at a given point in time and for a specific period of time.

As professionals, individual nurses still bear some degree of responsibility for their own personal safety. For example, every fall marks the arrival of a new flu season. Inevitably, as nurses contemplate getting vaccinated they reflect on the risks posed to them from close contact with feverish, coughing patients in their practice. What’s more, while some comfort can be taken in knowing that the vaccine mitigates a portion of their individual risks, they recognize that some risk remains. They do not want to “catch” the flu, but they accept that zero risk is neither practical nor economically feasible. In other words, when the common flu is concerned, some risk is deemed reasonable and acceptable.

Yet, it is interesting that when the flu threat was identified as Bird or Swine flu, risk tolerances, all the way from top policy makers down, were far closer to zero. Risks tolerance then is clearly lower as the mortality rates of an infectious disease increase. Even more interesting then is, since the mortality rate for Ebola is estimated to be up to seventy per cent and the more virulent flu strains were projected to be up to sixty per cent, wouldn’t the alarm of the risks associated with Ebola at least equal those that were generated when virulent flu was the threat? Not necessarily, since Ebola was not believed to be as “contagious” as the flu.

Little was obviously learned from the recent Bird Flu scare or the anticipated Swine Flu epidemics that didn’t happen. No one seemed to benefit–not the CDC, hospital administrators, public policy makers, the nation’s nurses or the general public. In hind site, and as it relates to the situation today, it is possible that the only outcome of all of the planning and training during the flu scares was the development of an inadvertent and wide spread culture of complacency, the epicenter of which is at the CDC. It is a culture of complacency verified by two women suffering from a life-threatening disease contracted in large part due to CDC’s abject failure to fully appreciate the threat of an emerging disease that was but a plane ride away from initiating a potential public health disaster. Unfortunately, as far as the CDC is concerned, two casualties thus far is a mere statistic, whereas, to the casualties and their families, friends and colleagues, it is a disaster.

The system is not, however, just suffering from complacency, incompetence, and neglect at the highest level of government, where public policy affects everyone nationwide. These undesirable qualities are also evident in the corner offices of our hospitals, as well as some accrediting and regulatory agencies. Most unfortunately, these undesirable qualities can be found at the service end of the system, where the boots meet the ground and direct patient care is delivered.

Yes, the system is suffering from complacency, incompetence, and neglect at every level. From the nurses who screen patients entering urgent care centers and emergency rooms to critical care providers in the ICU and the infection control nurse specialists, it is evident no one thought seriously enough about Ebola’s threat to individual safety and the safety of others. Not only did nurses abrogate (albeit unconsciously) their individual responsibility for personal safety, they abrogated institutional professional responsibility for the safety of each other and their patients. Nurses appear to have fallen into the same complacency abyss populated by a substantial subset of Americans who find it easier to depend on agencies of government for a wide array of benefits, rather than to embark on the more difficult task of taking care of themselves.

For nurses not to have recognized the disparities between the safety measures visible from West Africa (2) and Emory Hospital and those practiced in there own institutions, they either live in utter isolation from current events and are thus ignorant of the potential threat that a patient with Ebola poses in their workplace, or they just weren’t concerned or motivated enough to do a little homework to investigate the efficacy of their own safety measures. More than likely the latter is true since safety and preparedness responsibilities have been delegated or assumed by others, thus creating a rich environment from which a culture of complacency can emerged. Apparently, after viewing the images out of Africa and Atlanta, no nurse asked, “What should I do?” and “What do I need?” if an Ebola patient presents to me at work.

Ebola W.Africa2

 

A more serious question that should have been addressed (and now will be) is, “How does the patient isolation environments, practices, policies and procedures in my institution compare to those in the SPECIAL CARE UNIT at Emory Hospital, or to the images from West Africa of the personal protection equipment deployed at the source of the outbreak?” Did those images not ring some alert bells, particularly amongst the floor nurses and intensive care specialists who have wide experiences with various isolation methods? Oh, and what about their unit managers, who are theoretically competent and accomplished professionals? What about the nurses who are often the first providers to see patients entering the health care system to assess their immediate needs and to isolate them if they are suspected to have a contagious disease, such as the flu; or Ebola?

Perhaps a sentinel event was necessary to prompt management to ask the pertinent questions and to acquire the necessary personal protective equipment as well as the training to properly use it. Perhaps a sentinel event, and its subsequent crisis in confidence, was necessary to shake the CDC out of its lazy stupor and to prompt it to get serious about the threat Ebola portends to our citizens, especially our health care providers, and potentially to the entire economy.

Unfortunately, this sentinel event must forever serve caution to every nurse that a decision to be totally dependent on others for personal safety on the job could be a perilous one. So too, while it is unlikely that the fall-out from this event at this point will become a core reference in every hospital management course and nursing school across the country, nurses should always be cognizant of the fact that it is really easy for influential people, like the current director of CDC, to just blame the nurses. Nurses are and always have been dependable scapegoats. This situation is far more serious however, since blame is of least concern when your health or ability to continue living is at stake.

Yes, there are two nurses who are definitely victims to the neglect, incompetence and mismanagement of the Ebola events so far. They are not however, completely innocent victims, for as shown above, they too bear some responsibility for the situation. On the other hand, if the CDC demonstrates little concern and publicly downplays the risk to health care providers and the population as a whole, and hospital administrators, in turn, have no “rational” reason to be concerned, what is a nurse to do?

Up to now, the answer was to ignore it, to resign or just go along to get along, and to hope for the best. Now, however, the answer is to keep informed and not to quit, but to proactively engage with administrators and public policy makers as the professionals who have the most to lose and who have the practical knowledge and skills necessary to evaluate the efficacy of a given protocol or procedure as it applies to the direct care environment; and then to quit, if necessary.

Regarding the comparative question about isolation practices at Emory and local practices cited above, which of the three principal parties involved in this event had the most power not only to ask the question, but to effectively answer it, and thus avert the event all together? Rating them from least power to most, there is no doubt that the nurses’ only available power was to refuse to work and risk being fired, or to resign, since they had relegated concerns about major safety issues to the union. Hospital administrators could have effectively responded to the question if they wanted their operations to function under standards that reflected an abundance of caution, rather than those recommended by the CDC. They did not (nationwide few hospitals likely did) because they too are content to pass the responsibility to a higher “authority.” Ultimately then, it is the CDC who bears the brunt of the liability for this calamity of errors, and, as is too often the case in government bureaucracies, is unlikely to be held accountable. The hospital and their administrators will however, be held accountable, not necessarily in a court room where they will gladly exhibit the papers revealing that the boxes next to “Infection Control” were checked, but in the market place as patients and providers elect to seek care and to practice at institutions who demonstrate that they operate under higher standards.

Thus, hospital administrators, whose reputations are very important and nurses, whose lives may be at stake, would be wise to keep in mind an old pejorative that warns us to beware of men who claim, “We are from the government and we’re here to help,” and to be aware of their own common sense, especially when it conflicts with recommendations made by agents whose conclusions may in fact not be completely accurate.

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