Dallas Nurses Say Infection Control Ignored in Ebola Care

Troy Brown, RN

October 15, 2014

( Updated October 16, 2014 ) Nurses at Texas Health Presbyterian Hospital Dallas claim the hospital administration failed to follow basic infection control principles and provided inadequate training and personal protective equipment for them to use when caring for a patient with Ebola virus, according to a statement the nurses issued on October 14.

The nurses made their statement anonymously through National Nurses United, the largest union and professional association for nurses in the United States, because they say they are afraid of retaliation from the hospital.

Deborah Burger, RN, copresident of National Nurses United, read the statement at a press conference October 15. The nurses say the hospital's actions placed them and other patients at risk after Thomas Eric Duncan was brought to the hospital with suspected Ebola virus infection on September 28. He was later admitted to the hospital and died there on October 8.

Two nurses who cared for Duncan have since been diagnosed with Ebola virus infection, and an additional 75 individuals are being monitored for symptoms.

Other Patients Exposed in Emergency Department

The nurses allege that Duncan was not isolated for several hours after being brought to the hospital by ambulance and was left in an open area in the emergency department (ED) with as many as seven other patients. The nursing supervisor demanded that he be isolated and "faced resistance from other hospital authorities."

They say that patients who had potential exposure to Duncan were kept in strict isolation units for 1 day and then transferred to areas with other patients — even those with low-grade fevers who were potentially contagious.

Duncan's laboratory specimens were sent through the hospital's pneumatic tube system to the laboratory, potentially contaminating the entire pneumatic tube system.

The nurses say they observed hospital personnel going into and out of isolation areas in the ED without proper personal protective equipment. They also say they observed Centers for Disease Control and Prevention (CDC) staff and infectious disease department staff "violate basic principles of infection control, including cross contaminating between patients." They say these staff "went back and forth" between the isolation area and hallways that were not cleaned properly after they and other staff exited into them from the isolation area.

"No Protocols," Little Advance Preparation

The nurses claim that the only advance preparation consisted of a one-time hospital seminar on Ebola virus, but attendance was not mandatory. The nurses also said, via their prepared statement read by Burger, that for a hospital as large as theirs, this seminar would have had to be presented several times to reach all nurses.

They say staff did not know "what the protocols were" and were not able to verify what specific personal protective equipment should be used. The nurses claim "there were no protocols" and that they were instructed to contact the hospital's infectious disease department, which could not provide clear policies either.

The nurses add that after Duncan's diagnosis, the training that did occur did not include having the nurses demonstrate proper donning and doffing of protective equipment.

Inadequate Personal Protective Equipment

Nurses who first cared for Duncan "wore a non-permeable gown front and back, three pairs of gloves, with no taping around wrists, surgical masks with the option of N-95 [masks], and face shields." Some supervisors reportedly told them that N-95 masks were optional. The nurses report that Duncan had "copious amounts of diarrhea and vomiting."

The nurses state that they were later given suits with booties and hoods, which left their necks exposed near their faces and mouths. When they expressed concern about this, they were instructed to wrap medical tape around their necks several times. This tape was not impermeable and had permeable seams. The nurses had to apply and remove the tape by themselves.

They add that nurses were allowed to care for other patients after caring for Duncan, "even though they had not had the proper personal protective equipment while caring for Mr. Duncan."

According to the nurses, hazardous waste piled up to the ceiling because there was no one to pick it up and nurses had no policies for cleaning and bleaching the area.

Although hospital guidelines have changed since Duncan's hospitalization, the nurses say they still have not been given clear instruction regarding which guidelines to follow.

Nurses' Concerns Widespread

The statement from the Dallas nurses was read as part of a national conference call held by National Nurses United to discuss nurses' concerns regarding Ebola patient care and preparedness.

More than 11,500 nurses from around the United States participated in the call. Many said that their institutions are not prepared to care for patients with Ebola virus infection and that they have insufficient training and personal protective equipment to do so safely. Some said the isolation rooms at their facilities are inadequate for use by patients with Ebola virus infection.

Texas Health Presbyterian Hospital Dallas Denies Allegations

Hospital administrators responded to the nurses' allegations in a statement today, saying, "The assertions do not reflect actual facts learned from the medical record and interactions with clinical caregivers. Our hospital followed the [CDC] guidelines and sought additional guidance and clarity."

Duncan was moved immediately to isolation on his arrival at the hospital by ambulance on September 28, and hospital personnel wore appropriate personal protective equipment recommended by CDC at that time, the hospital said in the statement.

Staff used the pneumatic tube system to send Duncan's specimens to the laboratory on September 26, when Duncan visited the emergency department for the first time and was sent home, the hospital noted. "At no time did Mr. Duncan's specimens leak or spill — either from their bag or their carrier — into the tube system."

Administrators said that when Duncan returned to the emergency department on September 28, "his specimens were triple-bagged, placed in a container, and placed into a closed transport container and hand-carried to the lab utilizing the buddy system." They added that while Duncan was hospitalized, all laboratory specimens were "hand-carried and sealed per protocol." Wireless equipment was used to process routine laboratory tests in his room.

"Protective Gear Followed Governing...CDC Guidelines at the Time"

The statement goes on to say that nurses who cared for Duncan used personal protective equipment, as directed by CDC guidelines. "Staff had shoe covers, face shields were required, and an N-95 mask was optional — again, consistent with the CDC guidelines at the time. When the CDC issued updates, as they did with leg covers, we followed their guidelines."

According to the statement, "When the CDC recommended that nurses wear isolation suits, the nurses raised questions and concerns about the fact that the skin on their neck was exposed. The CDC recommended that they pinch and tape the necks of the gown. Because our nurses continued to be concerned, particularly about removing the tape, we ordered hoods."

Hospital administrators said that nurses were classified regarding risk/exposure levels according to CDC guidelines. "The CDC classified risk/exposure levels. Nurses who were classified as 'no known exposure' or 'no risk' were allowed to treat other patients per the CDC guidance."

Patients with possible exposure "were always housed or isolated per the CDC guidance," the statement continued.

"Above and Beyond the CDC Recommendations"

Regarding hazardous waste, the hospital said it did everything the CDC recommends and more. "Waste was well-contained in accordance with standards, and it was located in safe and containable locations.

"Admittedly, when we received Tyvek suits, some were too large. We have since received smaller sizes, but it is possible that nurses used tape to cinch the suits for a better fit," according to the statement.

The statement ended by saying the hospital is in the top 1% in the United States regarding employee engagement and partnership. "We support the tireless and selfless dedication of our nurses and physicians, and we hope these facts clarify inaccuracies recently reported in the media."

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