The Ebola Crisis: A UMSN Nurse Part of Analysis on What Went Wrong in the U.S.
The lone nurse scientist on an expert panel reviewing a Texas hospital’s handling of an Ebola patient was University of Michigan School of Nursing Associate Professor Patricia Abbott, PhD, RN, FAAN, FACMI. In September 2014, during the peak of the global Ebola crisis, a Liberian man arrived at Texas Health Presbyterian Hospital Dallas complaining of headaches and nausea. Despite informing the staff he had recently been in Africa, he was misdiagnosed with sinusitis and sent home. He was later readmitted and died two days later. Two nurses contracted Ebola after caring for the man, and the landscape of infectious disease preparedness in the United States was forever changed. This episode exposed major health care system gaps, poor emergency response practices, and a lack of coordination in the face of the highly contagious and deadly Ebola Virus Disease (EVD).
An expert panel was assembled to conduct and validate a root cause analysis related to the circumstances at Texas Health Dallas and to make final public recommendations geared to promote a stronger and more coordinated response by the U.S. health care system. The panel, composed of Dr. Abbott (University of Michigan School of Nursing), Dr. Chassin (President & CEO of the Joint Commission), Dr. Riley (President, American College of Physicians), Dr. Cortese (Emeritus President & CEO, Mayo Clinic), and Dr. Marshall (Director, Emory Ebola unit), found a number of contributing factors that led to the unfortunate events at Dallas Presbyterian Hospital.
“There was very poor team communication; an overreliance on the electronic health record (EHR); a deep lack of situational awareness; issues with coordination between the state Health Department, the hospital system, and Centers for Disease Control (CDC); and problems with leadership and accountability,” says Dr. Abbott. “As an informatician and a nurse I was saddened to see so many failures related to a lack of attention to the basic tenets of care – strong cooperative teams, the importance of communication, and EHRs that make the right thing to do the easiest thing to do – instead of what we saw here.”
The independent panel was assembled at the request of Texas Health Resources, the corporate parent of the hospital where the incident occurred. The panel made recommendations for the future, including clarification of the role of the CDC in local and regional disasters, improving preparedness for infectious disease emergencies, increased attention to high quality team-based care, an enhanced focus on the usability of EHRs, and a reevaluation of potential problems from an overreliance on the use of EHRs for communication.
“There has been a large public response to the issuance of this report, and we all believe that the lessons learned will help us all to be better prepared for the next infectious disease emergency” says Dr. Abbott.
Earlier in 2015
UMSN alumna and current U-M Health System nurse, Belinda Fish, spent six weeks caring for Ebola patients in West Africa’s Republic of Sierra Leone.“I knew I was going to see some awful stuff; [Sierra Leone] has some of the worst health outcomes in the world,” Fish says. “And yes, you do some crying, but most of the time you are so intent on just giving the best possible nursing care you can.”
