A hospital in the southern U.S. state of Texas was not prepared last year to treat the first person diagnosed with the Ebola virus in the United States nor to ensure the safety of the two nurses who contracted the virus while treating the patient, according to a new report.
In their report, a panel of independent experts said it was "evident" that personnel from the Centers for Disease Control and Prevention, plus federal and state officials, "were learning alongside" the actual health care providers at the Texas Health Presbyterian Hospital Dallas.
The hospital’s parent group, Texas Health Resources, released the findings Friday.
Thomas Eric Duncan, a Liberian emigre, initially sought treatment at the hospital’s emergency room September 25 for a headache, nausea and extremely high temperature. He had arrived several days earlier from his native country, where he’d helped carry a woman infected with the disease.
Duncan was sent home with antibiotics but returned three days later and was hospitalized. He died October 8.
"It is unclear why a patient who had developed a fever of 103 was not reexamined prior to discharge or whether the physician was advised or aware of the elevated temperature," the report said.
Communication was flawed
The findings revealed that while information about Duncan's travel history to Africa was gathered by a nurse, it "was not verbally communicated to a physician" because the information had been entered into the electronic health record.
"The health care team apparently relied too heavily on communication through the electronic health record," the panel said.
The CEO of Texas Health Resources, which owns the Dallas hospital and 23 others in north Texas, said he welcomed the panel’s report.
Barclay Berdan said he "believe[s] that it will lead us to better diagnoses of diseases in our emergency rooms, better care for our patients overall, and better coordination with local, state and federal officials in the event another rare event like this unfolds."
The hospital group already is utilizing measures recommended by the panel, it said.
"We have strengthened the care processes for our patients and implemented national best practices that embrace team strategies and added tools to enhance performance and safety,” according to a statement. “… High reliability training is being deployed across the organization, along with emergency preparedness drills and procedures designed to test our readiness for large-scale infectious disease scenarios."
Infected nurse sues
The panel report comes amid a lawsuit from Nina Pham, one of the infected nurses, the Associated Press reports. The suit alleges the hospital group failed to provide training and proper protective gear.
"It does not appear that issues such as personal protective equipment, waste management and other challenges that would emerge as critical were addressed by CDC at the onset of this event," the report said.
The findings said "health care workers had areas of exposed skin that were not fully covered or shielded," exposing them to "massive" and "highly infectious" fluids from Duncan.
Pham and nurse Amber Vinson survived Ebola.