New CDC Hospital Ebola Guidelines Fall Short of WHO Guidance on Personnel Flow

I’m either a lone voice in the wilderness or just another angry old man shouting at clouds on this, but, to me, the issue of personnel flow inside a facility treating a patient for Ebola is critical. Texas Health Presbyterian Dallas got that issue terribly wrong in the case of Thomas Duncan, and now, although they provide very good guidance on the issue of personal protective equipment and its use, new guidelines just released by CDC sadly fall short of correcting the problem I have highlighted.

The issue is simple and can even be explained on a semantic level. If a patient is being treated in an isolation ward, that isolation should apply not only to the patient but also to the staff caring for the patient. As I explained previously, National Nurses United complained that health care workers at Texas Health Presbyterian Dallas treated Duncan and then continued “taking care of other patients”.

Allowing care providers to go back to treating the general patient population after caring for an isolated patient is in direct contradiction to one of the basic recommendations by WHO in a document (pdf) providing guidance for treatment of  hemorrhagic fever (HF, includes Ebola):

Exclusively assign clinical and non-clinical personnel to HF patient care areas.

By exclusively assigning personnel to care of the isolated patient, then the isolation is more complete.

The new CDC guidelines, released on Monday, offer updated recommendations on the types of personal protective equipment (PPE) to be used and how it is to be used. The guidelines also stress the importance of training on effective PPE use prior to beginning treatment of an Ebola patient. Unfortunately, though, the guidelines still leave open the possibility of health care workers moving between the isolation area and the general patient population.

In the preparations before treatment of an Ebola patient commences, the guidelines state:

Identify critical patient care functions and essential healthcare workers for care of Ebola patients, for collection of laboratory specimens, and for management of the environment and waste ahead of time.

And then once treatment begins, we have this:

Identify and isolate the Ebola patient in a single patient room with a closed door and a private bathroom as soon as possible.

Limit the number of healthcare workers who come into contact with the Ebola patient (e.g., avoid short shifts), and restrict non-essential personnel and visitors from the patient care area.

So the facility is advised to identify the “essential” workers who will provide care to an Ebola patient and to limit the number of personnel coming into contact with the patient. And even though the patient is to be in an isolated room, the guidelines still fall short of the WHO measure of calling for the Ebola treatment staff to be exclusively assigned. Precautions for safely removing the PPE are described, but once removed, the workers presumably are free to go back to mixing with the general patient population. Hospitals are cautioned against allowing large numbers of care providers into the room and to avoid “short shifts”, but there still is no recommendation for workers to be exclusively assigned to the isolation area.

The first thing that comes to mind in this regard is to question whether the CDC recommendations fall short of the WHO call for exclusive assignment in order to allow US hospitals avoid the perceived expense of dedicating a handful of personnel to treatment of a single patient. Is the ever-constant push to reduce personnel costs responsible for this difference between CDC and WHO guidelines? In the US healthcare system, it appears once again that MBA’s can carry more weight than MD’s on critical issues.

8 replies
  1. lefty665 says:

    Clouds too? Damn, thought I was safe by avoiding windmills.
    Not a surprise I suppose that medicine is like politics. Follow the money to find the vector of infection. But, I’m sure the market’s all seeing hand will make everything ok.
    Suppose NIH and Emory are billing Dallas Presby for the cost of caring for the nurses, or are the rest of us picking up the tab?

  2. RUKidding says:

    The so-called “Free Hand” of Mr. Market is a rigged game run by avariciously greedy (being redundant because deserved) MBAs whose sole aim in life is to rake in the big buck$ via as much rent seeking as poss. Hey, Mr. Duncan died? SO???? Most of the rest of the people around him haven’t died yet, amirite?

    ERGO, why have sound practices at hospitals across the USA? It’ll cost money, and the big Cheese MBAs will have to take a hit. Can’t have that!!! Mr. “Free Hand” Market don’t like that!

  3. P J Evans says:

    An MBA may be a useful degree, but people who have them aren’t necessarily qualified to run businesses. (Personal opinion: MBA programs should require at least two years of real-world work experience between completing the previous degree and starting the MBA program.)

  4. Rayne says:

    One of the other critical threats hanging over our heads, thanks to MBAs-uber-MDs business model, is the number of patients to each nurse.

    I was told the largest hospital in Michigan’s Upper Peninsula has an 8-to-1 patient-to-nurse ratio in the ER. That’s unsafe; one major accident, and suddenly all the nurses are on one patient, nothing left for the rest. Low-risk patients ready for final discharge are regularly left alone for hours at a time because the nurses are too busy with more critical patients (cosmos help you if you are caught waiting at shift change). MBAs don’t want to pay for more nurses; they’d rather dance with death though the death won’t be theirs. (By the way, some states legislate this ratio — think California is somewhere between 2:1 to 4:1 ratio. If you get critically sick, do it in California, okay?)

    But this problematic under-staffed ER is in bum-feck-nowhere, you might say. Except that this hospital is owned/operated by a large hospital network based in Tennessee; it operates ~67 hospitals across the US to the same MBA-set standards.

    When these MBA-types won’t let nurses get assigned to and stay with an isolated patient, it’s because it threatens the already-dangerous nurse-to-patient ratio.

    Never mind the increased contact is a risk. That’s on the nurses to mitigate, right?

    Fecking MBA-dorks who’ve never worked a damned day actually providing healthcare have screwed up design of electronic records systems so that patients who should receive differentiated treatment aren’t flagged properly. I’ve been told this is a major complaint across numerous community sites where nurses congregate. Strikes me as ridiculous that a country with such granular domestic spying capabilities can’t adequately track a single sick patient through the system, or the few dozens of people who’ve come in contact with that patient, let alone indicate to a doctor a patient needs specialized care based on a nurse’s initial triage work.

    Doesn’t help that the head of the CDC has proven repeatedly he’s not up to Ebola’s challenge–from the day the first patients were flown back and he had a deer-in-the-headlights reaction when quizzed by media about their arrival and treatment.

  5. pdaly says:

    Great points, Jim White. Cannot believe the protocols allow for care workers to move between ebola and non ebola patients. Thought that mistake was due to the confusion in the first hours of treating Mr. Duncan in the emergency room.
    Another problem with the new CDC guideline is in the doffing process. Instead of following Doctors Without Borders’ method of SPRAYING down the gown and boots of the person doffing the contaminated PPE (personal protective equipment), the CDC suggests “WIPES” instead. How well will wipes get between crevices of the contaminated boots? Why not provide “gravel mats” that copy Doctors Without Borders?

    Here’s a link to the NY Times article mentioning some of these changes.
    “There are some differences between the new guidelines, intended for American hospitals, and those of Doctors Without Borders, which tends Ebola patients in makeshift field hospitals in Africa, some of which are tents built on open ground.

    For example, Dr. Frieden said, in Africa it is possible to disinfect workers with a sprayed chlorine solution as they stand in a gravel pit. But that would create slippery puddles in hospital corridors, so the guidelines now recommend bleach wipes.”

  6. pdaly says:

    The LA Times also has great videos (by Doctors Without Borders) showing donning and doffing technique.
    The doffing technique includes stepping into a shallow pan of bleach to clean the soles of the boots, then a series of sprays on the PPE as the layers are systematically removed. Notice the person drips chlorine bleach onto the handle of the bucket of bleach each time he/she washes his gloved hands. This decontaminates the handle, too.

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