There's been a ton of discussion and many questions raised in the news and social media about the two Americans, Dr. Kent Brantly and Nancy Writebol, who contracted the ebola virus while selflessly serving others in west Africa and were then brought back to the U.S. for treatment at Emory University Hospital in Atlanta. This has become a very politicized story and I'd like to avoid or ignore that the best we can here and in the comments. I'm interested in story from the perspectives of risk, protocols, and "standardized work" as we'd refer to procedures and best practices in the "Lean" methodology and management system. What do they need to do at Emory and how do they ensure it's done?
How were the Americans infected?
I've read references to medical standards and equipment in Liberia not being up to American standards. But, I would hope and presume that Westerners who are volunteering there would, at the very least, have been able to bring the proper protective suits and equipment with them.
Since ebola can be deadly for up to 90% of people who contract the virus, Dr. Brantly and Writebol, and all of their colleagues, would have every bit of self interest and motivation to follow the standardized work when treating ebola patients. The one thing that I have not been able to find in any news article is any sense of detail about HOW they contracted ebola. Was it a needle stick? A hole in a glove? Some other contact with bodily fluids? How did that happen? And how did it happen to the two of them? Bad luck or some sort of procedural breakdown?
The Daily Mail reports:
"Brantly, who had meticulously adhered to protocols when treating patients, immediately isolated himself when he recognized the symptoms and notified team members, Strickland said."
This article says:
"He knew the CDC and WHO protocols for safety inside and out," Samaritan's Purse spokeswoman Melissa Strickland said. "He was very meticulous in following that and making sure the entire staff was following that. That was one of the reasons he was given that responsibility....
Before he was infected, Strickland confirmed that Brantly sometimes spent three hours treating patients in the clinic. It's a feat few doctors can manage since the medical gear they have to wear ends up becoming almost unbearably hot." So how did he get infected then? Did Brantly really adhere to protocols 100% of the time? People sometimes THINK they are following a protocol (such as handwashing) but, in reality, do not. Sometimes our own awareness of what we're really doing isn't 100% accurate.
The Wall St. Journal reports that 15% of the Liberians who have died of ebola were healthcare workers.
Michael Stulman, information officer for Catholic Relief Services, said: Even with protective gear and precautionary measures, the stress of coping with so many gravely ill Ebola patients opens room for mistakes that allow the virus to spread, he added. "The doctors and nurses who are working on the front lines are working in a particularly high-risk environment. It's possible for someone to slip up and become infected. That's been a major challenge."
This is important to understand how the healthcare workers are getting infected, even with protective gear like this -- not to point fingers, but to better understand the problem and how to prevent other healthcare professionals (in Africa or elsewhere) from contracting ebola. A Washington Post report about the death of Sierra Leone's top doctor has an ominous warning: "Even with the full protective clothing you put on, you are at risk.” Let's hope the protective clothing at Emory is better.
If anybody has details (from reputable sources) about HOW the healthcare professionals, American or otherwise, contracted ebola, please post a comment below.
Emory is taking every precaution...
Emory University Hospital is a world-class hospital with well-trained, extremely caring healthcare professionals with the best education and the best equipment. Many hospitals have all of these advantages... yet a few hundred thousand Americans die each year as the result of preventable medical errors and many times more are harmed. They're not harmed due to people who get referred as "bad apples." In most cases, it's not a matter of asking "who screwed up?" but, instead, we need to ask "where did the processes break down?"
Even world-class hospitals in the top 10 or top 100 rankings from whatever publication still manage to harm and kill patients. That's not hyperbole, it's a sad truth. I don't mean to offend those who work in healthcare and I don't mean to overly alarm those of you who don't. But, our current health system is riskier than it needs to be, by far. This can be fixed.
Thankfully, many health systems are using Lean and other methods to dramatically reduce harm. This happens because of better management, better processes, and better communication - not as the result of having better people or better technology. It's certainly not the result of firing all of those so-called "bad apples." The hospital and medical professionals are downplaying concerns the public might have about ebola being brought into the country for the first time. The hospital has a special containment unit that was set up in collaboration with the CDC.
Emory says: Emory University Hospital physicians, nurses and staff are highly trained in the specific and unique protocols and procedures necessary to treat and care for this type of patient. The standard, rigorous infection control procedures used at Emory protect the patient, Emory health care workers, and the general public. As the Centers for Disease Control and Prevention says, Ebola does not pose a significant risk to the U.S. public.
As an engineer trained in risk analysis, I'd note that "no significant risk" is not the same as "zero risk." There are local news media reports in El Paso, Texas about the CDC prepping "quarantine camps," that would be used in the event of an ebola outbreak. I'm glad there's a specific team at Emory that's been highly trained, with regular practice. That's a huge positive in their quest to safely treat these patients while protecting caregivers and the public. One of the common systemic problems in healthcare is poor training on specific protocols and processes - and many patients are harmed as a result.
The people at Emory are being protected by strict protocols... yet Dr. Brantly was infected while working under strict protocols. This is puzzling, right?
Maybe I've become a bit of a cynic, working in hospitals for the past nine years. I've seen countless instances of physicians and nurses cutting corners and not properly "gowning up" to enter an isolation patient's room. Granted, none of these were ebola patients. But, policies and protocols are ignored for a number of reasons (lack of time, supplies not always being available, "I won't be in there that long"), but the everyday isolation precautions are generally there to protect the patient from germs, not the healthcare provider.
In the case of the ebola patients, the healthcare professionals have more at stake and are more likely to follow protocols and procedures. I read about a two-person "buddy system" that's used with one person constantly inspecting and looking out for risks to the other care provider. That doubles the cost of care, but the cost of an infection is enormous - whether it's ebola or c. diff in everyday hospital life. Everyday hospital infections are costly and deadly, so why aren't we doing more (even if that means spending more) to prevent them?
Why aren't hospitals always as cautious with every patient?
I'm not going to be as cynical as to assume that there will be a process problem in the containment unit at Emory. If there was ever a situation where people were under scrutiny to constantly do the right thing, it would be now. There's not as much scrutiny at 2 pm in a average hospital cardiac care unit on a normal Wednesday afternoon.
But, it makes me think... if hospitals CAN be extra cautious and make sure people are following protocols in situations like this, why aren't they doing a better job of protecting patients from the everyday infections that kill so many each year, even in the "best" hospitals? Why does the media generally ignore the deaths from post-surgical infections, central line associated bloodstream infections, and the like? How do we ensure that everybody protocols are actually followed 100% of the time? How do we make sure that checklists are in place and always followed?
Arguably, the normal everyday risks that Americans face when going under the knife or being admitted to the hospital are far more risky than exotic threats like ebola... yet these everyday risks are rarely in the news. We should pay more attention to the common everyday risks (and work to prevent them) and not just worry about the sensational.
By Mark Graban
Mark Graban (@MarkGraban) is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen. His latest, The Executive Guide to Healthcare Kaizen is now available. He is also the VP of customer success for the technology company KaiNexus. Mark blogs most weekdays at www.LeanBlog.org.
Michelle Stone-Moore (Clinical Advisor at Humana) writes in a reply to the above piece:
I want to respond first of all to the comment in the article that the precautionary use of personal protective equipment (PPE) is for the protection of the patients. It is, as well as for the caregivers involved AND the families - that is, IF you can get the family to comply with the isolation requirements.
As a nurse, we are taught to wisely use PPE based on the type of precaution needed. MRSA and VRE are contact isolation and depending on the amount of patient involvement, may not require more than gloves or may require the full gown, mask and shoes (VRE is some horrible diarrhea). That's not a breakdown in process, folks, that's using critical thinking. I am not going to gown up to deliver a pill to a VRE patient (as a for example).
The other issue I want to address is the fact that the general public doesn't understand how critical it is for them to utilize PPE. I have had several conversations with family members about using PPE with their sick family member so they don't take that infection home, to the lunchroom or even to the store with them. The give me a blank stare and say "well, we've already been exposed, so what's the difference". Again, not a breakdown in process on the part of nurses. We can only control so much of what goes on.
Droplet precautions are the most difficult to deal with and the most time consuming isolation issue Remember back when HIV was first isolated, the general consensus was that you can catch it from a toilet seat. Reality set in and by the time people understood that the virus can't survive outside the human body for very long (i.e. you can't catch it from a toilet seat), panic had set in and we had a new commune of HIV patients forming every minute.
Fast forward to now: health care workers (nurses) are trained to utilize universal precautions with each and every communicable disease - HIV, Hep C, even influenza. That is the standard that came out of the HIV panic. A good result. A good process and habit to get into. Droplet precautions are also used in TB patients, both active and inactive. How many of us nurses have gone into a room, used universal precautions and found out the next day that their patient from the previous day had HIV or Hep C or TB or C-Diff or VRE?
We, too, worry about taking this stuff home to our families. I have 6 children at home... do you not consider that every time I walk in the door I have to say "don't touch me, I have been with very sick people. You may give you mother a hug after having a shower from working 12 (14 or 16) hr shifts with very sick people". Not a breakdown in process, just trying to protect OUR own families NOT just the patients.
If you look at the nursing boards across America, nurses are considered expendable. We are consistently overloaded and understaffed and incase you haven't noted a trend in this article, PPE takes precious time. And what do you do when an isolation patient turns blue? Do you gown and glove prior to saving that patient's life? Or do you risk yet another person asking you with disdain "why couldn't you get here in time?"
There's a lot more than just CDC protocols and LEAN or SixSigma processes here to consider.
Share this news with friends!!!