When news broke that a Texas healthcare worker had become infected with Ebola, Centers for Disease Control (CDC) Director Dr. Thomas Frieden blamed the transmission on a “breach in protocol.” The unidentified breach may have been a failure by the nurse to wear or to properly remove personal protective equipment. Or, perhaps ineffective environmental infection control resulted in inadvertent exposure to infectious materials. But even if a protocol breach is to blame, Dr. Frieden’s explanation does not capture the systemic and organizational factors that might contribute to such an accident.
The challenge with protocols
Research shows that while plans and protocols can provide effective solutions to crisis situations, they often fall short because they contain unrealistic assumptions about individual and organizational performance. In order to be effective, such contingency plans must be well practiced in realistic operational settings. Otherwise, even seemingly well-crafted protocols risk becoming fantasy documents, procedures that are almost impossible to implement, rather than sources of practical guidance for a response.
When healthcare workers implement the CDC’s personal protection protocols, they are likely to make mistakes. This statement is not intended as a slight against the well-trained healthcare professionals that staff typical hospitals. Doctors and nurses skillfully perform complicated procedures on a daily basis. But, they may not be well trained on Ebola infection prevention protocols – and even if they are, their training has likely not been routinely practiced. An effective infection containment strategy requires that the CDC recognize that though every healthcare professional may be capable of implementing the proper protocols in an idealized environment, real-world performance may be far from ideal.
Even well-resourced and well-intentioned institutions make mistakes and ignore protocols. One need look no further than the CDC itself, which, in June, inadvertently transferred potentially virulent Anthrax samples outside of their containment laboratory. The CDC found that it was a lack of proper supervision and incomplete standard operating procedures that lead to the transfer of the dangerous samples.
Furthermore, there are substantial differences between the institutional capabilities of a hospital that is specifically selected to treat an Ebola patient and one that intakes an Ebola patient through a local emergency department (as was the case in the Texas Health Presbyterian Hospital in Dallas). When an Ebola patient is transported to a specifically-chosen medical facility for treatment, the doctors and nurses on the treatment team are well-trained specialists who can prepare in advance for a known event: the Ebola patient’s arrival. In contrast, in a local emergency department, the risk that any given walk-in patient carries Ebola is extremely small, so protective measures will not be undertaken until a diagnosis is made or the patient is otherwise suspected as at risk of Ebola.
Once a patient is identified as an Ebola risk, a typical hospital must rapidly deploy idiosyncratic protective measures for healthcare professionals, in a stressful environment, and possibly with minimal training. Stumbling blocks to a successful implementation can be mundane: Where are face shields and wrap-around goggles stored? Are the gowns on the ward fluid resistant? What are the hospital’s procedures for cleaning and disinfecting equipment, and when was the last time they were compared with the manufacturer’s reprocessing instructions? Are there masks available for every healthcare worker? It is such details that can undermine even a well-considered protocol.
Revising protocols to reduce risk
America’s health system is comprised of generalist hospitals, not specialized institutions like the National Institutes of Health’s Clinical Center or Emory University, which has successfully treated Ebola patients without collateral infection. With this in mind, the CDC and hospitals around the country need to recognize that protocols are implemented in organizations made up of fallible human operators, within existing hierarchies and resource constraints. When a patient arrives with Ebola, even if the containment protocols have been reviewed and practiced ahead of time, there may be inconsistencies in their implementation.
The CDC should revise the Infection Prevention and Control protocols to more broadly incorporate human and organizational fallibility. People have bad days, and protocols must take that into account. In the same way that two-person aircrews increase safety through checks and balances, members of a two-person healthcare team should check each others’ protective equipment and help to ensure that it donned and removed correctly (indeed, an updated CDC protocol recommends that hospitals encourage personnel to employ the buddy system and work with a trained observer.) Similarly, when a patient is identified as at risk for Ebola, procedures should not assume that that information will be shared seamlessly among medical personnel in a busy emergency department: the physician who saw Thomas Duncan during his initial visit missed the information in his chart that he was a potential concern for Ebola and discharged him. To reduce the likelihood of such errors, protocols should not merely describe procedural elements; they should incorporate cross checks that staff train and practice along with the procedures themselves.
Within hospitals and health systems, administrators should empower a high-level point of contact to overcome the novel challenges that will emerge from treating Ebola. He or she must be able to cross organizational boundaries, where errors and inefficiencies often originate, to clear the mundane roadblocks that can prevent the efficient procurement and distribution of protective equipment or slow down the audit and revision of outdated disinfection protocols. Finally, the point of contact should facilitate frank discussions about hierarchy and open communication, since cross checks lose effectiveness in authoritarian, hierarchical environments.
If a hospital is treating an Ebola patient, the point of contact should work to increase communication with line healthcare workers, from physicians to technicians and laboratory personnel, to understand what aspects of protocols are being consistently followed successfully, and which are falling short. Additionally, tracking “near-misses”—events that likely did not result in exposure, but had the potential to do so—can help provide feedback and improve infection control protocols. Hospitals that don’t already have such a system should implement a mechanism for healthcare workers to report (potentially anonymously), track, and discuss near misses, and the CDC should consider rolling out a national system specific to Ebola.
On a national level, public health officials should take care not to overestimate the capacity of the health system as they formulate response plans. Anyone who has worked in emergency services or even waited in a busy hospital knows that the healthcare system often operates at or near capacity. Hospital plans to address public health emergencies do exist, but they may contain untested assumptions that are difficult to evaluate in the absence of an emergency. For example, multiple hospitals’ plans may make competing claims for the same resources: healthcare professionals assumed to be available for staffing, CDC infection control experts who will deploy as advisors, or access to a cache of supplies, like N95 masks. In a public health emergency, as healthcare professionals may themselves become sick and supply chains are stretched from increasing demand, hospitals will have less capacity to handle the increasing public need, than what might be indicated by optimistic plans.
There is a loud chorus of public health and medical professionals who have declared that an Ebola outbreak in the U.S. is unlikely, and that the Ebola epidemic is stoppable. They are correct. But by being more sensitive to how organizational challenges complicate clinical issues, hospitals and the CDC can further increasing the effectiveness of protocols to treat and contain the disease. This will reduce the risk of Ebola transmission to healthcare professionals and to the public, and will help contain any cases that do occur on U.S. soil. Beyond treating Ebola, such sensitivity to organizational factors, which is slowly increasing in medicine, can improve patient safety, reduce the risk of errors, and make healthcare more efficient. It’s time to accelerate this transformation.
As published in Forbes.