Via Controversies in Hospital Infection Prevention, a fine post by Mike: What I learned this week. Excerpt (but read the whole thing):
It's Saturday morning and I'm sitting at my dining room table trying to reflect on and process the events of the last week. Without a doubt, this week will go down in the annals of infection prevention as a pivotal time point. Hospitals across the country furiously raced to prepare for Ebola, propelled by the unfortunate news of transmission of the virus to two nurses at Texas Presbyterian Hospital in Dallas. I'll share with you the lessons of this incredibly interesting week:
1. Texas Presbyterian Hospital isn't the exception, it's the rule.
It's easy to be the Monday morning quarterback and criticize the emergency medicine providers for initially missing the diagnosis of Ebola, but in the process of diagnosis physicians are trained to use probability in reasoning. And Ebola simply wasn't on their radar screens.
It's also important to keep in mind that even today given everything we know, fever in a returning traveler from Liberia is most likely not caused by Ebola virus disease. Malaria remains a much more common diagnosis. For this reason, our Ebola plan reminds physicians to consider infectious diseases consultation in the setting of a person under investigation for Ebola, so as to avoid having a patient die of falciparum malaria while Ebola is being ruled out.
In addition, there may have been, and likely were, systems issues at play. There are many distractions in the hectic environment of an emergency department that may have had impact as the physician worked through Thomas Duncan's case. Nosocomial transmission to healthcare workers would also likely have happened at almost any hospital in the United States with the exception of the four hospitals that have a biocontainment unit. While American hospitals have made great strides in reducing healthcare associated infections over the last decade, the challenges posed by Ebola virus in terms of the prevention of transmission are unparalleled.
2. The efficacy and effectiveness of personal protective equipment (PPE) are different.
By efficacy we mean how well PPE works in the ideal setting to protect the healthcare worker. Effectiveness is how well it works in the real world. For most pathogens, this difference is likely quite small. Not so for Ebola. Removing PPE in the Ebola setting without contaminating yourself is a Herculean effort, and we are dealing with what Dick Wenzel calls "an unforgiving virus." Before Ebola, the implications of minor errors in doffing were trivial. Now they're life-threatening. An article in today's New York Times sums it up beautifully:
Debra Sharpe, a Birmingham, Ala., biosafety expert, has overseen safety at a nonprofit laboratory that researches emerging diseases and bioweapons, and has run a company that trained workers to handle biological agents... “It’s totally shocking...It would take me anywhere from four to six weeks to train an employee to work in a high containment lab in a safe manner. It’s ludicrous to expect doctors and nurses to figure that out with a day’s worth of training.
To her comments I would add that the challenging setting of an ICU with an Ebola patient having 10 liters of vomiting and diarrhea per day is nothing like the controlled environment of a specialized laboratory dealing with contained aliquots of the virus. How well PPE works in the lab is a measure of efficacy. How well it works in the ICU is a measure of effectiveness.