Lack of teamwork, poor communication, and overreliance on the Electronic Health Record (EHR) were just some of the issues faced by the Texas Health Presbyterian Hospital at the height of the Ebola crisis, where one patient died and two nurses were diagnosed of the same disease.
The new report is the final product of Texas Health Resource's (THR) commitment to provide a more comprehensive and independent investigation on the October 2014 events. Led by Dr. Denis Cortese, CEO and emeritus president of Mayo Clinic, the report was conducted with the permission of the Dallas hospital's board of trustees and with the full support of THR.
The report revolves around three themes. These are the missed diagnosis of Thomas Eric Duncan, the patient zero who had contracted the disease in Liberia, one of the hardest-hit Western nations during the crisis; care provided on the three patients, including the two nurses; and event management and knowledge transfer.
Based on the findings, the panel believes that the care the hospital provided to Duncan reflects "larger organizational issues." The first time Duncan arrived at the hospital to report his symptoms, the staff created an EHR for him but failed to communicate the same information with the others. There was also no automatic alert set up to inquire about his travel history. The hospital eventually let go of Duncan, but a few days after, he was back after his condition worsened.
The report also cited the challenges in accessing the EHR and the missed opportunities for a proper evaluation and diagnosis during the patient's first visit. His Systemic Inflammatory Response Score (SIRS), for example, was 3, which was supposed to indicate he needed further medical intervention.
The panel commended the care and the steps undertaken to isolate the first patient after he tested positive of the Ebola virus. However, they also pointed out that health care staff who attended to him had exposed skin. Duncan was already heavily vomiting, which meant he was highly infectious. Some of the fluids might have landed on the skin of the two nurses who was later diagnosed with Ebola.
The THR welcomed the results of the panel's report, saying it would help them provide better diagnosis especially in emergency rooms and coordination should something similar to the Ebola crisis arises.