Dallas nurse contracts Ebola. Was a protocol breach to blame?

Experts say blaming a protocol breach puts the onus on the nurse

A nurse who cared for the first U.S. Ebola patient tested positive for the deadly virus this weekend, marking the first known Ebola transmission on U.S. soil and heightening concerns about the health system's ability to contain its spread.

The nurse was on the team at Texas Health Presbyterian Hospital that treated Thomas Eric Duncan, a Liberian national who died last week after spending 10 days at the hospital battling Ebola.

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The woman wore protective gear while caring for the patient and was considered to be at low risk for infection. She cared for Duncan during his second admission to Texas Health Presbyterian. According to CDC Director Tom Frieden, the nurse had "extensive contacts with" Duncan on "multiple occasions."

Daniel Varga, chief clinical officer for Texas Health Resources, says the nurse had been monitoring her temperature twice daily. On Friday night, she was isolated within 90 minutes of reporting a low-grade fever, CDC says. Tested conducted on Saturday and Sunday found that she had contracted Ebola.

"She was on voluntary self-monitoring," says Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. "She found she got infected, and she immediately did what she was supposed to have done. So even in this troublesome situation, the system is working."

The case is the second case diagnosed in the United States and the second transmitted outside of West Africa. (A nurse's aide contracted the disease while caring for a patient at a Spanish hospital.)

With the latest case, health officials are expanding the search for people who may have been exposed to the virus in Dallas, Texas. So far, they say only one person appears to have had close contact with the nurse after she developed symptoms, and that individual has been isolated.

The nurse is in stable condition in an isolation ward.

Meanwhile, dozens of people who may have been in contact with Duncan while he was symptomatic continue to be monitored by health officials, according to Frieden.

Texas Health Presbyterian is diverting ambulances from its ED, although patients already at the hospital are continuing to receive care.

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How did a nurse wearing protective gear become infected?

Top health officials say that the infection was likely a result of a breach in protocol at the facility. There was "an inadvertent, innocent breach of the protocol of taking care of a patient within the personal protective equipment," says Fauci, adding, "That extremely rarely happens."

Fauci says CDC is working to identify the breach in question. Frieden says the agency is focusing on possible breaches made during dialysis and respiratory intubation. Unlike other Ebola patients who received care in the United States, Duncan underwent the two "high-risk" procedures in an effort to save his life.

However, some health care workers say that the case doesn't highlight a protocol breach so much as a lack of adequate training for hospital workers. Infection control experts say hospital workers must be coached through treating Ebola cases.

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"You don't scapegoat and blame when you have a disease outbreak," says Bonnie Castillo, a registered nurse and a disaster relief expert at National Nurses United, adding, "We have a system failure. That is what we have to correct."

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Pennsylvania State University's Gavin Macgregor-Skinner says the protocol breach talk puts the onus on the infected nurse. "I think that is just wrong," he says.

Speaking broadly about hospital workers, he says, "We haven't provided them with a national training program. We haven't provided them with the necessary experts that have actually worked in hospitals with Ebola" (AP/Modern Healthcare, 10/12 [subscription required]; McKay et al., Wall Street Journal, 10/13; Hughes/Reinhard, "Washington Wire," Wall Street Journal, 10/12; BBC News, 10/12; Phillip et al., Washington Post, 10/12; Rudra, "Good Morning America," ABC News, 10/12; Steenhuysen, Reuters, 10/13).


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