The CDC claims a breach of protocol was responsible for a nurse in Dallas being infected with the Ebola virus. She was treating the man who died of Ebola. Let’s hope the CDC is correct and following the existing protocol exactly will prevent infection. But it’s possible the nurse followed protocol, but for Ebola the protocol needs to be reexamined.
If it was a breach of existing protocol the hospital and CDC may still be responsible. Apparently, the use of a supervisor or buddy system was not in the protocol. Doctors Without Borders always require someone watches every move a health worker makes when treating a patient infected with Ebola. Ebola is unforgiving. Any mistakes can lead to infection. A well trained supervisor can catch mistakes and require immediate decontamination.
How Many Duncan Caregivers Are at Risk? ‘Breach of Protocol’
By Darrell Preston, Margaret Newkirk and Caroline Chen, Oct 13, 2014 8:14 AM ET
The U.S. health worker who contracted Ebola after being in contact with an infected patient in Dallas is leading officials to examine how widespread the danger is for those who cared for him.
The unidentified employee at Texas Health Presbyterian Hospital wasn’t among the 48 people who were being watched because they may have been in contact with the patient before he was placed in isolation, said Thomas Frieden, director of the Centers for Disease Control and Prevention. Under the safety procedures in place, the caregivers were monitoring their own health.
“At some point there was a breach in protocol,” Frieden said at a press conference in Atlanta yesterday. “It is possible that other individuals were exposed.”
It’s the first time someone is known to have contracted Ebola inside U.S. borders, and only the second known case of an infection outside Africa. The diagnosis adds pressure on the U.S. government to tighten controls aimed at stemming the spread of the virus that’s killed more than 4,000 people this year in three African nations.
The Ebola Scourge
The health worker had been in contact with the patient, Thomas Eric Duncan, on multiple occasions, Frieden said.
The medical team members who helped care for Duncan once he was isolated at the hospital were responsible for monitoring their own conditions because they were considered to be at low risk, Frieden said. The infected worker noticed she had a fever, notified the hospital and was admitted on Oct. 10, Texas Health Presbyterian said in a statement. Her Ebola was confirmed by the Atlanta-based CDC yesterday.
The CDC will investigate how the lapse occurred while increasing training and safety procedures, Frieden said. Duncan died Oct. 8. He arrived from Liberia, one of the African nations being ravaged by Ebola, on Sept. 20 and didn’t begin showing signs of the disease until Sept. 24.
The infected worker, who has asked to remain anonymous, was involved in Duncan’s second visit to the hospital, said Dan Varga, chief clinical officer at Texas Health Presbyterian. The worker was wearing full protective gear, Varga said.
Protective gear doesn’t guarantee that an infection won’t occur, said Ashish Jha, professor of health policy at Harvard’s Public School of Health in Boston, in a telephone interview.
“The hard part is during the disrobing, when you take the suit off,” he said. “You’re removing material, getting skin exposed.”
The removal of the worker’s gear is one area being examined, Frieden said. “It’s not an easy thing to do right.”
Two other areas where the breach may have occurred are the respiratory intubation of Duncan and his kidney dialysis, Frieden said.
“Even a single inadvertent slip can result in contamination,” he said.
Health officials are assessing people the caregiver had contact with since she developed symptoms, and there has only been one who may have been with her while she could be contagious, Frieden said. That person is now under monitoring.
“We are broadening our team in Dallas and working with extreme diligence to prevent further spread,” David Lakey, commissioner of the Texas Department of State Health Services, said in a statement. The CDC has sent extra workers to help.
Complete story at: Breach of Protocol
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