Last September, a Liberian man named Thomas Eric Duncan went to the Emergency Department of Texas Health Presbyterian Hospital Dallas (THD) presenting with several non-specific symptoms and notified staff of his recent arrival from West Africa, where the world’s largest Ebola Virus Disease (EVD) outbreak was growing by leaps and bounds.


As we know now, Mr Duncan was discharged with a diagnosis of sinusitis. He was later brought to the same ED a couple of days later, admitted, and subsequently, two hospital nurses contracted EVD–Nina Pham and Amber Vinson.

In early October 2014, Thomas Eric Duncan died from EVD, the first such death on US soil.

Texas Health Resources, parent company of Texas Health Presbyterian Hospital Dallas sought an independent review of the care provided to the first patient diagnosed with Ebola Virus Disease (EVD) in the United States and two nurses who contracted the disease while treating him and the results of that review were release Friday.

So what went wrong?

The expert panel commissioned to look at the situation included Dr. Denis Cortese,  Emeritus President and CEO of the Mayo Clinic and the Foundation Professor and Director of the Healthcare Delivery and Policy Program at Arizona State University to chair the panel,  Dr. William C. Rupp, recently retired CEO of the Mayo Clinic campus in Jacksonville, Florida; Patricia Abbott, PhD, RN, FAAN, FACMI, Associate Professor & Director of Hillman Scholars Program, Department of Systems Leadership and Effectiveness, University of Michigan School of Nursing; Mark Chassin, MD, FACP, MPP, MPH, President and Chief Executive Officer, The Joint Commission;  G. Marshall Lyon III, MD, MMSc, Associate Professor of Medicine, Division of Infectious Diseases, Emory University School of Medicine and Wayne J. Riley, MD, MPH, MBA, MACP, Clinical Professor of Internal Medicine, Vanderbilt University School of Medicine; Adjunct Professor of Healthcare Management, Owen Graduate School of Management, Vanderbilt University; and President, American College of Physicians.

The panel found the following from the initial ED visit: Training for EVD preparedness had not been fully implemented in the THD ED and the awareness of risk factors for EVD across the entire clinical team was not well known at the time; Information concerning travel history from Africa gathered by the nurse was not verbally communicated to the physician because it was already recorded in the EHR; The sharing of the travel history data was not adequately designed into the workflow of the entire clinical team, therefore the information was not easily accessible to the physician. This required extra and non-intuitive steps to be taken by the physician to access information highly relevant to clinical decision-making; The physician assessment did not include gathering information about travel history, because he didn’t see it as a significant question in the scope of the patient’s symptoms and the patient’s response to questioning about where he was from yielded a different response than what was elicited by the intake nurse and the development and deployment of policies, procedures and practices to ensure interprofessional teamwork and communication were inconsistent, and the healthcare team apparently relied too heavily on communication through the electronic health record.


They then looked at the care and death of the patient and the infection in the two nurses and noted that it is clear that the CDC’s focus in early conversations with the hospital was on contact-tracing and notification. It does not appear that issues such as personal protective equipment, waste management, and other challenges that would emerge as critical were addressed by CDC at the onset of this event.

The death of Mr. Duncan and the infection of two nurses we see as coming from three distinct but overlapping issues:

1. THD and THR were not prepared to diagnosis and manage a patient who came to their facility without a preexisting diagnosis of Ebola. The ED lacked awareness of the risk and the required response to EVD. The improper diagnosis and release of Mr. Duncan on his first visit highlights a number of issues that were delineated earlier. How a department functions within a hospital or health system puts an entire health system and larger community at risk. It is not clear that the culture within the ED was focused on quality and safety as foundational for its role in a complex health system.

2. It was evident during this process that the CDC and others were learning alongside the actual providers. In retrospect, it appears that there was a lack of effective and efficient collaboration prior to the event between THR, Texas Health Presbyterian Dallas, the Centers for Disease Control and Prevention (CDC), HHS, and the Department of Transportation as well as city, county, and state public health resources. The roles and responsibilities of all parties were not clearly outlined in advance of the Ebola event, and this led to many of the consequences that ensued, particularly after Mr. Duncan was properly diagnosed.

3. When preparing for future disease outbreaks, hospital administrators, doctors, and nurses must understand that the CDC serves only in an advisory role and it is up to the institution to take care of individual patients and ensure quality, safety and high reliability of clinical operations. It is also critical for CDC to better communicate its role and to work collaboratively with health systems prior to, during, and after an event like Ebola.


What has been done since?

Texas Health Resources CEO, Barclay Berdan said Texas Health has implemented national best practices that embrace team strategies and tools to enhance performance and safety. The emergency department also has been reorganized into team-based pods of care, and an integrated physician-nurse chain of command for problem solving has been implemented.

In addition, Texas Health also has implemented a comprehensive deployment of the Systemic Inflammatory Response Syndrome (SIRS) score, which monitors patient symptoms and calculates risk of an infection being present, as well as sepsis order sets across its entities. This includes development of a “Code Sepsis” rapid response practice, including system wide training on awareness of SIRS score (sepsis rating) and inclusion of patients’ SIRS scores in pre-discharge reassessment.

Operationally, Texas Health has begun implementing a systemwide approach to emergency preparedness that incorporates best practices from High Reliability Organizations. The system is establishing clear definitions of command roles that flex with changing situations and expanding the scope of emergency preparedness to address clinical scenarios and public health emergencies.

Additionally, Texas Health is involving all levels of its system in a comprehensive drill twice a year with direct participation of system leaders, including a clinical disaster involving multiple entities.

Robert Herriman is a microbiologist and the Editor-in-Chief of Outbreak News Today and the Executive Editor of The Global Dispatch

Follow @bactiman63

Read the Shares Lessons Learned, Action Plans and Improvements and The Expert Panel Report