Hospital were following lax Ebola guidelines, experts say

Doctors Without Borders has decades of experience in fighting Ebola in Africa.
Francois Lenoir (/REUTERS
Doctors Without Borders has decades of experience in fighting Ebola in Africa.

Many US hospitals have improperly trained their staffs to deal with Ebola patients because they were following federal guidelines that were too lax, infection control experts said on Wednesday.

Federal health officials effectively acknowledged the problems with their procedures for protecting health care workers by abruptly changing them. At 8 p.m. Tuesday evening, the Centers for Disease Control and Prevention issued stricter guidelines for US hospitals with Ebola patients.

They are now closer to the procedures of Doctors Without Borders, which has decades of experience in fighting Ebola in Africa. In issuing the new guidelines, the CDC acknowledged that its experts had learned by working alongside that medical charity, which goes by its French initials, MSF.


The agency’s new voluntary guidelines include full-body suits covering the head and neck; supervision of the risky process of taking off protective gear; and the use of hand disinfectant as each item is removed.

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Sean G. Kaufman, who oversaw infection control at Emory University Hospital while it treated Dr. Kent Brantly and Nancy Writebol, the first two US Ebola victims, called the earlier CDC guidelines “absolutely irresponsible and dead wrong.”

Speaking by phone from Liberia, where he was training workers for Samaritan’s Purse, the medical charity that Brantly and Writebol worked for, Kaufman said he had warned the agency as recently as a week ago that its guidelines were lax.

“They kind of blew me off,” he said. “I’m happy to see they’re changing them, but it’s late.”

Melissa Brower, a CDC spokeswoman, said the agency was “taking a hard look at our recommendations and may be making changes.”


Dr. Thomas R. Frieden, the director of the CDC, expressed regret about his agency’s initial response to the first Ebola case in Dallas.

“In retrospect, with 20/20 hindsight,” he said a few hours before his agency tightened its guidelines, “we could have sent a more robust hospital infection control team and been more hands-on with the hospital from Day 1.”

Some major hospitals, aware of the inadequacy of the older CDC guidelines, have followed more stringent standards in training their staff. But many — including Texas Presbyterian Hospital in Dallas, where two nurses were infected by a dying patient — have not.

The MSF guidelines are even stricter than the new CDC ones in that they require full coverage of the body, head and legs with fabrics that blood or vomit cannot soak through, along with rubber aprons, goggles or face shields, sealed wrists and rubber boots. Doctors and nurses wear two sets of gloves, outer ones with long wrists that strap or are taped to the gown; janitors wear three sets.

As they undress in choreographed steps, MSF workers wash their hands with chlorine solution eight times and are sprayed with a chlorine mist. Most important, all personnel disrobe only under the eyes of a supervisor whose job is to prevent even a single misstep.


Risky procedures like blood sampling are kept to a minimum.

“I’ve seen the CDC poster,” said an MSF representative who spoke on the condition of anonymity because she did not want to be named criticizing the agency, and who was referring to CDC guidelines before they were changed Tuesday. “It doesn’t say anywhere that it’s for Ebola. I was surprised that it was only one set of gloves, and the rest bare hands. It seems to be for general cases of infectious disease.”

National Nurses United, the country’s largest union and professional association of nurses, with 185,000 members, criticized the CDC Wednesday for taking so long. Worse, the union said, many hospitals ignored even the lax guidelines because they were voluntary.

For example, the union said, nurses at the Texas hospital complained that the protective gear the hospital issued left their necks exposed — and they were told to wrap their necks with medical tape.

“They were learning infection control on the fly,” said DeAnn McEwen, chief of infection control for the union. “That’s no substitute for planning.”

Nurses United called for federal and state laws making CDC guidelines mandatory.

While Frieden has been criticized for arguing that almost any US hospital can handle Ebola patients and critics have demanded that all Ebola patients go to special isolation units, that debate is somewhat misguided, experts said.

The isolation units — which have filtered air, double doors and negative pressure — were built to prevent the spread of airborne diseases like SARS and tuberculosis.

The greater Ebola danger is large amounts of blood, vomit or diarrhea splashing caregivers. That is prevented by training, proper protective gear, rigorous cleaning and close supervision, specialists said.

Ebola victims resemble cholera victims in some ways.

In Bangladesh, which trains doctors all over the world in cholera treatment, hospitals do not place cholera patients on padded mattresses with bedpans under them. They usually lie on rubber sheets stretched across bed frames with holes cut so diarrhea can run out into buckets. That way, those too weak to move can be kept clean as they are rehydrated orally or intravenously — which is also the staple treatment for Ebola.

MSF places buckets or chamber pots under patients. Its protocols require cleaning pools of fluid not by mopping, but by spraying them with chlorine and then throwing large absorbent cloths over them. Like doctors, janitors work in pairs, watching over each other.

All infected materials are immediately burned, sometimes in a field right behind the hospital. Reusable rubber items like aprons and boots are cleaned with detergent and bleach. One important MSF step — chlorine sprays — could be dangerous inside hospitals because it would make corridors slippery.

A step considered absolutely vital — which the new CDC guidelines now include — is having a sharp-eyed “site supervisor” constantly watching for errors.

“The buddy system works for getting dressed, but not for getting undressed,” said Dr. William Fisher II, a critical care specialist from the University of North Carolina who worked in an MSF center in Guinea this summer and who said he was now designing training for the CDC.

Doctors go into wards feeling fresh, he explained. But they emerge an hour later exhausted, sweating and sometimes shaking from a close call, like one he had when a patient grabbed his mask.

In the exit area, he said, “there was someone in charge whose sole focus was helping you get undressed safely.”

“You stood in front of them and did nothing until they said so,” he said. “They didn’t care if it was your first time or your 800th time. I was exhausted and emotionally drained. I looked forward to it.”

Initial MSF training takes two to five days, followed by three to six weeks of supervised work.

The nurse’s group, which is unfamiliar with MSF protocols, sent a letter to the White House on Wednesday demanding the adoption of the standards used by the University of Nebraska Medical Center with some enhancements.

That hospital is a designated isolation center, and its guidelines resemble those of MSF in some ways. A recent update to them called for head and neck hoods and the wiping of rubber clogs with bleach. The nurses union also demanded hazardous materials suits and powered air-purifying respirators.

Those can be cumbersome and claustrophobic, and the Nebraska guidelines treat them as recommended, not as standard.