Ebola provides timely lesson for HeLa students

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Hospital of Ebola patient posts poor ER benchmarks

DALLAS (AP) — Diplomas from outstanding medical schools. Records free of discipline. A team trusted by a president.

For all the strengths of Texas Health Presbyterian Hospital Dallas, the first U.S.-diagnosed Ebola patient walked through its seemingly weakest link: the emergency room.

Presbyterian met or exceeded 75 percent of 138 specific measures of care, according to its most recent data. But its emergency department failed to meet all five national patient safety and quality benchmarks the hospital reported. Those measure how long it takes for patients to be seen, admitted, or otherwise cared for in the ER.

"When wait times get longer, it creates an environment where people are more likely to make mistakes," said Dr. Ashish Jha, a Harvard University professor and director of the Harvard Global Health Institute. "It's a recipe for things not going well."

The hospital itself says emergency wait times may indicate understaffing or overcrowding that "can result in treatment delays and more stress for patients."

Thomas Eric Duncan first entered Presbyterian's ER on Sept. 25, complaining of abdominal pain, severe headache, dizziness and nausea. He was discharged after a few hours, but returned two days later and eventually died of Ebola. Two of his nurses became infected.

For the year ending March 31, patients in Presbyterian's emergency department waited 44 minutes on average before their first contact with a health care professional, 50 percent longer than state and national waits. They spent more than five hours in the emergency department, on average, before being admitted, more than an hour longer than state and national averages. Presbyterian reported meeting one of six emergency department benchmarks in 2012-13.

Hospital spokesman Wendell Watson said, "Wait time is only one component of patient care and patient experience." Others insist longer wait times can reflect a workflow problem, with lags for X-rays, tests or admissions.

"To miss your benchmarks in emergency room waiting times is probably the greatest indication that your ER is not up to snuff," said Jamie Court, president of the nonprofit Consumer Watchdog.

In other areas where Presbyterian reported data and for which federal benchmarks exist, the hospital largely met or exceeded national averages.

Presbyterian — where former President George W. Bush underwent a heart procedure last year — exceeded seven national benchmarks for strokes, earned perfect scores on a number of surgical measures and met six of 10 criteria on heart attacks, according to its data. It had nearly no infections from IV insertions, about 75 percent fewer than national benchmarks.

Those infections had been a problem for Presbyterian in 2011, when increasing cases prompted a hospital task force. This summer, a Presbyterian infection prevention specialist published a study describing how the hospital dramatically decreased infections by strictly enforcing rules about how long to scrub the hubs of catheters before inserting them.

Health safety consultant Michael Millenson, a visiting scholar at Northwestern University, says it's laudable that Presbyterian addressed the problem, but added that federal standards are weak and it took years to do what should have taken weeks.

Texas Health Resources began posting detailed data online — from heart attack mortality rates to post-surgical infections — for each of its 17 hospitals this summer. U.S. hospitals are required to send such indicators to the U.S. Centers for Medicare & Medicaid Services, but do not generally post them on their websites.

"We've committed to show it all, both the good and the bad," said now-retired Texas Health CEO Douglas Hawthorne.

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When Duncan initially appeared in Presbyterian's ER, several potential warning signs apparently went unnoticed.

"He had symptoms that could be Ebola but could be any number of things when he showed up at his first visit," said Dr. Greg Moran, an emergency and infectious disease specialist at UCLA who reviewed Duncan's medical records. "The miss was basically a simple question that the physician didn't ask: Had he traveled? I don't see documentation that the physician asked that question."

Duncan had recently arrived from West Africa, where the largest outbreak of Ebola ever recorded is occurring. But the only reference to Africa came in a brief nurse's note.

Two medical specialists reviewed hospital records detailing Duncan's ER treatment for The Associated Press, which received the documents from his family. They noted that Duncan had somewhat abnormal blood and urine test results that could have raised questions, particularly about his kidney function. Along with a fever that spiked at 103, that might have indicated an infection, mild dehydration, the onset of diabetes, or nothing at all, they said.

But combined with Duncan's travel information, the results would have prompted them to consider the possibility of Ebola, they said.

Instead, Duncan was sent home after four hours with a prescription for antibiotics and a handout about sinus infections. Four hours later, a specialist reviewed his CT scan and ruled out a sinus infection. The records don't indicate that information was passed on.

"Diagnosing Ebola is very different from treating Ebola," said Watson, who added Presbyterian has changed the screening process in its ER to obtain a patient's travel history immediately and make it more easily visible in its electronic records system.

Jha, who also serves on a federal commission studying ER mistakes, said 5 percent of all emergency room visits are misdiagnosed — "a very high error rate."

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At Presbyterian, ER doctors don't actually work for the hospital.

Texas, like some other states, bars most hospitals from employing physicians directly, said Allison Winnike, a University of Houston health law professor.

"The idea is to keep the physicians independent from the hospital so they could act on what's best for the patient and not what's best for the hospital," said Dr. William Durkin, a former president of the American Academy of Emergency Medicine.

Presbyterian's ER doctors are private contractors who work with Texas Medicine Resources LLP, which has had the contract to provide them for 38 years, according to Dr. Ralph Baine, the president of Emergency Medicine Consultants, a related company that handles many administrative functions for the doctors. Those two companies operate out of the same Fort Worth office.

Supplies, support staff and other emergency department needs are provided directly by Presbyterian. The setup has no impact on care, Baine said, adding, "Our physicians are held to the same standard of care regardless of the legal structure under which they operate."

But Daniel Zingale, who pioneered California health reform plans, said having non-staff physicians creates a certain amount of risk. Even under ordinary circumstances, he said, it's a challenge to maintain coordination and flow of information in a system divided between health plans, hospitals and providers.

"In a public health emergency, there are clear advantages to a more integrated and seamless system," he said.

Consumer Watchdog says having physicians working in independent groups rather than directly for the hospital can lead to weaker care.

"If you have doctors who are not salaried and on staff, you're less likely to hit public health benchmarks as you are about the business goals of that contract," said Court, the group's president.

The AP has attempted to contact dozens of individuals directly involved in Duncan's care. None has been willing to speak. Messages left for the ER doctor who first treated and released Duncan, as well as his attorney, have gone unanswered.

Texas Medical Board records show that none of Duncan's 20 doctors have ever been disciplined, investigated by the board for malpractice, had restrictions placed on their licenses or been linked to any criminal history. Dallas County court records show relatively few malpractice cases filed against them.

Some earned medical degrees from schools including Harvard and New York University. On average, they have about 14 years of experience. Among 32 nurses involved in Duncan's care whose records could be located, none had a disciplinary record. They averaged about six years of experience in Texas.

Presbyterian has conceded its Ebola training was not fully deployed, and apologized for Duncan's initial misdiagnosis. A public-relations push has included posting videos of nurses praising the facility and a "PresbyProud" Twitter campaign. Watson says Presbyterian wants to move forward: "We are determined to be an agent for change across the U.S. health care system by helping our peers benefit from our experience."

But the mistakes are baffling, said Dr. William Schaffner, an infectious-disease specialist at Vanderbilt University Medical Center in Tennessee.

"I would have thought that literally every hospital would have said, 'Hmmm, one of those patients could walk into my emergency room and so we had better start reviewing our infection control program, make sure it includes these Ebola-specific issues, make sure we have the personal protective equipment and make sure that our staff is prepared,'" he said.

Gay community under attack in Liberia over Ebola outbreak

By Misha Hussain and Maria Caspani

Thu Oct 23, 2014 1:40pm BST

DAKAR/NEW YORK (Thomson Reuters Foundation) - Leroy Ponpon doesn't know whether to lock himself in his flat in Monrovia because of the deadly Ebola virus, or because he is gay. Christian churches' recent linking of the two have made life hell for him and hundreds of other gays.

Ponpon, an LGBT campaigner in the Liberian capital, says gays have been harassed, physically attacked and a few have had their cars smashed by people blaming them for the hemorrhagic fever, after religious leaders in Liberia said Ebola was a punishment from God for homosexuality.

"Since church ministers declared Ebola was a plague sent by God to punish sodomy in Liberia, the violence toward gays has escalated. They're even asking for the death penalty. We're living in fear," Ponpon told the Thomson Reuters Foundation by telephone from Monrovia.

Ebola has infected almost 10,000 people in West Africa since March, killing around half its victims. Liberia is the worst hit country where poverty, corruption and civil war have left a weak health system unable to cope with the exponential spread of the disease.

Some religious leaders have their own interpretation of the causes of Ebola.

Earlier this year, the Liberian Council of Churches said in a statement that God was angry with Liberians "over corruption and immoral acts" such as homosexuality, and that Ebola was a punishment.

In May, Archbishop Lewis Zeigler of the Catholic Church of Liberia said that "one of the major transgressions against God for which He may be punishing Liberia is the act of homosexuality," local media reported.

Francois Patuel, Amnesty International's representative in West Africa, said there had been reports of threats and violence against the LGBTI community in Monrovia since the incendiary remarks made by the local Christian leaders.

"Amnesty has received pictures of cars that reportedly belong to gays with their windows smashed as well as reports that gays have been forced from their homes and had to go into hiding," Patuel told the Thomson Reuters Foundation.

Neither the Catholic Church nor the Liberian Council of Churches could be reached in Monrovia. Representatives of the U.S. Conference of Catholic Bishops and the Episcopal Church did not immediately respond to a request for comment.

COVER OF DARKNESS

Ponpon prefers to move at night. He is scared to be identified in daylight after the local press splashed his picture and phone number across the front pages. But the Ebola curfew, running from 11 p.m. to 6 a.m., has complicated things.

"In the day, we move around wearing sunglasses and disguises. The problem with moving at night is that it is not safe in Monrovia in the dark, and also, if you violate the Ebola curfew, it is punishable by imprisonment," he said.

The curfew has affected the LGBT community in another way. When activists contact the police for protection, they reply that because of the Ebola emergency and the curfew put in place to combat the disease, they cannot help, Ponpon said.

Violence against the LGBT community was already common in West Africa before the Ebola outbreak, and same-sex relationships are still largely taboo in many African countries. A recent Gallup poll showed Africa as the worst continent for gay people.

National laws in West Africa are in line with public sentiment. In Liberia, 'voluntary sodomy' is a first-degree misdemeanor with a penalty of up to one year in jail, according to the International Lesbian Gay Bisexual Trans and Intersex Association (ILGA).

Patuel said Amnesty had received no reports of similar incidents in other Ebola-stricken countries in the region, and urged African states to stand up for minorities.

"In August this year the African Union passed a resolution for the protection of LGBTi rights. The authorities must adopt this into their national law and take action against homophobic statements to protect its citizens," Patuel said.

In Liberia, Ponpon's demands are simple: "Right now, all we want is protection. We want the government to come forward and say that this is a minority group and they deserve the same rights as anyone else and then people will stop attacking us."

(Reporting By Misha Hussain in Dakar and Maria Caspani in New York, editing by Tim Pearce)

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EU leaders seek more Ebola funding at summit

BRUSSELS (AP) — The European Union has contributed another 24.4 million euros ($31 million) to the fight against Ebola, as the bloc's leaders try to close in on a 1 billion-euro ($1.26 billion) fund to fight the deadly virus.

British Prime Minister David Cameron set that high target last week. Going into Thursday's start of a two-day EU leaders' summit, the bloc's total anti-Ebola commitments stood over halfway to that goal.

EU Commission President Jose Manuel Barroso on Thursday added 24.4 million euros more for medical research on an Ebola vaccine.

Britain says it has committed 125 million pounds ($200 million) toward fighting Ebola, more than any other of the bloc's 28 nations.

• Ebola
• European Union

How warnings from Ebola case spawned Richardson treatment unit

When the first Ebola patient showed up at Texas Health Presbyterian Hospital Dallas, a warning sounded that other hospitals needed to prepare space for a possible influx of new cases.

Methodist Health System quickly identified a place that might work — a small intensive-care unit in its Methodist Campus for Continuing Care in Richardson. The unit had been empty since April but needed only minor alterations to give medical staffers room to change in and out of the protective gear required for treating Ebola patients.

“Initially, we thought it would be just for us,” said Dr. Sam Bagchi, Methodist’s senior vice president and chief quality officer.

Then came telephone calls from the Centers for Disease Control and Prevention, Dallas County and the Texas health department. Officials wanted to see what Methodist was planning and find out how quickly an Ebola treatment center could be set up.

The idea was to meet the needs of all local hospitals in one location.

The nation’s first patient diagnosed with Ebola, Thomas Eric Duncan, had died Oct. 8 at Presbyterian. Two nurses who became infected while caring for him were airlifted to specialty treatment sites in other states.

And the clock was ticking for more than 125 people locally who had been isolated because of possible exposure to the deadly disease. If any of them started showing symptoms, there had to be a treatment center ready to provide immediate care.

“All of the hospitals were working on plans to take care of an extended stay by an Ebola patient,” Bagchi said. “Why not combine those efforts? It’s meant to take the pressure off the community.”

It took only a few days for Methodist to revamp its plan into a 10-bed Ebola treatment center. Parkland Memorial Hospital agreed to supply protective gear along with a team of nurses, lab technicians and other support staff. UT Southwestern Medical Center at Dallas would provide doctors.

Dr. David Lakey, the state health commissioner, toured the Richardson facility with CDC officials, said Stephanie Goodman, a spokeswoman for the Texas Health and Human Services Commission.

On Wednesday, the first two beds were ready for Ebola patients, allowing Methodist to officially activate the unit.

The facility has two negative-pressure rooms — rooms equipped to prevent the escape of contaminated air.

‘Nice collaboration’

If anyone is confirmed to have Ebola, it would take 12 hours to activate the facility and get it fully staffed. In all likelihood, an Ebola patient would have gone first to a hospital emergency room and been isolated and tested before being transferred to the Richardson facility, Bagchi said.

“This unit is for patients who test positive for Ebola,” he said. “Any patient would go through diagnostic screening before being transferred here.”

The state’s second Ebola treatment facility, at the University of Texas Medical Branch in Galveston, is expected to be ready for patients as early as Thursday. The hospital is home to the Galveston National Laboratory, a federal biocontainment facility that has extensively researched Ebola and other infectious diseases.

The Methodist Ebola center is on the third floor of the 51-year-old Methodist Richardson Medical Center at 401 W. Campbell Road. The hospital was replaced last spring by a new facility at Renner Road and the Bush Turnpike.

“We couldn’t have done it without the CDC’s involvement,” Bagchi said of the quick turnaround at the Methodist center. “It’s a really nice collaboration, where everybody is bringing something.”

Some experts outside Dallas questioned having UT Southwestern and Parkland involved together with the new Ebola treatment facility. The two came under federal scrutiny three years ago over lapses in infection prevention and other care.

“This track record of problems is, of course, concerning,’’ said Dr. Ashish Jha, an associate professor at Harvard University’s School of Public Health. “Have they really put these problems behind them, and do they understand what caused them?”

Parkland and UTSW declined Wednesday to answer questions about their past collaborations. In a joint statement, they spoke of their “70-year history of working as partners and a productive and constructive relationship.”

Meeting of neighbors

Wednesday evening, Richardson Mayor Laura Maczka addressed about 100 people at a regular meeting of the Canyon Creek Homeowners Association, where residents of the neighborhood just north of the hospital were agreeable to news of its designation as a treatment site.

“As a community, you hope and pray something like this never happens in your community,” Maczka said. “But if it does, you also hope and pray that you are prepared for it, and so I think we as a community should be really proud.”

Diane Jacobs, who lives near the Richardson facility, said she supported using it to care for Ebola patients.

“We’re excited that the city of Richardson can participate in this fight, because that’s what it is,” said Jacobs, who directs a church preschool.

Susan Yost, who also lives nearby, said she was “very proud” that the Richardson facility was chosen. “It makes our city more proactive and prepared. It makes me feel safer,” she said.

Rex Kathcart, another resident, said he had no concerns about the center being used as an Ebola treatment site because officials have been transparent about plans for the facility.

“I think the hospitals have learned from their mistakes,” Kathcart said. “If this was two weeks ago you may have seen some concern, but they have explained it really well.”

Texas officials said the Richardson and Galveston facilities would be available to handle outbreaks of other diseases beyond Ebola.

“Ebola is the current threat, but there are other infectious diseases that pose a risk,” said Goodman, the state Health and Human Services Commission spokeswoman. “These new centers will make sure Texas is well-prepared for whatever comes our way.”

The treatment centers aren’t costing the state any money, she said. “These hospitals already get state and federal funding, and they’re able to support the centers within their current budgets,” she said.

Treatment costs also could be billed to private insurers or Medicaid, she added.

Staff writers Leslie Barker, Julie Fancher, Wendy Hundley and Miles Moffeit contributed to this report.

sjacobson@dallasnews.com;

rloftis@dallasnews.com

Ebola ‘czar’ to skip House hearing, aide says

America's newly appointed Ebola ‘czar’ is not yet in the House — at least not the ones on Pennsylvania Avenue or Capitol Hill.

Ron Klain, appointed last Friday by President Obama to direct the nation's response to the Ebola crisis, sent his regrets Monday to the House Oversight and Government Reform Committee, which had invited him to testify this Friday, a committee aide told Fox News.

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Klain was invited to join Defense and Health and Human Services department officials also slated to testify at the hearing.

“The White House has informed us that he has not yet officially started and will not be able to attend Friday,” the committee aide told Fox News.

Klain, a former chief of staff to vice presidents Al Gore and Joe Biden, has yet to formally start his new assignment — though he was spotted on the White House campus on Saturday. Fox News was told, however, that he did not meet with the president – and was not part of an all-hands-on-deck Ebola meeting that same day.

He is expected to start sometime this week.

Despite bipartisan calls for an Ebola czar, however, the selection of Klain angered some Republicans, who complained he has no health care experience. Klain, after leaving Biden's staff, went into the private sector, serving as president of Case Holdings and general counsel for venture-capital firm Revolution LLC. 

“That the president chose a political operative rather than a health care expert to head up his administration’s response to an outbreak of a deadly disease says a lot – and nothing positive – about the White House’s line of thinking,” Rep. Tom Price, R-Ga., said in a statement on Friday.

Health officials, though, have defended Klain as someone who brings needed managerial experience to a complex task.

“He's a highly experienced, highly talented manager. He's been chief of staff for Vice President Gore, for Vice President Biden, has had experience in the Congress,” Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, said Monday at a town hall-style meeting. “He will be coordinating the interactions among a multi-agency endeavor that are involved, each of which have their own responsibility.”

Fauci also stressed that Klain is not a “czar.”

“It's an Ebola response coordinator is the title for Ron Klain,” Fauci said.

Fox News’ Mike Emanuel contributed to this report.

Ebola is a fear factor for stock market

NEW YORK (CNNMoney)

Fear has returned to Wall Street this fall and at least some of the heightened nervousness can be pinned on Ebola.

That's not to say the deadly virus is the number one thing keeping investors awake at night. There's concern about the global economy, deflation in Europe, China's slowing growth and Federal Reserve policy.

But Ebola has contributed to the negative psychology that has sent stock prices reeling this month.

Need proof? The chart below shows how the VIX volatility index has spiked since the summer. At the same time, the number of searches on Bloomberg terminals (a key resource for many investors) for news related to the Ebola outbreak has also skyrocketed. Of course, correlation doesn't imply causality, but it's worth noting.

Ebola is "not by itself directly responsible for everything, but it's obviously making things work," said Dan Greenhaus, chief global strategist at BTIG.

The VIX volatility index has clearly been on the rise since July 1. So have searches on Bloomberg terminals for news surrounding the Ebola crisis.

Greenhaus, who published a similar chart in a note to clients Sunday night, said he's noticed a change in how his investor clients have reacted to the Ebola issue.

"I saw the progression from curiosity and sideshow to something a little more paramount," he said. "In the context of everything else going on from European weakness to Fed tapering, if you layer on top of that whatever minor chance of a pandemic, you obviously have the recipe for additional volatility."

Turbulence hits stocks: That volatility was on full display last week. The Dow plummeted as much as 460 points on October 15 amid a plethora of concerns, including Ebola, before rebounding sharply.

Two days later the Dow surged 263 points -- its second best day of the entire year -- as Wall Street cheered strong corporate report cards.

A sense of calm returned to Wall Street on Monday, with most major U.S. markets climbing cautiously higher. The VIX dropped 11%, putting it on track for a third consecutive down day. There was positive news on the Ebola front as 43 people who were in contact with Ebola patient Thomas Eric Duncan were officially cleared.

Related: Is the nightmare on Wall Street over?

The Ebola concerns are not universal among investors.

Greenhaus said he's noticed that clients who believe there's a reason to be worried about Ebola are very concerned. But he said those that aren't concerned believe it's a "sideshow, a convenient excuse and stupid it would get brought up at all."

Volatile travel stocks: There's far less debate over what kind of impact Ebola is having on certain corners of the travel and pharmaceutical sectors of the stock market.

Just look at the bumpy ride airline investors are experiencing. Shares of Delta Air Lines (DAL) and American Airlines (AAL) have retreated more than 15% from their 52-week highs amid fears a wider Ebola crisis will scare people away from flying.

Cruise operators like Carnival (CCL) and Royal Caribbean (RCL) have also been hit, with their shares tumbling 12% a piece over the past month.

On the other hand, investors are betting on which companies will be able to capitalize on Ebola. Shares of Tekmira Pharmaceuticals (TKMR) and other drug makers working on Ebola treatments have shot up in recent months.

Lakeland Industries (LAKE), which makes Hazmat suits, has skyrocketed 100% since mid-September.

First Published: October 20, 2014: 2:49 PM ET