Quarantining Kaci Hickox


When I went to nursing school, it was called isolation.  When HIV became better known, ‘universal’ precautions were implemented.  Every patient was treated as though they were HIV positive and they still are.  Now, there’s that pesky little Ebola bug and it is causing nothing if not widespread fear and panic.  It’s not blood borne and at this juncture, isolation precautions are being threatened. 

Unlike HIV, Hepatitis and other blood borne diseases, nobody is able to state with complete certainty that there is no risk of exposure from casual contact with an Ebola infected patient.  The odds are clearly in favor of no infection but someone wins the lottery against staggering odds every week or so.  A very low risk is not the same as no risk.

We are Americans and we want absolutes; unwavering positions, assurances and guarantees.  We want answers before we ask the questions and we do not sit well with not knowing.

Lacking absolutes, we conjure up every possibility in the universe.  Fear sells.  Anxiety is contagious.  If you want to sell a newspaper, write about something frightening. 

On the other hand, if you are a politician seeking reelection, preventing widespread panic and fear is the way to go.  The end result is that Americans get mixed messages and trust is eroded.

Where we stand now is between the press and the politicians with two very different agendas and neither of them is completely trustworthy.  It is for this reason that it’s reasonable to ask those people who have been in contact with Ebola patients to lay low for a couple of weeks until the period of incubation has expired.  The risk may be very low (as per the politicians) but the consequences are dire (according to the press).  It is in that measurement between risk and consequence that decisions are being made. 

Kaci Hickox, a nurse, is bound and determined to convince us all that mandatory quarantine is barbaric and illegal.  She knows that if she goes out in public, the fears of the community will escalate but strangely that is exactly what she wants to do.  She is basing her position on science but science has not revealed all there is to know about Ebola as yet.  She is forgetting that science is only half of the ingredients of a good nurse – the other half being compassion.  Where is her compassion for those individuals, perhaps thousands, who will lose sleep if she breaks quarantine?  Where is her compassion for her neighbors who will voluntarily isolate themselves out of fear? 

I gather Kaci Hickox, who took care of Ebola patients for 4 weeks in Sierra Leone, is so utterly confident in her own isolation techniques that she believes it to be impossible that she is sick with Ebola.  I have seen that kind of confidence before and it never ends well.    

In comparison, Nina Pham and Amber Vinson took care of an Ebola patient in a US Intensive Care Unit – a far cry from the facilities available in West Africa.  Maybe Kaci Hickox is a much better nurse than the Dallas crew or maybe she is just selfish. 

Her lawyers are falling back on a supreme court opinion that says that quarantine cannot be enforced based on fear alone.   One look at the number of cases in West Africa and the trend would scare the Supreme Justices, too.  Just for fun, check out this graphic from the Economist.

I wish I had all the answers.  This much I know….  If I had been in Sierra Leone taking care of Ebola patients and then flew home to the US, I would be tired.  Jet lag is a killer all by itself.  If someone offered to bring me food and told me to hang out at my house for a couple of weeks, I could live with that.  I could appreciate that even though the risk of spreading the virus is very low, the risk of frightening my neighbors is very high and I do have compassion for most of my neighbors. 

Maybe Kaci Hickox is fearless and brave but a new mother who ran into Ms. Hickox at the mall with her infant child might very well live in frank, abject fear for weeks when she is already tired and cranky.  A corner grocery store where people shop might suffer enormously if Kaci Hickox showed up there. 

None of this matters to Kaci Hickox.  I am not used to nurses being selfish. She is like a three year old who wants to go out and play and doesn’t quite get that none of the other children want to play with her.  I understand that the fear is out of proportion to the risk but fear is as ruthless as Kaci Hickox appears to be. 

A greater concern is the fact that she is forcing the hand of authorities to use a higher level of vigilance than would be necessary if she took a break from the ‘all about me’ attitude.  She is taking the attention away from where it needs to be which is on the virus and it’s prevention and cure and bringing it to herself and her own desires to wander around aimlessly regardless of how uncomfortable her presence makes others feel. 

If any of you are brave enough to go to Sierra Leone, have no fear.  You will have our undying support.  Blog readers everywhere will make you wish you were isolated even longer so you could bask in our undying admiration for you.  But, please do not go if you are not prepared to lay low and err on the side of safety when you return if you err at all.  We don’t want to hear about your ‘rights’ when the consequences are so great even though the risk is small. 

When science tell us there is zero chance of spreading the disease, we will come and hug you but until the guarantee is in place and supported by evidence, we’ll worship from afar. 

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Nina Pham


 

The CDC, among others, have suggested that perhaps more training is needed to ensure that direct health care workers are properly using protective equipment.   According to that line of thought, poor Nina Pham simply did not know what she was doing when she picked up a touch of Ebola from her patient.  If only she had more education on how to put on gloves and a gown, this whole disaster could have been avoided.

I think not.

I posted my dismay regarding re-educating nurses on FaceBook and was amazed at how smart my friends are.

One non-nurse, Michelle said that education was a way to protect the facility.  In other words, when a policy is violated, the hospital is able to assure any surveyor or lawyer that they did, indeed, provide the education and training and have therefore met their responsibility.  Sadly, a successful healthcare facility (and by successful, I mean isn’t closed down) must cover all bases to minimize damages.  I would probably waste time and resources re-teaching PPE, too if I had to make the decisions.

She also pointed out that maybe protocols are not strictly enforced when the risks are lower which could lead to bad habits.  I agree.  Ever notice how MRSA is already a problem when we start monitoring hand hygiene?  (I love that.  Hand hygiene – soon there will be an aisle in the supermarket for hand hygiene products instead of soap, antibacterial gel and hand lotion.)

Lisa Selman Holman pointed out how very miserable PPE is to wear.  She is right.  It is hot and sticky, nothing fits right and it is ugly in the most unforgiving way.  I have yet to figure out how looking like Big Bird assists in the infection control process. Healthcare workers, especially those with a fashion sense, can’t wait to take it off.

If ever there was a time to spend money, this would be it.  Athletic clothing manufacturers have done amazing things with sports gear.  It seems like a clothing manufacturer who exists because they make comfortable, functional clothes that can wick away perspiration, kill enough germs to smell good and keep a body warm in water might be able to help design something comfortable, disease proof, easily taken on and off  with the assistance of an infection control specialist.

Sara Kawaguchi came up with the idea of having two people involved – one present simply to observe.  I love this idea and it is cheap to do when considering the stakes.  Having never met Miss Pham, I can only assume that she didn’t tear a glove, look at it and say, ‘Oh darn,’ and carry on with restarting an infiltrated IV line.   If she breached protocol, it was likely unnoticed by her.

My cousin, Steve, is a physician and his response was simple.

1) we are human
2) we make mistakes
3 there is no room for a mistake here, in flight or in surgery

There’s a lot of truth in that but we can minimize mistakes.  Even the world famous Quality Assurance plan designed by Toyota, Six Sigma refers to only six errors in a million.  When it comes to Ebola, nobody wants to be one of the six.

The Checklist Manifesto by Atul Gawande is written by a surgeon who almost killed a patient because he forgot to do something very simple and standard prior to surgery – type and match blood.  After this near catastrophe that left his confidence shaken, he set about researching how to prevent errors.  It turned out that aviation history was marred by the crash of the first B17 in which several people died.  It almost took Boeing aircraft out of the game completely.  The solution included a checklist which enabled the (highly skilled and trained pilots) to fly 12 planes a total of 1.8M miles without incident.  It is now used universally.

Checklists are not designed to educate anyone.  If you have ever turned in visit notes only to find out that you forgot to write a narrative because you were interrupted, you are prone to human error.  If you have ever been called about a bill you know you paid only to find the stamped envelope in your purse, you could have used a checklist.  They are designed to let you pick up where you left off in the event something slips your mind, you are preoccupied or there is chaos all around you.  They ground and center the user.

There are undoubtedly numerous approaches to improving the safety of healthcare workers but re-educating the staff in a critical care unit on how to put on and take off PPE is an intervention for the hospital – not the nurses.  Don’t tell me that the staff in an intensive care unit requires more schoolin’ to put on gowns, masks and gloves.  Make them more comfortable so they aren’t urgently ripped off like they were on fire the minute you clear the room.  Have someone else watch.  Use a check list.  Doing more of what was done in the past because it didn’t work doesn’t quite make sense to me.

What the healthcare staff needs the most is a cure for Ebola.  When it comes to caring for a patient with Ebola, especially at the end of life, perhaps the most important changes will come about from the staff who were actually there doing the job.  If the blame game stops and the focus is directed to increased protection of healthcare workers, why not consult that handful of clinicians who are the only ones in the United States to have cared for Ebola patients in US hospitals?

I know that you join The Coders in wishing Godspeed to Nina Pham’s recovery.  She was able to be there for a patient isolated from his family and friends when he needed them the most.  People like Nina Pham do not put their own lives on the line for a paycheck.  She has a calling and I pray she will be back at work sooner than later.

Also,  let’s not forget that Nina Pham is not alone.  A few dozen other healthcare workers who took the same risk as Nina Pham and so far, have been free of symptoms.  These include the staff in Dallas as well as Nebraska and GA where two other Ebola patients have been treated.  They are no less heroic because they have not contracted Ebola; they just haven’t made the news and I hope they don’t any time soon.

Ebola? Here in the States?


 

It looks like we have company in the form of another virus.  Ebola has caused quite a stir in the US and the media is torn between reporting it as a benign little incident so insignificant as to not warrant our attention and predicting Armageddon.  With all new viral pathogens, it is difficult to predict.  A virus will do what it can to survive and most times that means reducing the severity of the illness so as not to kill its host and prolonging the incubation period.  Who knows what Ebola will do.

If 40,000 fatalities from Ebola were predicted this year, there would be mass panic.  If there was a preventative measure, who wouldn’t do what they could to get it  no matter what the cost? 

We are looking at close to 40,000 deaths from flu and pneumonia this year.  There are legitimate questions about these statistics such as why are flu and pneumonia lumped together as the 8th leading cause of death?  They are not the same disease.  To dispel the statistical arguments, lets pretend that only 20,000 deaths will result from the flu this year.  Tragically, most cases of the flu are preventable at no cost to most people.

Setting death aside for a minute (or hopefully many years), consider the experience of having the flu.  The first day or so, patients are afraid they are going to die.  As it reaches its peak, they are afraid they will not die.

We don’t want our patients to feel like that.   Many home health patients will end up in the hospital if they get the flu.  Hospice patients may be terminal but most have plans to die from something less miserable.  It is okay to get between the flu and your hospice patient. 

So, while we are panicking about Ebola, let’s keep in mind that there are thousands of lives we can save with a simple flu shot.  The CDC has a ton of free resources that you can use in your agency, patient homes, and community to promote vaccination.  Most have room for your company logo and the CDC is fine with you adding it.  Think about it.  When was the last time that the government provided you with professionally designed materials to be used in promoting your agency or hospice? 

When we figure out what we can do about Ebola, we’ll post it here.  Until then, get out there and stick as many old people with needles as you can.  Here are some codes you can include on your care plan if you know upon admission that you will be giving a flu vaccine.

  • V03.82 Vaccine for Streptococcus Pneumonia (PPV)
  • V04.81 Vaccine for Influenza Virus
  • V06.6 Streptococcus pneumoniae [pneumococcus] and influenza

Is anyone qualified to write or help us write a short blog on how to bill for the flu and pneumonia vaccines?  Let me know below or by emailing TheCoders@hhcoding.com.