The Emperor’s New PPE

By Sally Sellers

SallyAnnSellersSally Speak is the effort of Sally Ann Sellers, RN, BSN, MA Ed, an old battle-ax who is just delusional enough to think her pen is mightier than a sword. Good night & good luck!

“There is no greater evil than men’s failure to consult and to consider.” ― Sophocles, Antigone

Hospitals in the US cause about 400,000 premature patient deaths each year due to preventable harm (iatrogenic causes). This equates to three jumbo jets falling out of the sky each day (James, 2013). Our dysfunctional healthcare system tolerates the carnage of preventable patient injury and death, and potential occupationally-acquired infectious diseases by healthcare workers (HCW). But with the introduction of Ebola Virus Disease (EVD), we may be creating unsafe conditions that threaten communities outside of the hospital walls if our isolation protocols and personal protective equipment (PPE) do not work properly. This deadly problem may add to the list of poor outcomes of our healthcare system, spreading the disease, since caregivers are vulnerable to being infected and carrying it into communities. In West Africa, as of mid-October, WHO reports 420 HCW cases of EVD, and 239 deaths, and 2 HCW cases in the US and 1 in Spain.

The deadly outbreak of EVD has created the need for change within the U.S. healthcare system, but the leadership at the CDC and other healthcare in-groups are reacting slowly, with groupthink, creating a situation where those who set policies actively suppress dissenting viewpoints, isolating themselves from outside influences and even taking irrational stances that dehumanize other outside groups, such as “sloppy nurses” and a “panicky public.” When groups make faulty decisions that lead to a deterioration of mental efficiency, reality-testing or moral judgment, they are displaying symptoms of “Groupthink”, a term coined by social psychologist Irving Janis in 1972. What are the signs of groupthink, and how do those signs present during a crisis when we need to change healthcare standards and policies?

suppressionGroupthink is the psychological phenomenon that occurs within a group that causes members to attempt to lower conflict and support group harmony or conformity even at the cost of independent critical thinking and functional decision-making. Groupthink consists of over-estimations of the power of the group, close-mindedness, and pressure to conform. Janis described eight symptoms of groupthink which exist within bureaucracies: illusions of invulnerability, unquestioning belief in the morality of the group, rationalizing warnings that challenge assumptions, stereotyping opposers as weak, self-censorship of ideas, illusions of unanimity, direct pressure to conform, and mindguards who shield the group from dissent.

First world arrogance

Do we see signs of Janis’ symptoms of groupthink in the current EVD crisis? One symptom is the illusion of invulnerability that creates excessive optimism and encouraging risk taking.” The stance of the CDC and executive branch are certainly optimistic about this epidemic. After learning of a second Ebola infected Texas nurse, Obama said:

“I want to use myself as an example just so that people have a sense of the science here. I shook hands with, hugged, and kissed not the doctors, but a couple of the nurses at Emory because of the valiant work that they did in treating one of the patients. They followed the protocols, they knew what they were doing, and I felt perfectly safe doing so.” (Obama, 10-15-14).

Obama probably felt very comfortable hugging nurses working at Emory because these nurses are safe from infection in the specially-constructed unit at Emory. But he probably wouldn’t have wanted to hug the nurses caring for patient zero in Dallas, who were operating using a standard of isolation protection that was two levels below what is used in the CDC’s own biocontainment labs, and at least one level below what was used at Emory and the three other biocontainment hospitals. CDC policies that expected critical care nurses doing rescue care that creates aerosols to care for deadly, messy EVD patients with traditional isolation protection turns out to be “absolutely irresponsible and dead wrong.” Obama’s faith that a highly specialized, bureaucratic system could turn on a dime and enact major changes in staff, stuff, structure, and systems is misplaced.

An ideal biocontainment setup
An ideal biocontainment setup

Ebola is a Biosafety Level 4 pathogen, the most dangerous group. The CDC standard of care for Ebola is a biocontainment lab with a controlled, uncontaminated setting, extensive training of staff, careful staffing, respirators, pumped in air, and 7-minute decontamination showers. In contrast, a modern acute care hospital setting is a contaminated, volatile setting with looser controls and inadequate gear, without the physical layout of the BSL-4 level CDC standards. Instead, nurses in a slowly-reacting system were stuck with hazardous, inadequate protection, existing policies and isolation rooms, and earlier staffing models.
Original CDC level precautions on left, Nebraska Level 2 suit which has since been upgraded, and North Shore Level 3 suit
BSL-4 suit

Illustrating other groupthink symptoms of illusion of unanimity” and “collection rationalization in which members do not reconsider assumptions,” Obama stated,

“The key thing to understand about this disease is that these protocols work. We know that because they’ve been used for decades now in Ebola cases around the world, including the cases that were treated in Emory and in Nebraska. So if they’re done properly, they work. But we have to make sure that, understandably, certain local hospitals that may not have that experience are walked through that process as carefully as possible and we’re going to make sure that this rapid response team can do that” (Obama, 10-15-14).

Some major hospitals, aware of the inadequacy of the older CDC guidelines, have reconsidered their assumptions and avoided groupthink by training staff according to more stringent standards. But many — including Texas Presbyterian Hospital (TPH) in Dallas, have not. At TPH, hospital management defended their decisions by saying they followed CDC recommendations. The MSF (Doctors Without Borders) guidelines are even stricter than the newest CDC protocols 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, while 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 people 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.

It is impossible in terms of training time, physical structure, and resources to adopt the BSL-4 standard at our current acuity of care within our 6000 or so American hospitals. But the nurses working in a community hospital environment in the presence of EVD using existing standards are not safe, especially since they are at higher risk than lab workers in a biocontainment lab, where the virus is controlled and not aerosolized when attempting to keep dying patients alive with extreme measures. What level of PPE and acuity of care will be safe and sustainable, to keep both patients and caregivers safe?

Worker safety in acute care settings

How do we keep our community hospital nurses safe? Fauci of NIH has been consistent in suggesting that the solution is more high-tech biocontainment hospitals or more intensive care, or more money for research. Can we afford more of everything as this epidemic expands? Doubling down on what’s not working is another symptom of groupthink. Since the growth of this epidemic is exponential, we need to position ourselves for where the disease is going, not where it is now. “Neal Ekengren” suggests that we begin with a care model of home based care. Full quarantine on the household with signs posted outside. We show up at the door with anything you need for free but you don’t get out until we say so.” Nursing care could be provided in a decentralized fashion through home visits. Assuming we had the nursing model infrastructure, that would make sense, as it would limit contacts and provide basic supportive medical and nursing care at the appropriate acuity level for this disease, but our frozen bureaucracies, medical hierarchies and ethics, and feedback loops will most assuredly not allow us to change the current system until it breaks. We will continue to resort to stopgap measures and work-arounds for existing hospital design, function, and staffing, until our linear responses are no longer able to keep up.

In the meantime, a second-best solution would be to adopt the MSF model of Ebola Treatment Units (ETUs), with dedicated, specially trained staff, MSF’s design, set-up, procedures, and reusable gear. We need standardized, clear, researched policies for PPE, decontamination, nursing care, and the safest standard for universal precautions. Experienced biosafety healthcare staff should be training the trainers all over the country now and not caring for patients at biosafety centers, or establishing rapid response teams, which are only a short-term, stop-gap measure.

wrongstoryOur third choice is to try to keep caring for EVD patients in acute care settings, by raising the standards to protect caregivers and to prevent extensive spread throughout the hospitals and surrounding communities, which is costly, requires additional staff, and is probably unsustainable. We can also make caring for EVD patients safer in acute care settings by lowering the acuity of care of EVD patients to prevent the extreme measures that contribute to infected HCW, such as intubation and other treatments that create aerosols. This third choice,  especially given the assortment and varying quality of healthcare settings, will probably lead to more HCW getting sick, and spreading the disease, since guidance on the issue is reactive, changing weekly. Lowering the acuity of care is probably a non-starter, as our system of medical ethics is arrogant and assumes that we can always provide the highest care to everyone.

Allowing nurses to design changes in hospital care would be the best way to limit this problem, but hospitals are subject to another symptom of groupthink. “Direct pressure on dissenters place group members under pressure not to express arguments against any of the group’s views, actions or decisions.” Examples of this were seen in the second admission of patient zero, who was left in a non-quarantined zone in the Emergency Department for several hours, while a nurse supervisor faced resistance from hospital authorities after demanding that the patient be moved to an isolation unit. Additionally, nurses said the patient’s lab specimens were sent through the hospital’s tube system, risking and potentially contaminating the whole system.  Once moved into isolation, nurses who interacted with patient zero were given the option of wearing special N95 masks, but some supervisors said the masks were not necessary. Groupthink is an anathema to a system in need of sudden rapid change. Groupthink decisions or practices create pressure by the group towards a dissenter, ensuring the silent complicity of the remaining members.

questioneverythingAnother symptom of groupthink is self-appointed ‘mindguards’ who are uniquely appointed “court jesters” that protect the group and the group leaders from information that is contrary to the group’s cohesiveness, view and/or decisions. Signals, evidence, facts, doubts, alarms, questions, concerns, critical and independent thought all challenge the group’s cohesiveness, views and decisions. “‘Mindguards’ ensure dissent is minimized and discredited while reinforcing the dysfunctional groupthink views.” One could argue that Obama’s appointment of Ron Klain for Ebola Czar, who is a political operative with no medical background, is just such a mindguard. Mindguards wield power as the gate keepers through which independent and critical thought must attempt to pass as we work to change the healthcare system.

Groupthink is a dangerous phenomenon during a crisis that mandates change. I have seen it on many occasions and find that the dysfunctional and unbalanced dynamics of groupthink serve the power structure of the in-group to the detriment of patients, clinical licenses and public health. There are actions that groups can take to ward off dysfunctional groupthink. Functional groups are based on not only allowing, but promoting outside influences.

Where are his PPE?

The impact of embedded groupthink can be seen in the financial fallout at Texas Health Resources, including damage to the brand and growing liabilities and loss of patients that could exert negative pressure on its current Moody’s Investors Services ratings. Moody’s called  the recent cases of Ebola at the Dallas hospital a “material distraction for management.” This while the CDC is rethinking their Ebola guidelines and protocols. The illusion of invulnerability that groupthink engenders is told in the Hans Christian Anderson fairy tale of “The Emperor’s New Clothes.” Maintaining old world views to the point where we are find ourselves allegorically parading down the street naked is not a situation we need to be in with a deadly epidemic. Once trust is shaken and the innocents shout “No clothes! trust in leadership collapses, leaving even more portals for the virus to enter the empire.

The entire series on EVD can be found at this link.