In late 2018 and early 2019, the Democratic Republic of the Congo (DRC) is experiencing the second worst Ebola outbreak in history. Since August 2018, close to 400 people died of the devastating disease.While this is a small number in comparison to the West African outbreak that killed 11,000 from 2013 to 2016, the World Health Organization, the United Nations and the world are growing increasingly concerned.
The Issue of Self-Contamination
The epicenter of the epidemic lies in the North Kivu and Ituri provinces, which are currently in a state of turmoil and civil unrest. Healthcare workers find themselves caught up in weekly waves of attacks by rebels and militia while trying to serve a skeptical and generally scared population. Yet, these brave healthcare workers still have a job to complete: to save lives. Becoming contaminated by the disease which they are trying to treat should not be a concern of theirs. There should be foolproof ways in which they can protect themselves from contracting Ebola, yet this is not the case.
Earlier this month, a United States healthcare worker was flow from DRC to Nebraska after having possible been exposed to the disease. Stateside, he was quarantined in the Nebraska Medical Center, the home of one of the only biocontainment units in the country. While he has not shown signs of Ebola yet, the incident highlights the need to reduce the risk for self-contamination in healthcare settings.
Ebola outbreaks are just one (extreme) example of how human factors can mean the difference between life and death for healthcare workers. The lives of healthcare workers, their patients, and the family members are at risk every day in hospitals and clinics across the US. In a recent joint study conducted by the University of Michigan and the University of Utah, researchers spent 9 months observing healthcare worker behavior. What they found was astounding: at total of 283 offenses that had the potential to cause self-contamination or transmission of infectious agents!
Of these offenses, 102 violations occurred when standard interaction protocols were not followed properly. Gloves, gowns and masks were often overlooked in situations in which they should have been donned (such as when speaking to patient family members). Over 140 violations occurred when it came to procedures – such as doffing gowns in improper sequences and using gloved hands to touch things like ID badges in order to access computers. In 37 cases, healthcare workers even touched their faces or cell phones with gloved hands. It’s important to realize that people violate or fail to follow protocols because of reasons associated with the design, the task, and the environment. These reasons need to be understood in order to solve the true cause of human errors.
Learning from the Past
At the end of 2014, it was announced that 600 healthcare workers were among the victims in the West African outbreak. Ebola infection in these cases most likely occurred due to exposure to undiagnosed patients and to incorrect use of personal protective equipment (PPE). Many of these deaths could have been prevented if healthcare workers were correctly using their PPE.
Instructions, labels, and training can be abundant in order to provide appropriate guidelines for donning and doffing PPE, but there is no assurance that the precautions set in place will be followed correctly. Johns Hopkins Hospital recently completed a study that found an overwhelming 103 ways the PPE doffing process failed – even after infection control experts reviewed very detailed CDC guidelines and web-based training in addition to watching seven simulated doffing sessions. In the study, self-contamination most often occurred when a healthcare worker removed their gloves and apron, when they self-inspected, and when they walked from clean to contaminated areas.
There were so many reasons for the breaches and why workers failed to follow protocols – from the design of the PPE to the breakdown in infrastructure to support the needed protocols. This included gaps in needed technical skills, team communication and integration, and lack of space for doffing. The study found that three people are truly needed for the safest doffing experience. These include the healthcare worker, the buddy and the trained observer. Human factors assessments and analyses could have been leveraged to identify these needs prior to costly incidents and outbreaks.
Human Factors is Human Safety
These are the moments that we must remind ourselves that human factors is the key to securing human safety. By submitting these protocols through rigorous human factors review, these systems and procedure’s will be optimized to protect these healthcare workers – whether they’re on the frontlines of Ebola epidemic or fighting an infectious disease at a local medical institution. Application of human centered design methodologies will not only help us to understand why guidelines aren’t followed consistently, but it will help us to develop data-based solutions for improving performance. Human factors will consider everything – from the design of the PPE to the computer access that’s needed when workers are likely to have gloves on. Human factors leaves no stone unturned in its quest to ensure safety and, ultimately, save lives.
While Ebola is an uncommon disease and experimental vaccines are being fast-tracked to stop its spread, we aren’t safe from it yet. The situation of the healthcare worker currently quarantined in Nebraska serves as a grim reminder of how a highly-lethal disease is just an airplane ride away from the US population. If we ever do have an outbreak, we need to be prepared. No matter what infectious diseases our courageous clinicians are working to stop, we need to make sure their safety is a priority so that we can all, in turn, be safe and healthy.