In the fall of 2014, Ebola broke out at Texas Health Presbyterian Hospital of Dallas. “We have the unique claim that we are the first hospital in the United States to miss a diagnosis, and the first hospital to make a diagnosis, of a patient with Ebola virus disease,” says Barclay Berdan, the CEO of Texas Health Resources.
Berdan, who has worked with Texas Health for about 30 years, had been in the role of CEO less than a month before a patient with the Ebola virus came to the emergency room on September 28 — and was sent home, undiagnosed. “Then on the Sunday following, September 30, he returned via ambulance, clearly very sick,” Berdan says, “and that was when we were able to make the diagnosis.”
Within hours of receiving confirmation about the Ebola diagnosis, the hospital held a press conference. “At the time, the folks who organized the press conference and were talking did not realize that the patient had been at the ER a few days before,” explains Berdan. “And as the news broke, the family, some relatives of the patient who were on the East Coast — who had been talking to him on the phone over a much longer period of time — started talking to the media.”
On October 8, the patient died. Three days later, one of the nurses who had been in contact with him was diagnosed, and three days after that, a second nurse. Both survived, cured at hospital systems outside of Texas Health.
The “October event,” as Texas Health calls the crisis, took place over the course of about six weeks. During that time, the hospital held press conferences, met with government officials and the Centers for Disease Control and Prevention (CDC), and cared for the two sick nurses until the decision was made to send them elsewhere. “We got to the point where we thought our staff was pretty exhausted and it wasn’t necessarily safe to continue to care for our two nurses,” says Berdan.
CDC guidelines changed during the course of the crisis as well. “We were having a dialogue after CDC reps came to the organization about the fact that our nurses were not comfortable with the original recommendations of the CDC with regard to protective equipment,” Berdan explains. “And that began to spur some of the discussion at the CDC about changing some of their recommendations.”
From the NEJM Catalyst event Leadership: Translating Challenge to Success at Mayo Clinic, June 2, 2016. Watch Part 2 of Berdan’s talk: Ebola at Texas Health: Three Lessons in Leadership.