Massachusetts Nurses Association Statement Urging Ebola Protection Measures Be Implemented for Massachusetts Healthcare Workers and the Community

May 12, 2015

Ebola in the US:

On September 20, 2014, Thomas Duncan travelled to Dallas from Liberia. He had helped to transport an Ebola-infected neighbor of his in Liberia four days earlier. On September 24, 2014 Mr. Duncan began to feel ill. Two days later, he came to the Texas Presbyterian Hospital Emergency Room with fever, abdominal pain, and chills. Mr. Duncan revealed his travel history at his triage interview. That information was documented in his medical record, but the physician who saw him apparently did not see or read the note. Consequently information which should have rung a ‘potential Ebola alarm’ for the hospital was not communicated. The hospital initially blamed the nurse; they later claimed the electronic medical record was inefficient. As a result, the physician failed to order test for Ebola, instead prescribing an unnecessary antibiotic. Mr. Duncan was discharged home and 2 days later returned to hospital by ambulance, very ill, and was placed in isolation. The staff began using the recommended PPE (personal protective equipment) at that time. On October 8, 2014 Mr. Duncan died. On October 12, 2014 one of his caregivers, Nurse Nina Pham, RN was diagnosed with Ebola. Two days later, on October 14, Nurse Amber Vincent, RN was diagnosed with Ebola. A third Texas Presbyterian nurse, Brianna Aguirre, who cared for her colleague Nina Pham, heroically disclosed publicly the utterly inadequate PPE that the hospital was providing to its caregivers, generating national media coverage and suffering ostracism from her hospital.

Nurses Reported:

On September 30, 2014, the National Nurses United, of which the Massachusetts Nurses Association is a founding member, released results of a study of 400 nurses across the country which found that:

• 80 percent of nurses reported that their hospital had not communicated to them any
  policy regarding potential admission of patients infected by Ebola
  

• 87 percent said their hospital had not provided education on Ebola with the ability for
  the nurses to interact and ask questions
  

• One-third said their hospital has insufficient supplies of eye protection (face shields or
  side shields with goggles) and fluid resistant/impermeable gowns
  

• Nearly 40 percent said their hospital does not have plans to equip isolation rooms with
  plastic covered mattresses and pillows and discard all linens after use, less than 10
  percent said they were aware their hospital does have such a plan in place
  

• More than 60 percent said their hospital fails to reduce the number of patients they
  must care for to accommodate caring for an “isolation” patient.

In light of the lack of response to the concerns of care givers on the front lines, nurses began protesting across the country. More than a thousand nurses held a “die-in” in Las Vegas to protest the alarming failure of hospitals or the government to provide adequate protection or education. They also called for a massive step-up in the response to the Ebola epidemic in West Africa.

Providers’ and Regulators’ Response:

The overwhelming response was one of broad institutional deafness. Hospitals fell back on
the fluctuating guidelines that the CDC (Centers for Disease Control) issued. The CDC has
posted its guidance using a “pull down menu” allowing the hospitals choice in the measures
they might choose to implement. Since hospital care has been based on a competitive,
market model for several decades, hospitals have a financial incentive to choose the
cheapest, short-term measures. However, even if the CDC had a single, optimal Ebola PPE
(personal protective equipment) standard, it does not have the authority to mandate that
standard be implemented. The CDC has no legal authority or control over state health
departments, even in a crisis.

There have been two notable exceptions to the general lack of response. The University of
Michigan Health System negotiated an agreement with their nurses through the Michigan
Nurses Association (an NNU affiliate). Within the agreement provisions dictated an
appropriate commitment to proper PPE and training as well as a provision to ensure nurses
would receive pay for time off if they were put in quarantine as a result of treating Ebola
patients and provided that nurses could return to their same work position after they were
deemed free of the virus. Their agreement was a first of its kind in the nation and a model
that other hospitals could have followed.

Moreover, in November 2014, California state officials due to strong advocacy by the
California Nurses Association (of the NNU) released updated Ebola guidance for all
California hospitals that require the optimal level of personal protective equipment,
comprehensive training procedures, and other protocols that mirror the standards that the
Massachusetts Nurses Association (MNA), NNU and nurses had been demanding across the
country for two months. In the case of the MNA, its members have warned of Ebola and
other dangers posed by the Boston University Level 4 biolab for over 10 years, testifying at
numerous legislative hearings, including to the Boston City Council and NIH (National
Institutes of Health).

Where we are now:

Most Massachusetts Hospitals still refuse to provide the same level of protection that
laboratory workers who work with deadly (“Level 4”) pathogens use on a regular basis in
their laboratories. Inadequate training and education in the safe and correct use of PPE
remains a big concern for nurses. There has been no guidance from the Commonwealth of
Massachusetts or the CDC to recommend that nurses and other healthcare providers be
protected to the same degree that scientists and lab workers are covered.

Furthermore, we have Ebola in the Boston area now The Broad Institute of MIT and Harvard
University have been carrying out genomic surveillance of the Ebola virus during the
ongoing outbreak. Boston University’s Level 4 biolab on the campus of Boston Medical
Center intends to study Ebola and other deadly pathogens in its lab, and in fact has plans to conduct “gain of function” research in which the pathogens are intentionally made even
MORE deadly that they are in their natural state, for research and defense purposes.

Current CDC recommendation for PPE is limited to double gloves, slip-on booties, fluid-resistant (not impermeable) gowns and N95 respirators with face shields.* This is
completely inadequate to protect caregivers and therefore, the public, from the risk of an
epidemic.

What Nurses are Demanding:

We are solely interested in a mandate directing every hospital, every US health facility, to
immediately implement the optimal precautions, in both personal protective equipment and
proper training. Caregivers are the ‘canaries in the mine’. The next epidemic of Ebola or
other new deadly Level 4 pathogen is just around the corner. The Massachusetts
Department of Public Health estimates that 3 to 5 new deadly agents will emerge every five
years, with global climate change and population growth and poverty escalating the risk of
spread.

Massachusetts caregivers must be provided with a comprehensive equipment and training
program including but not limited to the following

• Education of staff on specific current hazards posed by emerging infectious diseases
  and on state-of-the-art PPE and training programs (e.g. as used by Emory Hospital in
  Atlanta to protect workers from hazards posed by select agents and the current
  biological threats).
• Full body Hazmat suits that are body fluid, blood and virus impervious.
• 
  The PPE must meet the ASTM F1670 standard for blood penetration and the F1671
  standard for viral penetration.
• Powered air purifying respirators with an assigned protection factor of at least 50,
  with full hood.
• PPE must leave no skin exposed or unprotected.
• Staff must have interactive hands-on training for safe, proper donning and doffing of
  equipment, the point with the highest risk for a breach in protection.
• Initial and continuous education and training must be provided to ensure protection
  for at risk workers.

The Commonwealth must protect its healthcare workers and hospitals need to
exercise moral leadership now. The MNA most strongly urges a mandate for a
comprehensive program including environmental precautions, optimal personal protective
equipment and continuous education and hands-on training to prevent a deadly pathogenic
epidemic in Massachusetts.

* http://www.cdc.gov/media/releases/2014/fs1020-ebola-personal-protective-
equipment.html