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. OnOctober 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 the findings from 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 fall back on the fluctuating guidelines that the CDC (Centers for Disease Control) has 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 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 were 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:
Not a single Massachusetts Hospital has agreed 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. There has been no guidance from the Commonwealth of Massachusetts or from the CDC to even 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. 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 U.S. 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
Download a PDF of this statement.
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