March 24, 2020
His Excellency Charles D. Baker Governor of the Commonwealth of Massachusetts State House, RM 280 Boston, MA 02133
RE: UPDATE #3
Dear Governor Baker:
Thank you for the additional steps you have taken since our last update to address the novel Coronavirus (COVID-19). The establishment of more than 300 emergency child care centers across the state to care for the children of essential workers, including nurses and health care professionals, will help to ease the burden on these families and ensure that the public has access to these essential services. That these emergency child care services are being provided at no cost to the essential workers further demonstrates the state’s commitment to ensuring that our essential workers can serve the Commonwealth. The activation of the National Guard to support the Commonwealth’s COVID-19 response was a positive development as was news that you have been talking with the Army Corps of Engineers regarding emergency infrastructure for treating and quarantining patients. We are also encouraged by talks we have been having with health care facilities regarding temporary housing for health care workers. Confronting the challenges presented to our state and our health care system by COVID-19 will take a multi-pronged, multi-stakeholder approach. It is crucial that we begin planning for next weeks’ problems now.
Here is the latest update from the frontline nurses and health care professionals we represent.
What nurses are seeing The situation in our health care facilities is evolving at a rapid pace and changing by the hour. We offer these observations of where our health care facilities are still falling short:
- The lack of Personal Protective Equipment (PPE) for frontline health care staff continues to be a serious problem and some health care facilities are making dangerous recommendations informed by supply shortages not science.
- Where there is PPE, nurses and other staff are not receiving the proper PPE fittings or training. • Nurses and other vital, frontline health care staff are being furloughed or laid off. • Some hospitals are still not cancelling elective procedures. • Tests are still not widely available- including for some frontline health care workers. • While many health care facilities have taken steps over the past two weeks to establish isolated floors or units for COVID-19 positive and suspected patients, some hospitals are still not segregating known COVID-19 patients. • Capacity to treat the potential influx of individuals with COVID-19 continues to be a concern.
What Must be Done
As the frontline health care staff working to provide care for the COVID-19 patients, as well as meet other ongoing patient needs, we call for the following actions:
1. Protect frontline health care workers. At this point we should assume that all patients are COVID-19 positive. The inability to effectively segregate patients quickly, as well as the lack of available testing with quick results, has left us with co-mingled patients and the virus is ahead of us. It is not an issue of assigning blame, it is simply an issue of reality and therefore this approach is the only effective strategy going forward. The shortage of PPE is widely known at this point. Our health care workers are being put in the position of caring for their patients without the proper supplies to protect themselves and their patients. Over the past several days, we have worked with many groups to collect and distribute disposable N95 masks to frontline health care workers providing direct care to patients, but there are still not enough. And while the public’s generous offers of hand-sewn masks are appreciated, these are not appropriate for frontline health care workers. The N95 masks have micron filters made from melt blown fabric. This is necessary to filter out sub-micron particles. Homemade surgical masks do not offer this level of protection. Instead, for those providing direct patient care, we should be focusing on increasing the supply of N95 masks as well as Power Air-Purifying Respirators (PAPRs) which safeguard health care workers against contaminated air. The benefit of the PAPRs is that unlike N95 masks which should be disposed of after each use, the PAPRs can be safely cleaned and reused. All health care workers not providing direct care should be wearing regular surgical masks. Additionally, there is also a shortage of visors, face shields, goggles, ventilators and gowns. We again call for an immediate mobilization for domestic production of PPE. The MNA is being contacted directly by manufacturers who want to produce much-needed PPE. We need a coordinated, government-led effort to make this happen.
Beyond the shortages, however, there are additional concerns that must be addressed. Protective clothing including scrubs and gowns should be donned and doffed on location to reduce the risk of spreading the virus outside the health care facility. Showers should also be made available on site to health care staff. And given the shortage in paper gowns, we recommend that cloth gowns be utilized, as they can be laundered after each shift just as scrubs are laundered.
2. Designate specific areas to address suspected and confirmed COVID-19 cases. While we have seen many health care facilities move to designated floors for confirmed and suspected COVID-19 patients, several have still done so, despite this being a concrete step towards reducing the spread of the virus among patients and health care workers. The March 22 letter (Guidance regarding implementation of alternative acute inpatient space during the COVID-19 state of emergency) from the Department of Public Health (DPH) addresses this, too, encouraging all hospitals to establish dedicated care areas. We reiterate our call for: establishing ante-room triage; designating one or two specific hospitals per geographic area as triage hospitals; designating floors and ICUs specifically for COVID-19 patients or suspected patients. It is particularly important at this stage to turn our attention to establishing additional ICU capacity for COVID-19 patients and utilizing this time to train the staff of areas impacted by reduced patient census to assist the increased needs of COVID-19 patients.
We also recommend the Commonwealth create a state sanctioned site for volunteers, particularly licensed health care professionals who are not currently working, to be trained and deployed to assist with the anticipated increased demand in the coming weeks.
3. Support frontline health care workers. As noted previously, we applaud the progress made over the past several days regarding childcare options for essential workers. We now must take swift action on temporary housing options for staff who are caring for patients and cannot return to their home without causing undo risk to household members in a high-risk category. This should also apply to personnel placed on quarantine due to exposure. We have been in talks with some health care facilities on this front, but the time for action is now. We are also seeing disparate treatment of frontline health care workers who become infected with COVID-19 or are quarantined due to suspected COVID-19. In some cases these workers must use their own sick time or paid time off to self-quarantine and recover. This is unacceptable. We are putting them in the direct path of this novel virus and we should be supporting them, not penalizing them. We applaud quarantine and furlough policies being implemented at Partners Healthcare facilities, where no nurse will lose pay as a result of this crisis, and all will be made available to return to work when the need arises. All hospitals must adopt the same policies to ensure we can maintain a workforce ready and able to respond to this crisis. For those hospitals that lack financial resources, state and federal funding must be made available to support these initiatives.
4. Halt all bed, unit and facility closures. While we were encouraged by the halt to the MetroWest Medical Center closure, the potential surge in volume of patients with possible exposure to or symptoms of COVID-19 still has the capacity to overwhelm our health care system. This is not a time to be eliminating capacity at our health care facilities. We again call on the state to direct health care facilities to halt all planned bed, unit and facility closures. This includes the closure of behavioral health beds at Providence Hospital, as the lack of available behavioral health beds will lead to additional patients presenting in already overcrowded emergency departments (EDs). Once again, we ask that facilities such as Union
Hospital, Quincy Medical Center and North Adams Hospital be re-opened for the designated purpose of treating COVID-19 patients. We note that New York is opening the Javits Center, adding 1,000 additional beds to the state’s capacity as the expected number of patients needing care rises. We hope similar efforts are underway for Massachusetts. We must act now to increase capacity.
5. Halt all staff reductions. Despite dire warnings that we may not have enough staff to meet the increased demands that will be put on our health care system, health care facilities are proceeding with planned layoffs and furloughing health care staff. This is not the time to be eliminating frontline health care workers. Instead, we should be looking to train these nurses and deploy them into the areas that will see surges in patient volume. We will need nurses who can staff the any newly designated acute care or ICU units. The state should be working with health care facilities to coordinate this redeployment of health care staff and ensure they are properly trained. To date, Tufts Medical Center has made good efforts on redeploying staff following the cancellation of nonelective procedures. We should be using this time right now to recruit, train and deploy nurses to respond to this pandemic. In the coming weeks we will need all our frontline health care workers. We would additionally recommend addressing the increased needs of cleaning personnel due to the virus and would suggest redeploying and training laid off hotel workers, colleges and businesses to address the heightened needs as we convert rooms over for new patient admissions.
6. Cessation of all elective procedures to free up health care resources. We noted our concern that some hospitals are still not canceling all non-essential, elective invasive procedures. There is substantial subjectivity being utilized in directing the continuation of these procedures. The DPH must step up enforcement of this order. We also reiterate our call for clinics and all other health care facilities to cancel all non-essential, elective invasive procedures. This would free up personnel needed for other locations and assure all equipment and supplies can be directed to those in need when the inevitable surge in COVID-19 patients arises. Extending this order to all other health care facilities would further reduce the risk of spread, allow for triaging of potential patient needs without inundating EDs, and prevent problems arising from non-essential, elective cases that could take up valuable health care resources needed for COVID-19 patients.
7. Support vulnerable hospitals and health care organizations. We reiterate our call for the state and federal government to take whatever steps are necessary to provide financial support to vulnerable hospitals and other health care facilities during this critical phase as we prepare for a surge in our in-patient capacity.
8. Discharge all current inpatients as soon as practicable. Discharging patients who do not require inpatient treatment for COVID-19 or other conditions will free up resources and reduce those individuals’ potential exposure.
9. Prescreen all individuals presenting at Massachusetts hospitals. Prescreening of all allowed visitors and vendors coming in and out of health care facilities can help to reduce the spread of COVID-19 through that facility.
10. Increase access to testing. While testing capabilities increase each day, we are still not at the point where everyone who should get tested can get tested and receive their results in a timely manner.
- Make drive through testing widely available.
- For health care workers, while we understand the availability of testing is limited, it is important that we pursue consistent appropriate testing of health care personnel. These tests, where possible, should be available at the facility where worker is employed results available within a 24-hour period.
- Clinicians should be trained to provide testing at sites with high-risk populations, such as nursing homes and assisted living facilities. Our nurses have reported instances where these facilities have attempted to bring groups of individuals from these facilities to overcrowded EDs which overwhelms the ED and may put the individuals at greater risk of exposure.
11. Further curtailing public transportation. We reiterate our call that the state shut down public transportation to all but essential personal or individuals cleared to travel. Yesterday’s announcement closing all non-essential business (Order Assuring Continued Operation of Essential Services in the Commonwealth Closing Certain Workplaces, and Prohibiting Gatherings of More Than 10 People) should go hand in hand with this further curtailing of public transportation. This would allow those who must use public transportation to do so, while imposing social distancing standards and help to enforce the “stay at home” order. Again, we understand this will require thoughtful planning for those whose food and other needs will require alternative assistance or distribution mechanisms. Additionally, shuttle bus services at health care facilities should also be curtailed to comply with social distancing recommendations and where shuttle service must still be used to transport staff, regularly cleaned in compliance with appropriate standards. We continue to receive concerning reports of shuttle services packed with health care workers driving past empty visitor parking lots at health care facilities. This defeats the purpose of so many of the other protective measures you and the facilities have put in place. In lieu of shuttles, parking should be made available at no cost for health care workers wherever possible.
12. Activation of the National Guard to support COVID-19 response. We applaud your activation of the National Guard to support the Commonwealth’s response to the COVID-19 outbreak. We recommend some National Guard members should be posted at hospitals to assure restricted visitation is followed without having to pull direct care staff away from patient care. Unfortunately, we cannot rely on all members of the public to adhere to all directives issued by the state and federal government.
13. Further enlist the public in the response to COVID-19. At this point, all citizens of the Commonwealth should consider themselves as part of the health care team responding to COVID-19. The actions the public takes, or does not take, will greatly affect whether the flow of patients into our health care facilities is manageable or a deluge. We know it is difficult to ask people to drastically curtail their everyday lives, but the actions of the public are crucial to how this pandemic will play out in the Commonwealth.
• We recommend that the state impose a strict “shelter in place” order, similar to the one in place in San Francisco. The difference between “social distancing” and “shelter in place” could be the difference between an overwhelmed health care system and a manageable one. • We recommend the public wear masks when in public spaces shared with other individuals. This is a good use for homemade masks.
We seek implementation of these recommendations so that we can properly respond to this pandemic. If we wait too long, it may be too late to take meaningful action.
We will continue to be available as a resource to both you and the health care community as things progress and we look forward to working together in service to the citizens of the Commonwealth.
Donna Kelly-Williams, RN President, Massachusetts Nurses Association
Cc: Secretary Marylou Sudders