In new letter, Massachusetts Nurses Association makes 9 requests to Charlie Baker

"We recommend that the state impose a strict 'shelter in place' order, like the one in place in San Francisco. We think an increased directive from the state could help reduce the number of residents ignoring the current order to stay at home."

Maureen Shanahan-Frappier a RN uses sanitizer on her gloves.
–David L. Ryan / The Boston Globe, File

The Massachusetts Nurses Association released the following letter to Gov. Charlie Baker, dated March 30. The union also gave a separate statement on personal protective equipment.

Dear Governor Baker: 

I am writing to provide the latest update from the more than 23,000 frontline nurses and healthcare professionals we represent at 85 facilities in Massachusetts. This past week we have seen the opening of no-cost childcare centers for essential workers across the Commonwealth, the launch of the state’s Health Professional Volunteer for COVID-19 Relief program to connect healthcare professionals with volunteer opportunities, and passage of a federal stimulus bill that includes $130 billion in financial assistance for hospitals, though how those funds will be distributed has yet to be seen. We appreciate the progress made on some of our previous recommendations, but we must do more to effectively stem the spread of this dangerous virus. We urge swift and full adoption of our complete list of recommendations which were developed from the perspective of nurses and healthcare professionals working at the bedside. Their concerns are our foremost priority. 

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What nurses are experiencing at the bedside. The situation in our healthcare facilities continues to evolve at a rapid pace and is changing by the hour. Some of these are observations we have identified in previous communications that remain ongoing concerns. Others are emergent problems our members are experiencing that also need to be immediately addressed: 

  • The lack of Personal Protective Equipment (PPE) for frontline healthcare staff continues to be a serious problem and some healthcare facilities are making dangerous recommendations informed by supply shortages not science. 
  • Nurses and other vital, frontline healthcare staff are still having shifts cancelled, being furloughed or laid off even as we call for retired healthcare professionals to return to work and expedite licenses for out-of-state nurses. 
  • There is a high priority need for temporary alternative housing for hospital workers. 
  • Tests are still not widely available or results readily accessible — including for some frontline healthcare workers. 
  • Some healthcare facilities have still not established isolated floors or units for COVID-19 positive and suspected patients. 
  • While some hospitals have pursued areas of expanded ICU bed capacity and personnel to staff the increased capacity, many still have not. 
  • The need for increased capacity to treat the expected influx of individuals with COVID-19 remains a serious concern as does a shortage of ventilators to treat these patients. 
  • Some healthcare employers are still planning service closures amid this pandemic, including the elimination of 74 child and adult mental health beds at Providence Behavioral Health Hospital in Holyoke, the closure of the Somerville Hospital Emergency Department and the elimination of a detox unit in Springfield. 

What must be done. As frontline healthcare nurses and healthcare professionals working to provide care for COVID-19 patients and meet other ongoing patient needs, we call for the following actions: 

  1. Protect frontline healthcare workers. We reiterate in the strongest possible way that we should assume all patients are COVID-19 positive. For reasons explained in our last letter of [recommendations], this approach is the only effective strategy going forward. Those providing direct patient care should be wearing N95 masks and a face shield. Those providing care to patients in surgical procedures should be wearing surgical N95 masks and a face shield. Those not entering patient care rooms should be wearing surgical masks inside healthcare facilities at all times. We have heard multiple reports of nurses and other staff being told they cannot use any privately procured PPE, including N95 masks. This is unacceptable and we call on the state to issue a directive to healthcare facilities to stop this at once. If healthcare facilities are unable to provide the proper PPE, there cannot be a prohibition against workers supplying their own to protect themselves and their patients. 

We are deeply disturbed by the Executive Office of Health and Human Services memo dated March 27 regarding use of PPE (Guidance Regarding Requesting Personal Protective Equipment). As written, this memo entices employers to continue to justify lowering standards in the delivery of care. It puts both patients and frontline healthcare personnel at risk. In order to stop the spread of this virus among the vulnerable population within the hospital walls, we must be more vigilant, not less. Rationing PPE in the hospital and expecting that this will not exacerbate the infection rate is tantamount to re-opening the bars and restaurants and expecting the virus will not spread more quickly in the public. The answer is not to save for the coming crises — the crisis is here. We must utilize all available PPE to avoid making the crisis worse. Our efforts need to be focused on maintaining the best standard possible with what is available in order to avoid spread among patients and hospital staff. These standards should be based on guidelines established by the Center for Disease Control (CDC) and the World Health Organization (WHO) prior to this pandemic which were supported by decades of scientific research and infection control protocols. If direct care providers are not wearing N95 masks in patient rooms and surgical masks outside of the rooms, we are inviting viral spread among vulnerable hospital patients and increasing the risk that larger numbers of healthcare workers will contract the virus and be unable to continue to provide patient care just as the need for such care escalates. 

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We must continue to do everything possible to create a local manufacturing supply and distribution of PPE. It is imperative that production of PPE begin immediately within regional or domestic geography. Such production must be focused on increasing the supply of N95 masks as well as Power Air-Purifying Respirators (PAPRs) which safeguard healthcare 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. We must also address the shortage of visors, face shields, goggles, ventilators and gowns. 

Beyond these shortages, however, there are additional measures to mitigate the spread of the virus within healthcare facilities that must be taken. Protective clothing, including scrubs and gowns, should be donned and doffed on location to reduce the risk of spreading the virus outside the healthcare facility. Showers should be made available on site to healthcare staff. And given the shortage of paper gowns, we recommend that cloth gowns be utilized, as they can be laundered after each shift just as scrubs are laundered. 

  1. Designate specific areas to address suspected and confirmed COVID-19 cases. While we have seen many healthcare facilities move to designated floors for confirmed and suspected COVID-19 patients, several still have not done so. 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, including the unconventional use of single ventilators to support more than one patient. 
  2. Support frontline healthcare workers. Another week has seen some more progress on temporary housing options for frontline healthcare staff. However, these alternative housing measures are still not in place on a large scale. As this pandemic progresses, frontline health care workers are getting sick — and we have heard that in the near future they may need to work sick, if asymptomatic. Others are already in the position of having a member of an at-risk population in their home. This necessitates that alternative housing arrangements be in place for these frontline health care workers. Unfortunately, few individual hospitals are succeeding in their efforts to find such arrangements. We need the state’s help in securing these housing resources. The Commonwealth should identify a point person or team to coordinate these efforts and specifically address these pressing housing needs. 

Unfortunately, disparate treatment of frontline healthcare workers who become infected with COVID-19 or are quarantined due to suspected COVID-19, continues. There seems to be an attempt by employers to default to the assumption that employees who test positive must have contracted the virus in the community rather than in the healthcare facility and therefore, the employer does not consider their illness occupational. For weeks frontline personnel have raised concerns regarding the co-mingling of patients, failure to triage and segregate patients, the lack of appropriate PPE, the failure to provide timely testing and results to healthcare workers and the delay in providing onsite facility parking to employees, forcing healthcare workers to cram into crowded shuttle buses to get to work. To suggest that none of these issues may have contributed to an increased likelihood of viral spread among the workforce is both ridiculous and reprehensible. In some cases, these workers are being told they 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. 

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We applaud those employers who are supporting their workforce in such a challenging time and call upon the state to issue a presumption of occupational cause for those working in healthcare facilities who test COVID-19 positive. 

  1. Halt all bed, unit and facility closures. Despite repeated calls to halt these closures, we are still aware of employers who are moving forward with reduction plans. This is not a time to be eliminating capacity at our healthcare facilities. We again call on the state to direct healthcare facilities to halt all planned bed, unit and facility closures. This includes the closure of 74 mental health beds at Trinity Health-owned Providence Behavioral Health Hospital, as the lack of available behavioral health beds will lead to additional patients presenting in already overcrowded emergency departments (EDs). It also includes the planned closure of the Somerville Hospital Emergency Department, set to close on April 30, just as we are expected to see a surge in hospitalizations. Once again, we also ask that facilities such as Union Hospital, Quincy Medical Center and North Adams Hospital be explored for re-opening for the designated purpose of treating COVID-19 patients. We noted last week that New York is utilizing the Javits Center, with 1,000 additional beds coming online earlier this week to increase the state’s capacity as the expected number of patients needing care rises. We are encouraged by news that the DCU Center is expected to house up to 200 additional hospital beds. Similar efforts should be replicated across the state. We must act now to increase capacity. 
  2. Halt all staff reductions and take measures to ensure safe, appropriate staffing. Despite dire warnings that we may not have enough staff to meet the increased demands that will be put on our healthcare system, healthcare facilities are proceeding with planned layoffs and furloughing healthcare staff. This is not the time to be eliminating frontline healthcare workers. Instead, we should be looking to train these nurses and deploy them into the areas that will see surges in patient volume. As we said in previous communications, we will need nurses who can staff newly designated acute care or ICU units. The state should be working with healthcare facilities to coordinate this redeployment of healthcare staff and ensure they are properly trained. 

We are gratified to see the creation of an online Commonwealth site for volunteers. These individuals will need to be trained and deployed to assist with increased capacity needs deriving from COVID-19 patients in the coming weeks and months. We would expect the state will screen out any individuals who would be at a high-risk for mortality from exposure to COVID-19 through direct patient care. However, we are also mindful of the dichotomy between a call for volunteers, including asking folks to come out of retirement, and the dismissal of actively working, licensed healthcare personnel. 

The state’s recent waiver of the ICU staffing law has already seemed to entice employers to reduce staffing even when there are available staff, justifying their decision with the state’s waiver. COVID -19 patients are acutely ill — those needing ICU care and ventilation are not [stable] patients. With the lack of PPE, the best course of action is to put one nurse in the room with proper PPE and allow another nurse to act as a runner in the open unit so that nurses do not have to repeatedly don and doff their PPE, increasing the risk for infection. And yet at Carney Hospital, at the first opportunity to utilize the [state’s] ICU staffing waiver, the hospital has planned staffing for the COVID-19 ICU of one nurse to two patients — even as there is staff available to meet a one nurse to one patient standard. This action will likely lead to increased viral exposure for the nurses and a lower standard of care for the patients. This enhances the likelihood of nurses becoming sick with the virus and losing their availability to provide patient care. In Italy, where frontline staff had more available PPE than we do here in the US, 30% of the healthcare workers still became ill. With the lack of PPE supply and this staffing approach, we should anticipate a greater loss of workers to illness. 

  1. Support vulnerable hospitals and healthcare organizations. We are pleased to see state and federal efforts to provide financial support to vulnerable hospitals and other healthcare facilities during this critical phase as we prepare for a surge in our in-patient capacity. We must be vigilant that facilities are mindful of the intent and purpose of that financial assistance. For healthcare facilities and organizations that are truly financially struggling and have resorted to reducing healthcare staff through furloughs and layoffs as discussed previously, these funds should go to maintaining frontline healthcare staff. We have been informed that Atrius Health, which serves over 740,000 patients in Eastern Massachusetts, intends to furlough healthcare staff due to a lack of available finances. If facilities and organizations like Atrius can demonstrate a lack of financial resources even after receiving this recent financial support, including a lack of reserve funding, the state should offer financial assistance in the form of direct payments and/or no interest loans. As we look to provide such financial assistance to other industries, we must ensure that our healthcare workforce is supported. We also believe all providers must be required to access and utilize all funds held in reserve or parked in offshore accounts to maintain staff and resources to respond to this epidemic. 
  2. 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. We must make every effort to: 
  • Make drive through testing widely available. 
  • Prioritize testing for healthcare personnel. These tests should be available at the facility where worker is employed with 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 continue to report 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. 
  1. Activation of the National Guard to support COVID-19 response. We again applaud your activation of the National Guard to support the Commonwealth’s response to the COVID-19 outbreak, but reiterate our recommendation that some National Guard members be posted at hospitals to assure restricted visitation is followed without having to pull direct care staff away from patient care. As we are still seeing and hearing of residents who are not practicing safe social distancing, the Commonwealth should increase the National Guard’s visibility in areas common for large social gatherings to further dissuade those who choose to ignore this directives issued by the state and federal government.
  1. 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 healthcare team responding to COVID-19. The actions the public takes, or does not take, will greatly affect whether the flow of patients into our healthcare 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, like the one in place in San Francisco. We think an increased directive from the state could help reduce the number of residents ignoring the current order to stay at home. At a minimum, the current directive should be extended beyond April 7th to keep hospitals from being overwhelmed. 
  • 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 respond effectively to this pandemic. Our members are on the frontline and they are increasingly anxious and frustrated by the slow pace of action on their calls and use of their expertise as they look at the experience of their colleagues across the globe, now in New York City and with each day, here. 

We will continue to be available as a resource to both you and the healthcare community as things progress and we look forward to working together in service to the citizens of the Commonwealth. 

Thank you. 

Donna Kelly-Williams, RN President, Massachusetts Nurses Association 

Cc: Secretary Marylou Sudders
Massachusetts Legislature 

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