Nurses at an Oakland, California hospital caring for patients being tested for Covid-19 received instructions this week to reuse disposable medical equipment, including masks and eye protection. The hospital, Kaiser Permanente Oakland Medical Center, issued guidelines to nurses explaining how to clean single-use supplies to serve multiple patients during one shift.
Staff at the center have been caring for a number of people who were aboard the Grand Princess cruise ship, which docked in the city on March 9 after being stranded offshore for several days with 3,531 people on board. At least 21 passengers tested positive for the coronavirus. Patient privacy protections prohibit health care providers from disclosing how many patients aboard the ship are now receiving treatment at the facility.
Two nurses at the hospital spoke with The Intercept about working conditions amid the outbreak, describing hastily changing directives and frustration among nurses who feel they are being asked to endanger themselves and other patients. Staff only started to receive training on how to care for Covid-19 patients after the first cases had already arrived at the hospital, one nurse said, asking for anonymity to avoid retaliation from their employer. “We’ve been blindsided the whole time,” they said. “And we knew the boat was there, so I don’t understand why.”
“Being grossly unprotected is not acceptable, and shouldn’t be acceptable.”
Before the ship disembarked, Vice President Mike Pence, who is running the nation’s Coronavirus Task Force, said people would be quarantined as necessary, and every person on board would be tested. Passengers were later informed there weren’t enough tests to do that. Last week, they were told it was up to them whether or not to be tested, the New York Times reported. More than ten days after the ship docked, many passengers are still quarantined at various military bases.
California Democratic Gov. Gavin Newsom declared a state of emergency earlier this month after the first Californian died from the virus. The man had been on the same ship for a previous cruise in February.
“Without widespread testing, there’s no telling how many of us are going to silently pass Covid around,” the nurse told The Intercept. “I don’t mind caring for people and being in the front line of this, that’s fine. But being grossly unprotected is not acceptable, and shouldn’t be acceptable.”
As the nation begins to grapple with how underprepared the medical system currently is to handle the rapid spread of Covid-19 in the United States, hospital and medical facilities are being forced to choose between risking the safety of patients and staff, or running out of critical medical supplies.
Nurses at the Oakland facility were told that new guidelines distributed to staff this week would not put them at higher risk, and that they were crucial to keep the system from collapsing. “If we do not adopt these measures now, COVID-19 will pose a critical risk to the capability and sustainability of an already strained workforce and healthcare system,” a document obtained by The Intercept reads.
The hospital had previously been following protocols aimed at protecting medical staff from airborne contamination. The new guidelines follow those set out by the Centers for Disease Control and Prevention, which earlier this month downgraded to protocols for contamination via droplets and contact in response to a shortage of N95 masks. That change prompted protests from other nurses’ groups. The CDC noted that those changes were based on supply, not science.
Hospitals in other states have adopted the droplet protocols as well. Other countries are using stricter precautions, and the World Health Organization is reportedly considering enforcing airborne precautions.
Nurses at the Oakland facility are pushing back, saying the new guidelines do indeed increase risk. The California Nurses Association, a union representing a number of nurses at the Oakland hospital, sent an email to members on Thursday noting concerns with the new guidelines and encouraging members to raise them with hospital executive staff, Oakland Chief Nursing Executive Darina Kavanagh and East Bay Area Vice President Ed Chan. The union provided a pre-drafted email with the subject line: “We Deserve a Safe Workplace.”
One of the nurses who spoke with The Intercept said that a patient of theirs had been tested for Covid-19. The nurse said they’ve been making calls to ask people for medical supplies.
“I’m trying to get supplies, that’s what I’m doing with my time,” they said. “I’ve been asking friends, I’ve been asking anyone I know that works in any business that I think uses protective equipment. Because at this point N-95 [masks] would be great, but just anything would be helpful. Gowns, anything.” They also made a call to Newsom, the governor.
“In other countries, they’re wearing full protective garb, head to toe, no skin exposed,” the nurse said. “And here, we were never wearing that. But we need something.”
“We’re mixing patients. All really wild and unsafe things that we don’t usually do.”
When staff first started caring for patients impacted by the pandemic, they used far more extensive protection, the nurse said: “We were wearing full N-95 masks, face shields, head covers, thick gowns.” Nurses were only caring for patients one-to-one, so as not to risk exposing healthy patients to others they were caring for who might be positive or in the process of getting tested. Now, the nurse said, a coworker had “one surgical mask and a paper bag, and she has to use it for three rooms. Two of those patients are being tested for Covid and one is not.”
“We’re mixing patients,” they said, taking a deep breath. “All really wild and unsafe things that we don’t usually do.”
The new guidelines inform nurses that N-95 protective shields and CAPRs/PAPRs, shields that enclose the entire head, are not required. “Regular masks are appropriate,” the document says.
“The reuse of PPE” — Personal Protective Equipment — “is expected throughout the shift, as long as they are not soiled or damaged; reuse will require safe handling and proper storage. When caring for cohorted patients who have the same conditions … healthcare workers can continuously wear [PPE] without doffing and redonning between patient contacts, as long as they are not soiled, contaminated or damaged,” the guidelines read. “It is critically important that we move to these revised PPE guidelines to ensure critical supplies such as N-95 masks, PAPRs and CAPRs remain available so that we can safely care for our patients as cases of this virus increase.”
There’s no guidance on how to determine whether disposable supplies have become soiled, which is particularly tricky because potentially infectious droplets from a patient’s cough are invisible, the same nurse said. At least one new study indicates that the virus can survive in aerosols and on various surfaces longer than originally thought.
The same people are caring for patients being tested for the virus and those who aren’t, said the nurse, and exposing them to one another in the process. At first, nurses were told they shouldn’t be caring for anyone except for Covid-19 patients to avoid spreading the virus. “But now they’ve kind of disregarded that. So a lot of nurses are rejecting that. You know, we’re doing our best to prevent that,” the nurse said.
Lab staff are no longer going into rooms, the nurse said, and the hospital’s environmental workers aren’t cleaning rooms or emptying biohazard bins anymore. One of their nursing colleagues was asked to mop a room.
On Thursday, the account for Kaiser Permanente’s Northern California Branch, which includes the Oakland facility, tweeted that current protocols for Covid-19 patient care would ensure staff were protected. Marc Brown, a spokesperson for the hospital, wrote in an email to The Intercept that for procedures that would generate airborne particles, staff are still using airborne protections. “We would not be using droplet protection protocols if it were unsafe or put our care teams at greater risk,” he wrote, adding that the guidelines were in line with recommendations from the World Health Organization and the CDC. “Experts and public health officials all over the world now have confirmed that the coronavirus is spread through respiratory droplets produced when an infected person coughs or sneezes.”
Brown said the facility understood staff concerns, and would continue to communicate with them as the situation evolved. “We engage with our labor leaders every week to keep them informed and make sure there is two-way dialogue,” Brown said. “It is important that all health care systems protect staff and patients based upon the science and evidence available.”
One of the nurses who spoke with The Intercept underlined that what could happen if experienced frontline nurses are directed to risk their own health. “The people that are working right now are the most skilled to make the decisions for critical care patients, which is what we’re gonna face in the hospitals,” the nurse said. “And once those skilled workers contract Covid, they’re not going to be able to work.”