Kaiser Permanente nurses who have been working nonstop on the COVID-19 front lines are planning to picket the Oakland hospital Monday evening to protest the lack of adequate personal protective equipment.
The nurses — who intend to stand 6 feet apart as they demonstrate — say Kaiser is asking them to wear and reuse surgical masks instead of more protective N95 respirators. That violates the standard set by Cal/OSHA and puts them at risk of contracting COVID-19, they said.
“We’re being asked to put our lives on the line and we have nurses going into these rooms unprotected,” said Robin Watkins, a critical-care nurse at Kaiser Oakland and a labor representative for California Nurses Association.
Kaiser nurses said that when they are evaluating whether a patient is COVID-19 positive or likely to be, they are only wearing surgical masks and surgical gowns, which offer less protection than N95 masks. Once a patient is diagnosed, nurses get the more protective gear, including the N95 respirator, a durable gown, gloves and an eye shield. By alternating between less protective and more protective gear, nurses risk being exposed to this novel coronavirus while treating sick patients, some contend.
“It would be hard to accept contracting this virus when you don’t feel like you’ve been protected in the first place,” said Watkins.
This concern about sufficient protection comes as East Bay hospitals expect the number of people with COVID-19 to surge. There had been 112 laboratory-confirmed cases — and one death — in Alameda County as of Monday, as well as 10 other cases reported in Berkeley, which has its own health department. Doctors and nurses say the number of patients with COVID-19 symptoms entering the local health system is increasing rapidly.
“This is like a tsunami coming down on us,” said Luci Riley, a critical care nurse at Summit Hospital in Oakland.
Without adequate personal protective equipment (PPE), the chances of nurses getting sick rises. And if there isn’t a sufficient number of healthcare workers, it will be harder to take care of patients.
“[There is] a day-to-day anxiety on every level, whether it’s administration, management, doctors, housekeepers — everybody,” said a critical care nurse at an Oakland hospital who asked to remain anonymous. “There is general anxiety as we prepare for what we know can be a huge amount of patients coming to us all at once.”
“This is like a tsunami coming down on us.” — Luci Riley, critical care nurse, Summit Hospital
Gov. Gavin Newsom estimates that 56% of Californians, or 25.5 million people, could be infected with COVID-19 within eight weeks without mitigation efforts, and has ordered residents to shelter-in-place to slow the spread of disease. An earlier shelter-in-place order went into effect in the Bay Area on March 16.
In spite of the orders, Riley estimated that as many as 200 new patients displaying COVID-19 symptoms could have entered Sutter Health’s Summit Hospital in Oakland and its sister hospital, Alta Bates in Berkeley, over the weekend.
Health workers are handling the pressure in different ways. An operating room nurse at UCSF Benioff Children’s Hospital in Oakland said some of the anesthesiologists have been increasingly panicked about contracting COVID-19 from patients, so much so that one anesthesiologist tried to hide an N95 respirator mask so he could reuse it. Now, the protocol is to check out a respirator from the charge nurse prior to use.
“Panic never moves the conversation forward, panic doesn’t solve problems,” said Riley. “Laser-focused attention to detail solves problems. That’s where we are trying to be on the front lines of this thing, and, while of course all of us are terrified, we are presenting that emotion in different ways.”
“What do you do if you run out of equipment and your patient still needs you? You’re in a real ethical dilemma.” — Rochelle Pardue-Okimoto, neonatal intensive care nurse, Alta Bates
Many health workers say they are also concerned that hospitals don’t have enough essential equipment such as ventilators and negative pressure rooms for COVID-19 patients. By some estimates, California has approximately 7,500 ICU beds and 7,600 ventilators across the state.
“I fear less actually taking care of the patient as much as I fear being exposed and being unable to care for a patient who needs me or needing to take care of a patient and not having the right equipment,” said Rochelle Pardue-Okimoto, a neonatal intensive care (NICU) nurse at Alta Bates Hospital and a councilwoman in El Cerrito. “What do you do if you run out of equipment and your patient still needs you? You’re in a real ethical dilemma.”
A critical care nurse at an Oakland hospital, who asked not to be named, concurred.
“I’m not scared of getting the disease and getting sick,” the nurse said. “I’m afraid of 100 people coming in and needing ventilator support — because no hospital can do that.”
Hospitals around the country short of masks and equipment
The Bay Area isn’t alone in facing a critical shortage of protective gear for health workers. That problem exists across the nation. In a national survey conducted by National Nurses United, only 29% of nurses said their hospitals have a plan to isolate a coronavirus patient, and only 30% said their employer has enough PPE if there is a surge of COVID-19 infections.
“The front-line people don’t have what we need to be safe and we have to make the decision: Do we continue to provide care risking ourselves or do people not get the care that they need?” said Katy Roemer, an obstetric nurse at Kaiser Oakland. “Well, we’re not going to do that, these are human beings that need our care. The hospitals know we aren’t going to do that.”
Some health workers out of Kaiser Hospital in Oakland said that, because of the shortage of N95 masks, they are being asked to reuse these masks or wear and reuse a surgical mask as they travel from patient to patient, some of whom may be positive for COVID-19.
“If you look at all the pictures of the hospitals in Europe and China, they’re in full garb and our hospital people are telling us that you just wear a mask, you don’t have to worry about your clothes or your body,” said a resident nurse at Kaiser Hospital in Oakland who asked to remain anonymous.
Reusing a surgical mask or respirator is called for in times of scarcity, according to the CDC, but is far below the threshold for PPE outlined by Cal/OSHA.
Another major problem is the lack of testing available, meaning a patient without COVID-19 who has similar clinical symptoms could be taking up a valuable isolation room that could be used for a COVID-19 positive patient.
If a patient is suspected of having a virus that transmits through airborne particles, such as tuberculosis or measles, the standard of care as outlined by the Centers for Disease Control and Prevention is for the patient to be placed in isolation in an airborne infection isolation room (AIIR) – or negative pressure environment — which ventilates a small space to prevent cross-contamination.
“We’re literally cutting holes in the walls of every room to create filter systems to treat these patients appropriately,” said the critical care nurse at an Oakland hospital.
Conflicting statements on PPE protocols
Health workers in California who are treating COVID-19 patients or patients under investigation for COVID-19 are protected by the Cal/OSHA aerosol transmissible disease standard for PPE. The standard says that, because SARS-CoV-2, the virus that causes the disease COVID-19, is novel to humans, health workers are to wear N95 respirators, eye shields, gowns and gloves while treating confirmed or suspected COVID-19 cases.
But on Thursday, the California Department of Public Health released a statement allowing hospitals to follow looser standards, those set up for diseases transmitted by droplets rather than through the air. Those droplet protocols only require the health worker to wear a surgical mask when treating a patient.
“Nurses or staff on the front lines – respiratory therapists, physicians, everyone – we’re not having the N95 masks, which, according to Cal/OSHA, is the standard to protect you from this virus,” says Sheryan Fisher, a resident nurse who asked that her place of work not be identified. “They’re asking us to use just regular surgical masks for droplet precautions and possibly wear a gown as well. Those are also not fully impermeable and so we just feel very at risk.”
The CDC defines COVID-19 as a disease that is spread person-to-person through infected droplets, which is why the federal standards for PPE currently align with droplet precautions.
“Droplet precautions assume that the droplets that are big enough will drop before they reach you at 6 feet,” said a resident nurse at Kaiser Hospital. “I don’t know how you can hand a mother a baby and stand 6 feet away.”
More research needed to confirm COVID-19 route of transmission
Scientists usually consider the route of transmission for a virus when writing the guidelines for the types of PPE health workers should wear, but there is still a lot that is unknown about SARS-CoV-2.
Current evidence indicates the virus is spread person-to-person through infected droplets, which will be pulled to the ground within 6 feet of a sneeze or cough. But SARS-CoV-2 is still a new virus and there is still the possibility that the virus could be transmitted through the air. If SARS-CoV-2 is airborne, that would make the route of transmission more like measles or tuberculosis than influenza, which is spread by droplets.
“What everybody thinks but nobody is saying is that the only reason we’re treating this like a droplet transmission is because we know that no hospital has the capacity to treat an airborne disease outbreak of this magnitude,” said a critical care nurse at an Oakland hospital.
Under airborne precautions, the patient is placed in a negative pressure room because the droplets are small enough that they are aerosolized. The health worker treating the patient wears PPE for airborne protection, including an N95 respirator, gloves, gown and eye protection. PPE for airborne protection is what is mandated by Cal/OSHA for California health workers treating COVID-19 patients.
“It’s scary for the nurses to take care of a patient that is being ruled out that doesn’t have symptoms because, basically, we’re not getting full airborne protection, we’re just getting droplet precautions,” said Pardue-Okimoto. “So, if they cough on you directly, they aren’t going to get the cough on your face but is that cough aerosolized? Kind of like this whole ‘stay 6 feet away from people’ is what we are being told outside and then, in the hospital, we’re being forced to hold and feed a patient that we think has COVID-19.”
Community rallies to help provide more masks
While personal protective equipment is scarce, health workers are turning to social media and the community to ask for N95 respirators in particular, but also gloves, gowns and surgical masks.
Health workers, like emergency room nurse John Pearson at Highland Hospital in Oakland, have been posting on social media about a lack of PPE and cleaning supplies at the facility, as well as inadequate training on how to treat COVID-19 patients.
As #COVID19 comes to the Bay Area, we need more resources and we need them yesterday.
— John Pearson RN (@OaklandNurse) March 20, 2020
Fisher — the nurse who asked that her employer not be identified — shared a plea for donations of N95 masks on Nextdoor. Within 24 hours, she received what she estimates to be 100 wrapped N95 masks. She sanitizes the plastic wrapping with clean hands and distributes the masks to her colleagues in the hospital, as well as elderly or immunocompromised neighbors.
“We want to keep people safe, that’s the whole reason why we were called to this job,” said Fisher. “If there is any way people can donate eye protection, face masks, anything at all, we would be so grateful for any donation of any kind. We just want to stay in the game longer, we want to be there for people a little bit longer.”
Another donation location is in Fisher’s neighborhood at a spot at Brooklyn and Hanover Avenues in Oakland. Masks and protective gear can be dropped off from 9 a.m.-5 p.m. daily. Email email@example.com for more information.
Berkeley City Councilwoman Rashi Kesarwani has also put out a call for new and unused N95 masks, medical gloves, hand sanitizer and disinfecting wipes. She said a member of her staff can pick them up. On the first day of collection, “there were multiple large boxes of medical gloves and multiple large bags of face masks” picked up, she said.
Corporations are donating millions of N95 masks
Donating PPE to health workers is one way the community can give back, but many health workers said the most important thing neighbors in Berkeley and Oakland can do is to comply with the state’s shelter-in-place order.
“If I was Dave Chapelle I would do the funniest standup routine that’s ever been watched on your DVR and it would be called ‘stay the fuck home,’” said Riley. “We cannot emphasize enough how important it is to flatten the curve.”