Registered nurses at Berkshire Medical Center represented by the Massachusetts Nurses Association are calling for stronger personal protective equipment (PPE) standards for frontline nurses and healthcare workers and a triage area outside the hospital to limit the exposure of coronavirus (COVID-19) to patients, staff and the community.

BMC instituted an expanded personal protective equipment (PPE) policy on March 26, requiring all staff in contact with patients to wear surgical masks, eye protection and gloves. However, only BMC staff who are in contact with COVID-19 positive patients or patients being ruled out for COVID-19 are provided the N95 masks that offer the highest level of protection from infection when used in combination with eye protection, a gown and gloves. In fact, BMC is not even giving N95 masks to every nurse in the emergency department.

"We all know that coronavirus is a highly infectious and stealthy virus that can be spread by asymptomatic people, leaving frontline healthcare workers and hospital patients at risk unless we have the highest standard of protective equipment," said Alex Neary, an ICU RN and Co-Chair of the BMC MNA Bargaining Committee.

"Every nurse and healthcare worker on the front lines at Berkshire Medical Center must be able to use personal protective equipment that can effectively guard against the widespread risk of exposure to COVID-19," Neary said. "At this point, to be safe and limit the spread among staff and our community, we must assume any patient could have the virus and act accordingly."

• 97 BMC nurses had been furloughed and instructed to self-quarantine after potential exposure to COVID-19 as of March 28. All were exposed without PPE. Of those, 75 nurses DO NOT work on units designated for COVID-19 positive or COVID-19 rule-out patients.
• According to BMC's PPE supply numbers provided to the MNA, if the hospital changed its policy to reflect universal N95 masking for those in contact with any patient, the hospital would still have a 28-day supply of N95 masks.
• Acknowledging a looming shortage of PPE and committing to universal N95 masks for frontline staff would prompt additional donations of equipment. A local company is already preparing to manufacture N95 masks.
• BMC nurses requested the enhanced PPE policy in a meeting with management on March 27. Management did not agree.
• BMC nurses also called again on March 27 for a triage area to be set up outside the emergency department. Management had said it was discussing the topic after a previous MNA BMC meeting on March 20 but the hospital has yet to take action. Patients with respiratory problems should not be entering the main ED lobby. Instead there should be a designated area outside of the entrance to the ED to screen and triage patients with respiratory symptoms, so they do not comingle with other ED patients.

Areas of Progress/Appreciation

BMC nurses acknowledge and appreciate areas in which the hospital has made progress and/or has supported frontline staff during this outbreak:

• The hospital has ensured staff on furlough for potential exposure to COVID-19 receive their full pay by supplementing workers' comp.
• The hospital has agreed to supplement the essential personnel childcare the state has provided and make sure staff have no-charge childcare during this crisis.
• The hospital has worked to create a significant number of negative pressure rooms for COVID-19 patients that help limit infection exposure.

Background on Asymptomatic COVID-19

Infectious disease experts studying COVID-19 have detailed how infected people can be asymptomatic for periods of time and be able to spread the virus to others:

• A study in the journal Emerging Infectious Diseases shows more than 10% of patients become infected from somebody who has the virus but does not yet have symptoms.
• Japanese researchers looked at 634 passengers who tested positive for COVID-19 on the Diamond Princess cruise ship. They found that 17.9% of these passengers were asymptomatic.
• Dr. William Hillmann, associate inpatient physician director at Massachusetts General Hospital, told the Guardian, "A significant proportion of people who are totally asymptomatic are contagious for some portion of time. We just don't know [for how long] at this point, because we don't have the kind of testing available to screen for asymptomatic infections."
• A study of COVID-19 cases in China in the New England Journal of Medicine found that even among patients who required hospital admission for treatment of COVID-19, fewer than half (44%) had fevers at the time of presentation.

Massachusetts Nurses Association PPE Recommendations

Despite the CDC's change in its PPE guidelines during the outbreak, the MNA maintains that healthcare workers should be provided the PPE under previous CDC guidelines and World Health Organization standards. The MNA also calls for everyone frontline healthcare worker to be able to use an N95 mask to limit spread within their facility and flatten the curve in their communities.

From MNA Letter to Gov. Baker on March 24, 2020:

"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

"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."

Founded in 1903, the Massachusetts Nurses Association is the largest union of registered nurses in the Commonwealth of Massachusetts. Its 23,000 members advance the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Legislature and regulatory agencies on health care issues affecting nurses and the public.

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