Letter: Nurse Association outlines issues related to opening hospitals for normal care

To the Editor,

The following letter was sent to Gov. Charlie Baker from the Massachusetts Nursing Association May 4.

Dear Governor Baker:
We write this week to specifically address issues related to hospitals seeking a return to elective procedures, appointments and general care. These comments will also be submitted to the Reopening Advisory Board. A list of ongoing issues and recommendations associated with the Commonwealth’s response to the novel coronavirus (COVID-19) raised in previous communications is provided as an attachment.

While we anticipate the plateauing of coronavirus (COVID-19) admissions and deaths will vary by region across the state, it is likely significant pockets of high acuity will exist for another week to ten days even as hospital admissions begin to decline. Therefore, we must approach a return to these services in a thoughtful and measured manner. We believe healthcare facilities can only begin to return to providing these services under specific protocols and guidelines which we have delineated below. Your administration has invested too much time and too many resources in addressing this health crisis. If we open the doors to elective procedures without putting in place the proper safeguards, we could face spikes in COVID-19 cases that could cause additional hospitalizations and death as well as further delay the reopening of the Massachusetts economy. In addition, frontline health care staff have spent the last weeks in an unprecedented, demanding care setting. Returning to elective procedures without proper measures in place could undermine their ability to provide the appropriate level of care which would harm all patients.

Throughout the pandemic it has been clear that too many decisions were made by those not on the frontlines. It is also clear too many hospitals have been incapable of making prompt, appropriate decisions in the best interests of their staff and patients. We fear the desire to generate revenue through elective procedures could override the need to ensure proper protections are in place before resuming these procedures. Unfortunately, these fears are not unfounded. This week, Tenet-owned St. Vincent’s Hospital has begun taking aggressive steps to reopen elective procedures without implementing the best practices outlined in this letter and while refusing to meet with and work with frontline staff to ensure this process is safely implemented. This has been poorly handled and cannot be repeated at other hospitals as we move to ease restrictions your administration put in place in March. We urge you to intervene and ensure that any return to non-emergent procedures is done in a measured, collaborative manner.

This week also brought the announcement that an advisory board has been created to provide thoughtful direction on reopening the Massachusetts economy, but we are alarmed and dismayed to see no frontline workforce representation. We ask that you rectify this lack of representation immediately. Representatives from various frontline worker groups, including those identified as providing “essential services”, should have a role on this advisory board and direct involvement in any decisions that are made. The involvement of frontline workers is vital as decisions are made in the coming days and weeks. There is so much at stake in the reopening of these healthcare facilities, we should be mindful of not repeating previous mistakes.

Criteria for normalized operations for healthcare facilities
Several criteria must be met to allow for a thoughtful reopening of healthcare facilities and a return to elective, non-emergent procedures and appointments. These criteria may be institutionally, system or regionally based.
1. COVID-19 census must decline over a 2-week period. Before permitting a return to pre-COVID-19 operations, the level of COVID-19 admissions must decrease for a period of two weeks at the facility. This will help to ensure that what is observed is a trend and not an anomaly or lull. This recommendation mirrors the joint recommendation put forward by the American College of Surgeons, the American Society of Anesthesiologists, the Association of periOperative Registered Nurses, and the American Hospital Association.
2. Testing and screening of all incoming patients. To mitigate the risk of spreading the virus in healthcare facilities following a return to normalized operation, healthcare facilities must test all incoming patients.
• Any facility wishing to resume elective, non-urgent procedures must test all patients with planned admissions for COVID-19. In order to admit a patient and proceed with the elective procedure, the patient must have two negative tests at least 24 hours apart prior to admission.
• Any patients not arriving in a pre-planned manner must be screened in an anteroom area with staff in full Personal Protective Equipment (PPE) and utilizing generally accepted infectious disease principles in place prior to the Center for Disease Control (CDC) alteration of those standards. These protocols should be followed until the patient is discharged or has two negative COVID-19 tests at least 24 hours apart.
• All maternity patients and any support persons should be tested prior to admission.
• All healthcare facilities wishing to return to elective procedures and appointments should have the capability to test all patients for COVID-19 on site with results available within hours. These patients should be treated as presumptive-positive until testing indicates otherwise.
• Any new COPVID-19 patients, whether a new admission or current admission who subsequently tests positive, must be treated in a COVID-19 specific unit established at the facility. Therefore, any facility wishing to return to elective procedures must create or maintain at least one COVID-designated medical/surgical floor and one COVID-designated ICU, each of which shall have its own dedicated staff with appropriate PPE. |
• All patients should be tested for COVID-19, with results received, prior to discharge to a subacute care facility or other inpatient facility. Given the potential public health impact for premature resumption of full service at these facilities, there must be strict oversight of this process and no institution should be allowed to resume normal operations until these measures have been documented and verified.
3. Resumption of Care Standards. Prior to any return to normalized operations at healthcare facilities, the state must address several provisions that were suspended over the past two months to specifically address the anticipated COVID-19 surge.
• Hospitals must prove they can safely care for elective surgery patients and COVID-19 patients without resorting to a crisis standard of care.
• The waiver of all staffing regulations, including Intensive Care Unit staffing limits and the prohibition of mandatory overtime, must be reversed prior to allowing resumption of elective procedures.
• There must be enough staff to allow for the staffing patterns necessary in the COVID-19 units as well as fully staff the other areas of the facility. Staff cannot be floated between these units.
• Any change in schedule to accommodate an increase in capacity due to elective procedures must occur with the direct involvement of the staff. Facility management must allow for appropriate staffing to accommodate the increase without burning out already exhausted and overwhelmed staff. Where staff are unionized, the employer must meet their obligations under the law and existing collective bargaining agreements with respect to any proposed changes.
• Accommodations must be in place to assure staff can travel to and park at work while maintaining social distancing. For example, staff cannot return to cramped shuttle buses.
4. Transparency, oversight and enforcement. A return to elective procedures must include safeguards to protect patients and frontline staff.
• The state must clearly establish census criteria to identify when and what numbers of procedures are allowable based on a healthcare facility’s COVID-19 census, admissions and discharges and ensure that if an increase in COVID-19 acuity or occurrences happen, there is in place an automatic mechanism to reduce or halt elective procedures and/or general admissions. Additionally, if halting admissions and procedures is insufficient to assure proper care of COVID-19 patients, there must be a state mechanism in place to admit and/or transfer such patients to ensure we do not return to co-mingling of patients.
• In the event the number of COVID-19 patients exceeds the designated beds on the COVID-19 designated floor(s) and/or ICU, elective surgeries must be placed on hold until such time as the bed capacity can be decreased. In no circumstance should a facility be allowed to simultaneously maintain or increase bed capacity for COVID-19 patients and increase elective surgery and general admissions.
• Hospitals should be required to report bed capacity, including non-COVID ICU beds, COVID-19 ICU and medical/surgical beds, infection rates at each hospital and PPE burn rate for the foreseeable future. This data should also be made publicly accessible.
• Facilities must provide a written plan regarding their plans for returning to normalized operations and the continued care of COVID-19 patients as well as attestation that they meet the state-designated census criteria to resume operations. This plan should be available to the public.
• There must be a designated reporting site with immediate investigation and enforcement for any violations.
5. Personal Protective Equipment (PPE). In order to return to elective procedures and admissions, there must be appropriate PPE available to all staff who come in contact with COVID-19 positive or suspected COVID-19 positive patients. If a facility cannot provide frontline staff with the appropriate PPE, then that facility is not prepared to resume elective procedures.
• PPE should be provided to any and all staff whose job requires it.
• Available PPE should be industry standard according to the guidelines established by the CDC prior to the lowering of standards in response to the anticipated COVID-19 crisis.
• Healthcare facilities must confirm they have the appropriate PPE on hand to assure the pre-COVID standard can be maintained. This should include the availability of N95 masks are utilized in the manner they were intended for use as disposable non reusable respirators.
• A minimum stockpile of 21 days of PPE at the current facility-specific burn rate must be on hand with the capacity to replenish as needed.
• If a healthcare facility persists in utilizing PPE in a non-traditional manner, particularly the re-use of disposable N95 respirators, the facility must treat such use as voluntary by employees including requiring consent for de contaminated mask use or continued use.
6. Extend the current visitor policies. A return to elective, non-urgent procedures should not bring about a change in the current “no visitors” policies in COVID-19 areas but if allowed, must be significantly restricted in non-COVID-19 patient areas. Visitor areas should not co-mingle with areas frequented by the healthcare workforce. Social distancing has helped to flatten the curve in the Commonwealth, we must maintain these practices for the immediate future.
7. State operated facilities. State operated facilities should maintain contingency plans and use of National Guard to supplement staff through the end of June. The rate of infection is high among these facilities and has rolled out at a slower pace than in the acute care hospital system and the staffing issues at these facilities that existed prior to the pandemic were exacerbated when the virus hit.
8. Student Nurses under reopening. Anticipating the surge in COVID-19 patients, the state allowed as-yet-unlicensed student nurses to provide direct patient care. Now that we are moving towards a time where hospitals wish to return to elective, non-urgent procedures and normalize their operational practices, it is important that we revisit the state of student nurses and not-yet-licensed nurses in the Commonwealth.
• All student nurses should be prescreened at the start of every clinical shift.
• All student nurses must be provided with PPE as described above.
• Student nurses should not be assigned to COVID-19 units to complete their clinical rotations.
• If a student nurse tests positive for COVID-19, she or he should be subject to the same standards as other employees with regards to returning to work.
9. Workforce considerations. Frontline healthcare personnel have been in the eye of the storm, responding to this crisis for the past two months. A return to more normalized operations should be accompanied by:
• The lifting of any monthly, quarterly or year to year caps on vacation/earned time.
• The ability for staff to utilize sick time, vacation time or other forms of paid time off (PTO). Employers should not be able to refuse or disrupt appropriately requested time.
10. Preparing for a second wave. As we look at a return to elective, non-emergency procedures, we must be mindful of the potential for a resurgence of the virus in the fall. We must take steps now to both mitigate a return of the virus and prepare for its possible reappearance.
• Hospital should build a 90 day-stockpile of PPE so we do not see a repeat of the PPE shortage crisis experienced this spring.
• Hospitals should file a surge plan outlining their proposed response to a second surge, including both ICU and non-ICU capacity, PPE availability, housing options, and staffing plans.
• The state should create a hotline for complaints or issues that are not being addressed. Healthcare workers need a direct line to the Department of Public Health to report concerns.
11. General Public and Business Reopening. While this communication focuses specifically on what must be done to reopen the healthcare sector, we are mindful that the behavior outside healthcare facilities will play a large role in determining what happens inside these facilities. We will be submitting additional comments to the Reopening Advisory Board on recommendations related to the reopening of the larger economy and will include those in a future communication.
Thank you for your continued efforts on behalf of the Commonwealth. We continue to be available as a resource to you and your administration.

Donna Kelly-Williams, RN
President, Massachusetts Nurses Association

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