Testimony of the California Nurses Association to
the Assembly Committee on Health
"Anthrax and Beyond: California Health System
November 6, 2001, 1:30pm
Mary C. Jue, RN, MSN, PHN
Nursing Practice Representative
Chair, Statewide Public Health Nurse Advocacy Group
California Nurses Association
Madam Chair and members of the Committee,
Thank you for holding this hearing and inviting us to testify here today. The California Nurses Association is the largest organization of registered nurses in the state, representing thousands of RNs in over 120 hospitals, clinics, home health agencies and public health departments. In the last 2 years, we have put together a Statewide Public Health Nurse Advocacy Group, representing PHNs in most of the counties throughout California. As such, CNA is often asked to speak on behalf of staff nurses, including being invited to participate in the Subcommittee on the Protection of Public Health, established by the Governor's State Strategic Committee on Terrorism.
Basically, public health and emergency room nurses are the front line responders in any public health crisis. Yet, with a severe and growing nursing shortage, there just aren't enough nurses to handle the daily work, let alone a public health disaster, like the ones we are anticipating today.
Even before the events in Washington, D.C., New York, New Jersey, and Florida, what we needed was a well functioning, coordinated and fully staffed public health system.
In the event of a disease outbreak, whether occurring naturally or intentionally, nurses are key players in the initial response. Public health nurses are the first line responders in the public health arena, strategically stationing themselves in key locations in the community providing early surveillance, critical public education and administering vaccines or prophylactic therapies when needed.
In the hospital setting, where emergency departments are the Mecca to which concerned people will be heading in the case of a bioterrorist attack or other large-scale medical crisis, nurses are the first to assess and are key to ensuring adequate care throughout the patient's stay.
Unfortunately, our public health system is neither coordinated nor fully staffed. There is no formal system for putting out an emergency alert among the key agencies that will be involved in such a crisis, other than the phone call one agency director could place to another. (Key agencies include hospitals, public health departments, law enforcement, public safety) As well, there are no linked data systems between these agencies that can assist in tracking.
In a 1999 survey done by the National Association of County and City Health Officials, the staff most wanted by public health organizations was public health nurses. Yet, nationwide, there is a severe and growing nursing shortage in both the acute care and the public health setting, due to the abominable working conditions in the hospitals and the non-competitive salaries and benefits in the public health departments. We are barely functioning with dangerously thin staffing in our public health departments. (Enrollments in BSN nursing schools down 16%, nursing vacancies 10%, data not clear for public health nursing, within 10 years, 40% of nurses will be 50 years or older).
According to public health nurses from Alameda County, they are already overwhelmed with calls from providers and the public wanting information or reporting possible exposures to anthrax, handling at least 20 calls/day. Public health nurses in the communicable disease unit answer those calls - providing the critical early surveillance. But any chemical or bioterrorist agent will not make tuberculosis, Hepatitis C or HIV go away. We will still need our nurses to provide the ongoing public health services we have come to rely on.
The meningitis situation last Spring in Livermore provides a very concrete example of how easily public health department resources can be overtaxed. After 2 reported cases in the middle school and one in the high school, where a student died, the Public Health Department received an onslaught of calls from concerned community members. They needed to respond. Public health nurses in that county and nurses pulled from neighboring counties were instrumental in answering the calls, setting up community informational meetings and erecting clinics in those schools to screen and administer prophylactic therapy when needed. A total of 35-40 front line public health nurses was required to meet the need, including several retired public health nurses. A total of 1300 students and staff received care. Alameda County reports that in the case of a smallpox emergency, they would have to vaccinate 1.5 million people in that county alone.
All counties report an inadequate number of public health nurses. And if there were an event that necessitated the mobilization of all nurses as responders, including retired nurses with active licenses, there is no reliable system in place to activate them. And though some select public health nurses have received bioterrorism training since September 11th, not all nurses, by far, have received appropriate and comprehensive training.
Pulling public health nurses away from their normal assignments also has ramifications due to the way public health nurse services are funded. In the 1970's, the combination of budget cuts and the availability of reimbursement through Medicare and Medicaid for individual clinical rather than population-based community-focused services led many public health agencies to change their focus to "capture" these funds. Public health nurse services are now largely funded in a piecemeal fashion, supported through specific targeted categorical or project funding (AFLP, CHDP, BIH, etc.). Largely, public health nurses pulled from their categorical programs do not get reimbursed for their work. There is currently no separate funding mechanism for surveillance.
Hospital nurses also report that they are already at capacity in their emergency departments. In a normal flu season, ERs are overwhelmed with overcrowding and long waits. In the May 2001 issue of the American Journal of Public Health, in an article titled, "Hospital Preparedness for Victims of Chemical or Biological Terrorism," the authors note that hospital emergency departments are not prepared in an organized fashion to treat victims of chemical or biological terrorism. The planned federal efforts to improve domestic preparedness will require substantial additional resources at the local level to be truly effective. In a survey conducted with registered nurses and ER physicians, the results show:
*slightly more than 1/2 of the respondents were aware of local or state preparedness plans
*only 21% of hospitals reported having an ED indoor area with isolated ventilation, shower and water containment system
*most hospitals reported having no respiratory protective equipment that would be appropriate against chemical agents
*1/2 reported having enough cipro and doxycycline to provide 2 days of prophylaxis for only 50 hypothetical anthrax-exposed individuals
*few of the hospitals had developed plans and arranged training for response to a possible incident involving chemical or biological weapons.
Our survey of ER nurses corresponds with this study. All expressed deep concern about unsafe staffing under current conditions.
How should the state's thinking change for bioterrorist/disaster preparedness after September 11th and after transmission of anthrax through the mail? If, as I stated at the beginning of this testimony, we are all coming to realize the vital importance of a well functioning, coordinated and fully staffed public health system, we cannot wait until disaster strikes in California to make that public health system a reality. We need to have the will, because we have the ability, to build the capacity of our public health system. This heightened capacity would need to take us through any immediate disaster, be able to sustain longer-term necessary services AND still be able to provide the basic core public health services for which we are relied on.
There is clearly a lot of work to be done to confront the large deficiencies in local preparedness. Specific recommendations that nurses in both the public health and emergency department settings suggest include:
*increase the number of nursing positions in public health departments
*address the nursing shortage by developing competitive wage and benefit packages so that health departments do not lose nurses to other settings or other careers
*implement loan forgiveness for nurses working for any county health department - a public health nurse working in a rural community in San Joaquin County cannot qualify for the loan forgiveness programs - every public health department provides services to low-income, disenfranchised at-risk communities.
*amend funding for public health nursing services to include surveillance, population-focused interventions and disaster-related services
*increase funding for training of first responders in public health - any training should include a mental health component as public health nurses are often called on to provide mental health services for community members and other emergency personnel, such as during the September 11th disaster
*funding for appropriate field equipment, including reliable communication devices
*increase funding to Schools of Nursing to provide realistic and positive public health nursing clinical experiences
*implement CNA recommendations on acute care staffing ratios to ensure adequate staffing at the bedside
*improve and increase the number of hospital drills as a preventative measure
*develop or improve the system for coordinating emergency alerts and for soliciting volunteer nurses in the event of an emergency; more than one system will have to be created, i.e. email, telephone, radio, public service announcements
*a moratorium on all ER closures - give Emergency Medical Services Authority regulatory authority to stop ER closures
Thank you for your consideration.
11/19/2001 USA Today
Hospitals ponder bioterror spending