OAKLAND, Calif. — A group of bandana-clad nurses protested outside Kaiser Permanente's Oakland Medical Center on Monday night with a message: "We need PPE."
On Tuesday evening, a similar group of Kaiser nurses rallied in the rain — while maintaining recommended social distancing — in nearby Richmond.
PPE, an initialism for "personal protective equipment," has become a flashpoint for nurses in the San Francisco Bay Area who work for Kaiser Permanente hospitals, an indication that nationwide shortages of hospital supplies are causing tension between health care workers and hospital systems.
NBC News spoke with seven nurses and a nurse anesthetist who work at Kaiser Permanente locations in Northern California across five hospitals. They described a grim scenario in which they are not being given access to PPE early enough in the medical care process, such as with patients who are suspected cases.
Nurses outside the Kaiser Oakland hospital are singing “we need PPE [personal protective equipment]” right now in protest of shortages and rules limiting protective masks they can wear. #coronavirus#COVID19pic.twitter.com/8bu8YOWkoz
Currently, Kaiser nurses are being given access to N95 respirator masks or PAPRs, a particular type of protected suit, only when confirmed patients with COVID-19, the disease caused by the coronavirus, are receiving respiratory treatment, according to internal hospital guidelines from March 18 that were shared with NBC News. A spokesperson said that Kaiser is adhering to federal health guidelines and that it told Kaiser members as recently as Tuesday evening by email that it is "ensuring we have adequate access to protective equipment."
The nurses said the lack of protective equipment and what they see as questionable decisions by Kaiser Permanente have pushed them to the breaking point. The California Nurses Association, part of a union of more than 100,000 nurses nationwide, has considered calling for individual nurses to invoke a legal refusal to provide care — known as a "safety stop" — over working conditions at some hospitals, according to an internal union email seen by NBC News.
Nurses at other hospitals in California and nationwide have also been experiencing acute shortages of PPE. Even the medical school at the University of California, San Francisco, which operates multiple hospitals regionally, has been organizing drives for equipment, one of them at UCSF Benioff Children's Hospital in Oakland.
Nurses have also increasingly used intermediate steps, such as lodging formal complaints known as "assignment despite objections," according to the documents and the nurses who spoke with NBC News. They have also lodged formal complaints with the state's occupational safety department, known as Cal OSHA, according to a document filed March 19.
"The safety stop is critical to protect ourselves and our patients," a union official said in the communications. "It is Kaiser's policy that we are obligated to call for a 'time out' to state things that are unsafe. We do not have to depend on an outside agency, we can use our own clinical judgment."
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Cal OSHA did not respond to requests for comment.
The dispute underscores a deepening crisis for nurses, who remain one of the first lines of medical defense, and for hospitals that are running short on crucial protective equipment. Government officials and hospitals across the U.S. have warned about declining stocks of a variety of PPE, including masks.
3M, the primary manufacturer of N95 and similar masks in the U.S., reiterated Sunday that it is "currently operating at maximum production." Major corporations, including Facebook, Apple and others, have said that together they will donate millions of masks — in some cases from their own wildfire and earthquake preparedness stockpiles — to medical professionals.
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Five of the eight people NBC News spoke to, four nurses and a nurse anesthetist, spoke on the condition of anonymity out of fear of retaliation. They all said Kaiser leaders' decisions were based on mitigating supply shortages rather than on science.
"They're putting us in danger," said Kristine Fry, a nurse at Kaiser Santa Clara, who was recently put on a brief administrative leave after having raised questions internally about the availability of personal protective equipment. "They're putting our families in danger, and they're putting our co-workers in danger."
Kaiser spokesman Marc Brown said in an email that Fry's leave "did not involve a matter of employee safety."
The nurses said their hospitals' guidelines around the coronavirus have changed and are not in line with state directions, particularly around the use of N95 masks, which can filter out air particles that carry the virus and are considered by the hospital as necessary only for confirmed cases, and even then only during particular stages of treatment.
"These are institutions that say that they are providing safe and effective health care, and they're not," said registered nurse Deborah Burger, co-president of the California Nurses Association.
An advisory from Cal OSHA earlier this month referred to the coronavirus as an "airborne infectious disease" that requires that health care workers be provided with respirators — such as N95 masks — which remain extremely difficult to come by. The advisory remains current, according to state authorities. California's advisory also differs from guidance from the Centers for Disease Control and Prevention, which acknowledges that there may be a shortage of respirators.
In addition, the CDC has further guidance for "extended use and limited reuse" for N95 masks. The CDC does not explicitly declare COVID-19 an airborne infection in the same way California authorities do.
Kaiser officials say widespread distribution of N95 masks is unnecessary, and they advised the state to change its guidance to provide such materials only when there is a confirmed case of COVID-19, and even then only during respiratory treatment.
"Continuing to use unnecessary and increasingly scarce equipment, instead of the appropriate gear, will dramatically limit our health care system's ability to deliver care to those who need it," Marc Brown, a Kaiser spokesman, said in an email.
Kaiser, a nonprofit that is among the largest health care organizations in California, has treated known coronavirus patients, including some in Oakland who disembarked from the Grand Princess cruise ship on March 9, according to two nurses.
Brown declined to answer specific questions about many confirmed COVID-19 patients the health organization has treated or is treating.
UPDATE: California has distributed 24.5 million N95 masks. We have now ordered 100 million new masks.
But it isn’t enough. We’re working around the clock to secure the personal protective equipment needed for those on the frontlines of #COVID19.
On March 16, one week after the Grand Princess patients disembarked, Kaiser downgraded its coronavirus guideline to so-called droplet protection protocols, meaning the hospital is primarily concerned about the virus' spreading "through respiratory droplets produced when an infected person coughs or sneezes," according to Brown.
The decision, combined with concerns about the outbreak, has left some nurses fearful of working.
"We are really afraid now — there are nurses writing their wills," said an Oakland Kaiser nurse who spoke on the condition of anonymity for fear of retaliation. "There are many people considering their mortality. It's bad."
Brown said Kaiser is managing its supplies as best as possible and adhering to guidelines from the CDC.
"For patient care procedures that would generate airborne particles, our care teams are using airborne protections," Brown wrote in a statement. "By shifting to the evidenced-based protocols for droplet protection, we can help ensure that we have the resources, capacity, and staff available to care for our members and the communities we serve, and continue working toward slowing the community spread of COVID-19."
Kaiser's efforts have done little to alleviate the concerns of many of the nurses.
"Whoever has N95s, just help us, because we really want to do our job," said a nurse who works at Kaiser South Sacramento and says she has treated COVID-19 patients. "We want to take care of our patients."
Cyrus Farivar is a reporter on the tech investigations unit of NBC News in San Francisco.