Transformational Leadership: Advocacy and Influence TL5 Nurse Leaders lead effectively through change. TL5a: Provide one example, with supporting evidence, of the strategies used by nurse leaders to successfully guide nurses through unplanned change. Introduction Ebola Viral Disease (EVD) is a very serious illness caused by one of the five species of the Filoviridae virus. The virus is naturally harbored in Pteropodidae bats, a family of fruit bats that live in tropical and sub tropical areas. The bats act as reservoirs of the virus that infects wild animals in the surrounding geographic area but are not always infected themselves. The disease spreads to other animals and humans through direct contact with blood, body fluids, or organs of an infected animal. Human to human transmission also occurs via direct contact with blood and body fluids of an infected individual, as well as from inanimate objects that are contaminated with infected body fluids. EVD is characterized by sudden onset of fever, fatigue, muscle pain, weakness, and severe headache. These signs are followed by abdominal pain, diarrhea, vomiting, rash, and in some cases, internal and external bleeding. Impaired renal and hepatic function can also occur. According to the World Health Organization (WHO, 2016), the disease carries a mortality rate of approximately 50%. In mid-March of 2014, the first cases of the most recent outbreak of EVD were reported in the West African countries of Guinea, Sierra Leone, and Liberia. This outbreak was considered the largest since EVD was initially reported in 1976, in that there were more reported cases and more deaths. It was also considered a more complex outbreak, eventually defined as an epidemic, since it spread beyond remote areas to urban areas. Between March and July of 2014, the number of cases and related deaths increased exponentially, but the outbreak was contained to West Africa (WHO, 2016). In early August 2014, two American missionary aid workers who were caring for victims in the affected area developed EVD and were evacuated to the United States (US) for treatment. Confirmation of the disease in these individuals put EVD on the radar screen of most Americans. At the same time, the hospital that treated them became the test case and guide for how to treat those infected with EVD and how to prevent the spread of the extremely contagious disease to those caring for them in the American medical setting. On August 7, 2014, a “Public Health Emergency of International Concern” was declared by the WHO. On September 4, 2014, a third American, a physician aid worker was diagnosed with EVD and evacuated from West Africa to a different US facility for treatment. On September 26, 2014, the WHO described the EVD epidemic as “the most severe acute public health emergency seen in modern times” and went on to state that “Never before in recorded history has a biosafety level four pathogen infected so many people so quickly, over such a broad geographical area, for so long.” Two days later, an

American man who had recently returned to the US from West Africa was diagnosed with EVD. This was the first case of EVD diagnosed in the US and the index case of travel-associated EVD in the US. He received intensive care for 10 days before he succumbed to the disease. On October 10, 2014, a nurse who cared for the patient was diagnosed with EVD and became the first case of transmission to a health care worker in the US. Another nurse who also cared for the now deceased patient was found to have EVD on October 15, 2014 (CDC, 2014).

Throughout this time period, the EVD epidemic was constantly being monitored at Massachusetts General Hospital (MGH). Decisions were being made for how to identify and manage potential cases, as well as maintain healthcare worker safety in the care of these patients. By mid-October, the Emergency Department (ED), Medical Intensive Care Unit (MICU), and Pediatric Intensive Care Unit (PICU) were identified as the units that would care for patients with known and suspected EVD. Leadership of these units contacted the hospitals that had cared for the patients in the US, and they and their care teams began to consider the impact on their units. It was recognized that the EVD situation was dynamic and that there was an urgent need for an institutional response plan that was comprehensive and protective. There was also a need for a formal and streamlined communication plan to manage the rapidly changing information and recommendations.

MGH Organizational Preparation for EVD Patients

The MGH senior executive leaders elected to utilize the existing Hospital Incident Command System (HICS) disaster response system as the format for addressing this issue. On October 21, 2014, the first meeting of the institution-wide EVD HICS was held. At that meeting, Jeanette Ives Erickson, RN, DNP, FAAN, NEA-BC, Senior Vice President for Nursing & Patient Care Services and Chief Nurse, who served as Incident Commander for this group, and Robert Seger, Executive Director for Emergency Medicine Administration appointed chiefs for four areas of focus: Logistics, Planning, Finance and Operations. Nurse Leader Kevin Whitney, RN, DNP, NEA-BC, Associate Chief Nurse (ACN) for Surgical, Neuroscience, and Orthopedic Nursing, was given the responsibility of Operations Chief for the MGH EVD response (attachment TL5a.a). According to the EVD HCIS, in the role of Operations Chief, Whitney was responsible for “developing and implementing strategies to carry out the priorities established by the Incident Commander... and will organize, assign, and assess the impact to patient care.” This role also provided oversight to four major areas of focus: Ambulatory Care, Ancillary Services, Psychological Support, and Medical Care. The Medical Care area encompassed medical and nursing care in the three units that had been designated as locations for placement of Ebola patients, as well as the Nursing Supervisors. Nurse Leader Theresa Gallivan, RN, MS, NEA-BC, ACN for Medicine, the Heart Center, and Emergency Nursing was assigned responsibility for these areas (attachment TL5a.a).

MGH Nurse Leaders to Guide Staff in Nursing and Patient Care Services Whitney and Gallivan recognized the enormity of their responsibilities and realized that, in order to lead and guide their nursing colleagues efficiently and productively through this unplanned change, they would need to rely on unit-based leadership and other leaders to address key needs. At the October 30, 2014 meeting of the EVD HICS (attachment TL5a.b), Whitney and Gallivan reported that there was a sense of urgency to finalize a plan for personal protective equipment (PPE) training and communicate it to leadership of the units and support services that would encounter potential or actual Ebola patients. They recognized the time-sensitivity of initiating training for all direct care disciplines and role groups. Whitney and Gallivan also reported that training of 22 interdisciplinary staff members, who would be responsible for training others, was complete, and the planning process for the large scale training that needed to be done was underway. As CDC recommendations changed throughout the process (e.g., the type of recommended respirators) and the possibility of PPE supply shortages, a decision was made to briefly delay the start of training for other direct care providers. Seger verbalized the need for someone with clinical, administrative, and educational skills to lead the training effort from a central perspective. Monica Staples, RN, MSN, ACNS-BC, Clinical Nurse Specialist for General Medicine (White 10) and a member of the MGH Hazmat Team, was suggested as an expert nurse whose experience would make her a good candidate for this role. Whitney asked Gallivan to explore this recommendation as White 10 was part of Gallivan’s span of control as ACN. She agreed to negotiate with Jennifer Mills, RN, MS, NE-BC, Nursing Director of White 10 to determine how Staples could be made available to serve in this role for the remainder of 2014. Nurse Leaders Guide Personal Protective Equipment Training for Staff At the November 6, 2014 meeting of the EVD HICS (attachment TL5a.c), Whitney and Gallivan reported that the plan for PPE training was complete and that Gallivan had been successful in making Staples completely available to coordinate all aspects of PPE training until the end of 2014. Both were essential to the preparation of nurses to manage this unanticipated and unplanned clinical change. Staples embarked on putting a training plan in place that encompassed all shifts. The goal was to achieve a critical mass of staff that had completed PPE training within one week. Whitney and Gallivan worked with Nursing Directors for the ED, MICU, and PICU to ensure that staff would be able to attend training, and Staples provided updates regarding the training schedule that she shared with unit leadership via email. A sample of such a communication is found in (attachment TL5a.d). The comprehensive training package for all end-users consisted of an overview of EVD, care of patients with suspected or known infection, general concepts related to PPE, and a rigorous, observed practice of donning and doffing the protective equipment.

Through the ongoing support of Whitney and Gallivan, the interdisciplinary healthcare teams in the ED, PICU and MICU were trained by Staples and her faculty. An excerpt from the EVD PPE Training database showing the ED, PICU and MICU nursing staff that were trained between October 31, 2014 and December 23, 2014 is found in attachment TL5a.e. The work of Whitney, Gallivan, and colleagues was put to the test on December 2, 2014 when the first patient with suspected EVD, technically referred to a “Person Under Investigation” (PUI) arrived at MGH. To the relief of all involved, the patient did not have EVD, but the opportunity to test all aspects of the plan proved to be very valuable. Whitney and colleagues met to collectively share their experiences, and they conducted a debriefing with the staff in the MICU, where the patient received care. Ultimately, the plan was activated again on June 9, 2015 for another PUI who also did not have EVD. Although the plan has only been formally activated twice, it is regularly tested, exercised, and up-dated to ensure it remains current and that MGH is ready to manage another response to EVD or another highly pathogenic disease. On June 12, 2015, the MGH, in partnership with the Massachusetts Department of Public Health (MA DPH), was designated as a special regional treatment center for the care and treatment of Ebola patients by the US Department of Health and Human Services (HHS). This designation included a monetary grant of $3.25 million to be used to support MGH’s and DPH’s ability to care for EVD patients from all over the world. The funding will be allocated over the course of five years. Dr. Slavin communicated this news on June 30, 2015 in his monthly on-line newsletter, From the Desktop, which is posted the last day of every month.

_____________________________________________ From: Broadcast MGH Sent: Tuesday, June 30, 2015 2:19 PM To: All User MGH Subject: From the Desktop of Peter L. Slavin, MD

From the Desktop of . . . Peter L. Slavin, MD

MGH President June 2015 Mass General Highlights Hospital Designated a Regional Treatment Center for Ebola This month the MGH, in collaboration with the Massachusetts Department of Public Health, was selected by the U.S. Department of Health and Human Services to be one of nine designated regional treatment centers for patients with Ebola virus disease or other severe, highly infectious diseases. As part of this designation, the hospital will receive about $3.25 million over the course of the five-year project. The support comes from emergency funds approved by Congress to enhance preparedness in the wake of the 2014 Ebola epidemic in West Africa. As you know, planning and preparing for the possibility of an Ebola

patient at the MGH was a significant undertaking involving many departments and staff, and I thank all those who have worked hard to ensure that, if called upon, we can safely take excellent care of a patient who needs our help.

Whitney’s and Gallivan’s leadership, initially with the organizational response and then with ongoing work, prepared and guided nurses through a critical time of unplanned change and was instrumental in the designation of MGH as a regional treatment center.

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EVD HICS Senior Command Meeting October 30, 2014

Presiding: Ives Erickson, Jeanette, R.N., D.N.P., Incident Commander Present: Aiena, Cindy L.; Calderwood, Stephen, M.D.; Castaldo, Robert; Gallivan, Theresa M., R.N.; Hughes, Maryfran, R.N.; Krupa, Robert M.; Michelman, Bonnie S.; Nally, Jacquelyn M., RN; Prestipino, Ann L.; Prosswimmer, Allison L.; Raeke, Edward; Reisman, David J.; Seger, Robert; Shenoy, Erica, M.D., Ph.D.; Slasman, Peggy; Smith, Brian; Whitney, Kevin B., R.N.

Please note: action items are designated in bold

Contributor Topic Details R. Seger Introduction • R. Seger stated that the purpose of the HICS Senior Command

meeting is to do any follow-up from the larger HICS meeting heldon Tuesdays and to plan for issues leading into the weekend andfollowing week; the smaller group will facilitate decision-makingand assignment of tasks.

E. Shenoy,M.D., Ph.D.

Situation Update

• E. Shenoy, M.D., Ph.D. provided an EVD situation update asfollows:

o There is still only one individual infected with EVD in theUnited States, a doctor at Bellevue Hospital in New York.

o The most recent data suggests there are 13,000 confirmedEVD cases in West Africa, and there is a preliminary reportthat the epidemic may be slowing in Liberia.

o The CDC has issued new guidelines regarding quarantineand monitoring; we do not have clarification from MDPHor Boston Public Health on how closely they will align withthese recommendations. R. Seger reported that A. Gottlieb, N.P. from

Occupational Health will be joining the group andS. Taranto from Human Resources is already partof the group.

E. Shenoy, M.D., PhD. Reported that a FrequentlyAsked Questions document for staff is in the laterstages of development and should be finalized onMonday; T. Gallivan, R.N. asked whether thisdocument would incorporate questions aroundrestrictions, and E. Shenoy, M.D., Ph.D. confirmedthat there is a question about whether an employeecan refuse to care for an EVD patient. HumanResources is still finalizing wording anddetermining the details of what happens withfinances if an employee is furloughed.

• S. Calderwood, M.D. raised an issue related to the updated CDCguidance as follows:

o The new CDC guidance adds to the ‘low risk’ categoryanyone who has been to Sierra Leone, Guinea, or Liberia in

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the past 21 days and requires active monitoring of such individuals even if they are asymptomatic. This concern was brought up by Oncology since patients come from Liberia to the MGH for routine care. In addition, patients traveling to the MGH from affected areas for routine surgery would have to be isolated and treated as EVD patients if they developed a fever post-op. S. Calderwood, M.D. expressed concern about having the capacity toisolate such patients as suspected EVD cases and suggestedgathering data on how many patients are coming to theMGH from the affected areas; the group should considerwhether elective care for patients from these areas shouldbe postponed or whether patients should be offered theoption of doing a voluntary 21-day quarantine beforecoming to MGH. It was noted that such patients must gothrough the Massachusetts Department of Public Health.

o J. Nally, R.N. asked whether this changes the screeningprocess in clinics, but it was clarified that our casedefinition has not changed.

o J. Ives Erickson, R.N., D.N.P. pointed out that anothergroup of patients comes to MGH through the InternationalCenter; it was recommended that A. Kimball, M.D.,M.P.H., P. Dunn, M.D., D. Tenney, R.N., B. Orcutt, andL. Carbunari, R.N. do a deep dive to understand howmany patients may be affected by the new guidelines. Inaddition, it was pointed out that given the media attentionon the nurse being quarantined in Maine, staff will continueto ask about what MGH’s policies are.

K. Whitney,R.N. and T.Gallivan, R.N.

Operations and Planning Update

• K. Whitney, R.N. and T. Gallivan, R.N. provided an operations andplanning update, having conversed with P. Biddinger, M.D.;attendees were provided a grid of outstanding questions and issuesin progress as follows:

o Departments are anxious to receive a finalized PPE trainingplan and timeline. J. Nally, R.N. reported that faculty has been trained

and is ready to resume end-user training on the N95PPE tomorrow, 10.31.14; the appropriateequipment should be on each unit, and the trainingdocumentation is available on the Infection Controlwebsite. Faculty will be trained to use PAPRs nextweek.

M. Hughes, R.N. clarified that although staff is notyet trained on the new sequence for the N95 PPE,we must emphasize that the completed training isacceptable to care for a patient who walked in thedoor today. T. Gallivan, R.N. articulated that theprevious trainings have established importantfoundational knowledge on donning and doffing. J.Ives Erickson, R.N., D.N.P. clarified ourphilosophy that although we want to move to ahigher level of PPE, if a patient came through the

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door we are prepared to safely provide care; it was suggested that this message be incorporated into the next communication.

E. Shenoy, M.D., Ph.D. clarified that we need tocontinue working on the Trained Observer and SiteManager roles and J. Nally, R.N. suggested that wewill continue to build on our PPE, curriculum, andtraining.

D. Reisman reported that the large, multi-disciplinary groups assisting with PPE and trainingare helpful, yet there are many opinions and fewpeople who feel comfortable making decisions; theneed to more quickly adapt to changing CDCguidance was identified. J. Nally, R.N. also notedthat although we want to train to the PPE wecurrently have, we have to plan ahead.

• R. Seger announced the EmergencyPlanning team’s request for an individualwith clinical, administrative, andeducational skills to manage the trainingcentrally for the ED, PICU and MICU (e.g.manage training schedule, incorporate newCDC guidelines, communicate changes,etc.). Monica Staples, R.N. was identifiedas a clinician with HazMat experience whois already a member of the faculty whowould be ideal in this role.

• J. Ives Erickson, R.N., D.N.P. summarizedthe situation: J. Nally, R.N. and G. Chisari,R.N., D.N.P. have been working oncurriculum development, individualstrained in HazMat were freed from theirusual responsibilities to serve as faculty,we paused training until we received anupdate on PPE availability, a trainingstructure was developed but someone isneeded to manage it, and M. Staples, R.N.has been identified as a strong candidatefor becoming the point person for training.K. Whitney asked T. Gallivan toinvestigate how to free up M. Staples,R.N. from her usual responsibilities soshe can become the full-time pointperson for training through at least theend of the year.

o Another unanswered question is whether we have aconfirmed plan for showering, clothing, and shoes. It was reported that although we do not yet have a

product for shoes, Materials Management has aplan for providing a shower kit that will contain achange of scrubs, etc. Once shoes arrive, they will

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be placed on carts. E. Raeke reported that the MGH Gift Shop may be able to help source inexpensive shoes.

E. Raeke reported that there are two showers oneach unit available to staff exiting the doffing area.In addition, G. MacNeil has ordered a portableshower that is easy to hook up; there is potential forplacing it in the doffing room. J. Ives Erickson,R.N., D.N.P. pointed out the need to understandthe specifications of the portable shower beforemoving forward with the construction plans forthe units.

The question remains about how to deal withshowering after a breach. E. Shenoy, M.D., Ph.D.suggested that showering could be incorporated asthe last step in the doffing process. J. Nally, R.N.clarified that there are two processes, one forshowering after a breach and a second forshowering for comfort; J. Nally, R.N. suggestedthat showering for comfort be the last step in thedoffing process since this will be the most commonoccurrence, but that additional written guidance beavailable for showering after a breach. E. Shenoy,M.D., Ph.D. will update the Infection Controlplan with detail about showering after a breachfor the various units; faculty will be referred tothe plan as a resource for answering questions.

o There is a need for clarification regarding transportingpatients from the ED to the MICU or PICU. E. Shenoy, M.D., Ph.D. clarified that Police &

Security should avoid contact with the patient andthat the MICU or PICU team will come in PPE toretrieve and transport the patient in a controlledfashion.

T. Gallivan, R.N. reported on a conversation withP. Biddinger, M.D. wherein two scenarios wereidentified: 1) a non-symptomatic patient in the EDcould be walked to his/her final destination and fullPPE is not required and 2) a symptomatic patient inthe ED would require full PPE for transportation. Itwas noted that having caregivers walk through thehospital in full PPE may cause alarm and that wemay not want even an asymptomatic patient to bewalking through crowded areas of the hospital. B.Michelman emphasized the importance ofcommunicating with Police & Security when apatient is being moved because the team can assistwith clearing hallways, commandeering elevators,etc.

It was pointed out that other institutions arebypassing the ED when possible because it is one

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more place that requires rapid bed availability; it was noted, however, that it could take 2-4 hours to set up the wall and prepare the MICU to receive an EVD patient. It was noted that there are two distinct scenarios, one where the patient is being transported from a distance, which would give us time to set up the MICU or PICU, and another in which the patient is quite close to the hospital.

B. Michelman emphasized the importance in beingspecific about which routes (stairways, elevators,etc.) will be used to transport patients.

J. Ives Erickson, R.N., D.N.P. reported that theBrigham is using a recently completed enclosedgarage as a staging area from which they wouldquickly move into an endoscopy unit; we do nothave such capacity at MGH.

A. Prestipino suggested that it would be helpful tocreate a flow chart depicting the entire plan,referring to supporting documentation relevant toeach step; as Incident Commander, J. IvesErickson, R.N., D.N.P. should have this centraldocument. A. Prosswimmer, K. Whitney, R.N.,and E. Shenoy, M.D., Ph.D. to create a flowchart.

o With regard to medical emergency interventiondocumentation and flow sheet documentation, it wasreported that a solution using eBridge is being investigated;M. Hughes, R.N. clarified that the ED already haselectronic documentation.

o It was reported that pharmacy is working on a mini code kitfor drugs that may be needed early in a code, plus anti-emetics, anti-diarrheals, and electrolytes. J. Nally, R.N. pointed out that it may be wise to

refer to the kit as consisting of emergencymedications rather than calling it a code kit becauseit is unclear whether care will be provided during acode; it was mentioned that an Ethics group willconvene next week to discuss this issue.

E. Shenoy, M.D., Ph.D. to provide K. Whitney,R.N. and the pharmacy with a list of additionalmedications that might be useful, like malariamedications.

o Various issues are outstanding with regard to the lab asfollows: The lab is asking for clarification about required

PPE and would like to be included in PAPRtraining; J. Nally, R.N. reported that arepresentative from the lab will be trained to thefaculty level. E. Raeke reported that a possiblesolution to the PPE issue is to invest in bio-containment equipment that would eliminate the

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need for significant PPE and would be useful beyond EVD; it costs $140,000 for two units. It was also pointed out that reserving part of the lab for EVD testing could result in delays for other areas of the hospital; such delays would be eliminated through an investment in the bio-containment equipment. J. Ives Erickson, R.N., D.N.P. stated that the group feels the investment iswise, but there is a need to understand theassociated capital, lease, and operating costs.

• J. Ives Erickson, R.N., D.N.P. and C. Aienaclarified that a budget is important, butjudgment on spending should be based onwhether the plan is the right one. There is acentral cost center to which expenses canbe charged, but where possible, it isimportant to identify what is operationaland what is capital. C. Aiena noted thatancillary items should be kept in a listbecause federal funding may becomeavailable at a later date.

It was noted that the lab must be included in thewaste disposal plan.

• S. Calderwood, M.D. asked about whetherwe have been in communication with wasteremoval teams and Boston Sewer, etc.; itwas clarified that since MGH has anautoclave, this is not as great a challenge.

With regard to transporting specimens to the lab, K.Whitney, R.N. reported that a group is meeting todiscuss POC testing. It was clarified that either theRN or RRT will draw the specimen in the room,and that a member of the team will hand deliver thespecimen to the lab. It was suggested that Police &Security escort anyone bringing a specimen to thelab.

• K. Whitney, R.N. reported that the lab ishappy to do all testing themselves if we donot want to do POC testing in the room.

• J. Nally, R.N. reported that there is aDOT requirement that only atrained/certified individual can(HAZMAT) package a specimen fortransport outside of the hospital; E.Shenoy, M.D., Ph.D. to follow up withthe lab.

o Various issues were discussed related to psychologicalsupport: D. Burke, R.N. is investigating whether pediatric

funds are available to purchase iPads that can be

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used to facilitate communication between EVD patients and their families in all three care areas.

• It was noted that although D. Burke, R.N.is assisting with the iPad project, M.Gioella, MSW is working on many of thepsychological support issues.

P. Slasman reported that B. French, R.N., and thePublic Affairs team have collaborated on creatingtwo informational documents, one for visitors andanother for staff. It was noted that there needs to beconsistency in messaging and that there needs to bea mechanism for making sure all documents are upto date. In addition, documents must be translatedinto other languages.

A. Prestipino reported that there will be a pressconference on 10.31.14 regarding the preparednessof the 7 large teaching hospitals in the area; thegroup discussed whether there needs to be internalmessaging about preparedness since staff will seethe news and hear that MGH is one of theinstitutions that may care for an EVD patient. P.Slasman reported that a blurb was going to beincluded in the next From the Desktop but that dueto confusion, it was removed; it can be reinserted orthere may be a need for a separate communication.In addition, P. Slasman pointed out that the 7hospitals were being called “referral centers,”which was concerning, but this language will notbe used during the press conference.

• J. Ives Erickson, R.N., D.N.P. added thatthe feedback on communication that hasgone out to the workforce has been positiveso it should be continued, and thatcommunication for visitors mustcontinue to be developed. It was notedthat communication for visitors shouldbe translated to Spanish, French, andKrio as it was for the travel posters. Foodtray communications were noted as apossible strategy.

• P. Slasman stated that Public Affairs has aprocess for holding community lecturesthrough the Russell Museum that could beutilized.

o K. Whitney, R.N. reported that there have been requests fortown hall meetings specifically for staff from EVD-designated areas, plus the lab and respiratory care. The frequency of such meetings remains a

question; R. Seger volunteered to assist with thescheduling.

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A. Prestipino pointed out that once a master flowchart is created, it can be shared with all areas andthen specifics for the area in question can bereviewed.

o There remains a need for a plan for backup equipment. The need for a central monitor in the MICU was

emphasized.o There is a need for additional guidance on MGH’s process

for quarantine. E. Shenoy, M.D., Ph.D. clarified the guidance for

MGH staff caring for an EVD patient. Absent abreach, staff can continue their work with twicedaily monitoring (what CDC calls “active directmonitoring” wherein one of two temperatures a daymust be taken by another individual; thisresponsibility may be designated to OccupationalHealth but Massachusetts authorities have yet toclarify). The plan for accommodations whenthere is a known exposure is still being discussed;K. Whitney, R.N. relayed that staff is reluctant toreturn home to their families if there is a breach.The CDC states that if an individual is in the high-risk category but asymptomatic, he/she shouldremain at home. S. Calderwood, M.D. expressedconcern around the message that if caretakers havean exposure they cannot go home; EVD is notcontagious until symptoms emerge and we will notbe able to manage all of these individuals in thehospital. J. Ives Erickson, R.N., D.N.P. pointed outthat since many will reflect on the New Yorkexperience, it is important to clarify in the townhall meetings which policies originated in NewYork and which with the CDC.

E. Shenoy, M.D., Ph.D. clarified that the policy forstaff returning from West Africa is furlough for 21days.

E. Raeke Update on PPE

• E. Raeke provided an update on PPE as follows:o We have received the first shipment of 250 PAPR hoods,

but we have not yet received any of the PAPR hosesrequired for use with PAPR hoods.

o Within two weeks, we should have over 800 PAPR hoods.o The new suits should arrive on Monday, including larger

sizes (3x, 4x, and 5x).o MICU construction will occur on Monday, the ED door

will go in on Wednesday, and there was a meetingregarding construction in the PICU scheduled for the sameday, 10.30.14.

• The group discussed the need to clarify the notification plan forwhen a patient arrived; is Code Disaster a reasonable way to notifyeveryone about a suspected EVD case?

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o It was pointed out that there are various trigger points,including erecting a wall, transporting PAPRs to the unit,etc.

o It was determined that the group should revisit thetelephone tree that outlines who pages who at whichstage of the process; B. Seger to re-circulate.

o The group was reminded that all up-to-date documents arehoused on the Infection Control website.

J. IvesErickson,R.N., D.N.P.and R. Seger

Conclusion • It was reported that there is a meeting of the larger HICS groupevery Tuesday.

• It was determined that this HICS Senior Command group wouldmeet again before the larger HICS meeting, specifically on Friday,10.31.14 at 1PM.

o D. Reisman highlighted the value of getting the HICSSenior Command team together to make decisions,especially with regard to PPE; an outstanding question iswhether we should adopt a tiered approach for PPE.

Logistics Chief Raeke

Planning Chief Biddinger

Finance Chief Aiena

Operations Chief Whitney

Facility Unit Leader MacNeil

Env Services Banchiere

Biomed Engineer Volpe

Situation Status Krupa, Prosswimmer

Human Resources Taranto, Larkin

Training/PPE Nally

Medical Care Gallivan

Ancillary Services

Ambulatory Kimball, Sapir

ED Biddinger, Hughes,

McIntyre

MICU Bajwa, Livelo,

Ananian

PICU Cummings Kelleher,

Beauchamp

Labs MacMillan

Radiology Shore

Respiratory Kacmaryk

Nursing Schnider

Incident Commander J. Ives Erickson

Public Information Officer Slasman, Marshall

Safety Officer Castaldo

Security Officer Michelman, Crowley

Senior EM Advisor Hughes, Biddinger

Liaison Officer Nally, Krupa

Medical Officer Nicholson

Compliance Officer Belknap

Emergency Mgnt Coordinator Reisman, Seger

Biological Agents Advisors Hooper, Shenoy,

Calderwood

Chiefs of Service

Occupational Health Gottlieb

Training Managers Staples, Chisari

Senior Advisor A. Prestipino

Infection Control Suslak, Wright

ED Site/PPE Managers

MICU Site/ PPE Managers

Concierge RN

Psychological Support

Herman/Gioiella

Ebola Viral Disease Hospital Incident Command System

October 2014

HICS Senior Command Meeting November 6, 2014

• Debrief on tabletop – Dr. Biddingero Purpose was to examine interfaces between ambulatory/ED/unitso Did identify areas where we need to do additional planningo Needs to be followed with full-scale exercising – planning for unit exercises are well

underwayo Please send feedback – very successful and as always, one step in the processo We will make it clear what the issue is, who is responsible (which section)

• Lab proposal (Donna MacMillan and Kent Lewandrowski)o Kent Lewandrowski - Introduction – to provide lab support for this effort, currently using

microbateriology biosafety hood – iSTAT for electrolytes etc., mini blood culture devicefor malaria – don’t have to use large, automated machine

o Amount of testing done in a small area is limitedo Pathology put together a wish list of things needed to prepare

Optimal thing is to have a biosafety cabinet, which is a glove box that allows forhandling of specimens and instruments – safer and will allow for expandedmenu of tests

• Dr. Lewis, chief of pathology, very supportive• Could take up to 8 weeks – sooner we can make a decision, sooner we

can get the process going Other instrumentation would allow potential expansion of the test menu

• For example – Biofire – measures spectrum of pathogens includingbioterrorism agents – do have an ebola test

Biggest wish list is glove box, which allows doing testing in a safe mannerwithout PPE

o Ann Prestipino – propose we do it all and do it righto Donna MacMillan – cabinets are 8 weeks out – other devices are more easily acquired

but do need to do standard validation process – manufacturers will have validation kits There may be some backorders

o Ann Prestipino - any associated renovation or installation? Donna - Do not think so, but starting that discussion, biosafety cabinets are

mobile• Update from MHA Department of Public Health Call – Dr. Biddinger

o CDC held a call with 6 (now 7 – Children’s) hospitals that would be willing to receive acase

o Erica and Katie on callo 1) Moved goal posts – agreement was that hospitals were expected to identify a

hospital to which they would refer an EVD patient...CDC wants to designate whichpatient goes where

o 2) Patients are not going to be leaving the state once they come into one of our centers– we have been planning for this all along, the Brigham has not

o November 11, 2014 – another call with DPHo Partners call – later today, November 6, 2014

o Our planning assumptions are consistent with state, and only in bad shape if we are the only hospital left in the state to accept a patient

o Ann – are other hospitals beyond Brigham challenging? Erica - BI said it would be a real challenge because close down a ward...rest of

the hospitals seem okay Dr. Biddinger - Brigham made a public statement that they would transfer

someone in a few days Dr. Biddinger - Patient with suspect EVD at the BI – ED volume down 27% the

following day until that patient was discharged o Ann – get those in Dr. Biddinger’s role from all hospitals in the same room to review

plans might be helpful Started among physician leaders last night

o MHA was going to take this with the Brigham and come up with a proposal o Some proposing a standalone facility – not a good idea short-term but maybe for long-

term For region, should create a bio-containment facility – might help prevent some

of the operational impact we are talking about – real cost is in the capital (only $37,000 a year operating budget at Emory when unit not in use)

o Cindy – concern about language that federal funding will only be available to federally-designated centers – since MA didn’t have one and you’re one of the 6 receiving hospitals maybe can get it – we should think about the financial impact Ann – if need be, we will work with governor to say MGH stood up and said it

would help • Operations Update – Kevin Whitney

o Asked MICU and PICU to review med list provided for kits – should have finalized today – pharmacy will deliver to room if have patient

o Talked with Joe Crowley this morning about floor plans and mapping out routes from ED to units – may need to change existing VIP routes Write into plan, work with Erica to outline the escort process

o Work with MICU and PICU on site manager plan (Theresa working with units) Unit based and IC duo for this – Erica

o Theresa was successful in ensuring Monica is able to devote full-time to working on PPE Training for remainder of year. Has completed training plan and is working closely with leadership to expedite registration of nurses, physicians and other care team members in MICU, ED and PICU. Training includes all shifts and weekends. Cindy – are we taking folks off floors or training during shift? Both

o A few other things on the list that require follow up • Training and PPE update – Jacky Nally and David Reisman

o PAPR training for faculty has happened this week – tomorrow is a final session – some have started end user training for PAPRs By next week, we will be full scale on PAPR training but do not have an

adequate supply to roll out PAPRs so looking at two weeks We have between 1 and 2 days of PAPR supplies

o Still catching up on N95 revision training o Monday – scheduled meeting with Gino to look at simulation to start some of the

clinical training in PPE for some of the invasive procedures Can Jim Gordon be helpful in terms of expanding? (Ann) – maybe work with

Knight Center and Jim Gordon

There was a request to do as much training off the unit as possible to minimize disruption so trying to pursue simulation

o Andy Gottlieb – if potential that we will do N95 PPE, should we consider re-fit testing before we get a patient? Current policy is medical screening and fit testing at new hire and as needed – PICU and support staff especially – reassure people that they are the size they think they are If we can get a roster of all people being trained – it is an OSHA standard to have

them medically screened Nursing Directors have all reports – support and professional staff is Andy’s

worry? Jacky send Andy training rosters

o Walkthroughs – is there an expectation that the rooms on the units will be held? Dr. Biddinger - Start with walkthrough without making the room open, we will

have to do a full-scale exercise including the room later • Occupational Health – Andy Gottlieb

o As of right now, have not been able to find written guidance from CDC (emailed state and BPH) about excluding certain workers – assume we would exclude pregnant and immuno-compromised workers but no written guidance Unless we want to internally exclude them, it is self selection Staff are being protective of pregnant colleagues – leave it alone

o Working with Hilarie about those who have gone overseas – Following CDC guidelines with regard to monitoring – if the state delegates

monitoring to us, that’s fine • PIH will provide rosters if know that they are from MGH • Anyone coming and going, we are monitoring

o Document for Partners being presented next week • Ambulatory – Alexa Kimball, Erica Shenoy, Bob Seger

o Bob - ask Dr. Kimball if there are issues this group needs to address? o Two weeks ago there were many questions – lots of communication o Moved towards standard communication platform o Various types of communication

Practice support unit to practice managers Did not have a distribution list for ambulatory physician leaders – putting this

together – may need help identifying these people – first bulletin sent today o There are a few questions about the signs, but no suggestions were much value added o Not many equipment issues – people feeling pretty secure o Site sweeps looking for signs (plus flu) o Dee Dee and ICPs who cover ambulatory have been going to locations and answering

questions • OB Patients – Jeanette Ives Erickson

o This is part of containment of trying to keep patients to two inpatient units and is consistent with OB patients who are critically ill (moved from OB to MICU or SICU) If patient presented and pregnant, would go to the MICU

o Question Jeanette got yesterday – periodically there are patients who are pregnant coming from other countries not for planned care but have pains etc. and show up to MGH – what happens if they have a patient in their big triage area who starts to bleed, etc. – we need to do a walkthrough with them similiar to what we are doing in ambulatory

o Dr. Biddinger – we think this is extremely unlikely since everyone from those countriesare being followed by public health so if they are at-risk we should have advancednotice – plus we have been drilling the security protocol, volunteers, valets to bringpatient to ED if worry about EVD

o Have talked to OB about how to dress and get down to MICU – will be a fluid issueo Jeff Ecker and Laura Riley wrote guidance – because outcomes are so poor, no

recommendation for fetal monitoring...assistance with delivery is from a distance –discussed at Ethics meeting

o Maryfran – who is the team delivering baby? attending plus L&D nurses – already beenthrough PPE training – would join ED attending and RN in the room

o Epidural? Perhaps just morphineo We don’t know how data from Africa translates here but neonatal mortality has been

essentially 100%o Walkthrough on how to get patient to MICU plus discussiono Planning to have open sessions for designated providers (OB included, anesthesia, ID)

Theresa and Paul to provide a list of those who need to be trained from OB Putting an updated training schedule in the IAP as well as on SharePoint site Are we making recommendations on numbers? Leave it to them to determine

sufficient numbers for coverage – e.g. anesthesia chosen enough that they willalways be on RICU schedule

• Planning Update- Dr. Biddingero Still training on N95s and that is our operational plan

Surgical hood is here and will be incorporated into training If we did get a patient today, we may need to burn through staff more quickly

because of heat stress issueso Commissioner of Public Health Bartlett will come here tomorrow to observe training

and showing involvement with hospitals Peggy – Commissioner wanted to visit the hospital – news saying hospitals not

stepping up to the plate and she’s not supporting – visit to counter this – she iscoming at 1:30 – Ann meet her in the lobby and walk her along the path of apotential EVD patient (present in ED, are people there ready, walk back toHAZMAT room), David/Paul there – go to the training room where there will bea PPE Training and then come into Wilkins for overarching discussion aboutpreparedness

Ann – strongly suggest the group that comes back here...let Paul drive it (e.g.Erica, will you please address that question) – make sure we have the rightexperts speak to the issues she may raise

Peggy – had conversation with communications person from Commissioner’soffice – number of cameras – put all in training room because will be mostvisually interesting place

Monica and Todd are doing the training and are on board with the plan Bonnie – send a communication so people do not see media vans and hear the

commissioner here and assume we have EVD?• Peggy – Commissioner and 5 others – should not attract much attention

and should be pretty self contained – we will know later today abouthow much media interest there will be

Peggy – idea we want to try to convey is that the Commissioner is working withhospitals

Jeanette – MICU nurse at Staff Nurse Advisory spoke up about how confident she felt

• People assume that if they don’t know about it, it’s not happening – weekly emails great

Bob – if people get separated, can you have a Public Affairs person in each place o Moving into more specialty concerns e.g. psychosocial, security, ethical/legal o Overall patients from public areas plan – Bonnie’s staff provided draft plan and will get

back to them Ambulatory / non-ambulatory and sick/non-sick determines whether walk and

PPR – final destination is ED o Strongly recommending that people don’t actively ask EVD questions if someone is

having a medical emergency and more likely to leave someone there with a condition that is not EVD Need to send the right message that we are caring for everyone If EVD is identified by patient, we will respond

o Bob Seger was in process of scheduling town halls for units – still in progress, asking IC folks about being faculty for that – very informal, on units, not a PPT, more like a Q&A – Maryfran had mentioned questions about the science – some of the panic has gone away Town Hall – 300+ there, 700 people streamed in for the first one

o Incident Action Plan – different formatting – if we could change everyone’s reporting structure and give each section chief a format they could report priorities in top and action items underneath Provide a template that section chiefs can complete and we put into the IAP –

reviewing these documents, there is a lot on them • Crosswalk to make sure that someone on there doesn’t fall off when we

IAP will cover a length of time so things will fall off of it Targeted completion dates – we can add it to the sheet

• Logistics Update – Dr. Biddinger o Renovations for ED done tonight MICU rooms are re-opened, PICU has no renovation o Questions about PAPR rehab o Shower for breach – ordered and being tested

• Finance Update – Cindy Aiena o Federal funding is the reason that we need to track (construction, purchases being made

to central cost structure) Have info on training Do we need to capture back fill when people are taken off the floor?

o A vague estimate of where we are would be helpful for conversations with Partners – may be delayed

Massachusetts General Hospital Log of Nurses in ED, MICU and PICU Trained in PPE & Ebola 101

October 31, 2014 - December 23, 2014

ED STAFF NamePPE Type

(N95, PAPR, or Both) Ebola 101 PPE Training DateAnahory, Lisa N-95 X 10.31.14Audin, Curtis PAPR X 12.8.14

Bisio, Ray N-95 X 11.4.14Breault, Kara N-95 X 11.8.14

Breed, Colleen Both X 11.16.14Burke, Kelly PAPR X 12.5.14

Collina, Shannon N-95 X 10.31.14Conley, David N-95 X 10.31.14Conly, Bridget Both X 10.31.14Curtis, Frank Both X 11.3.14Deletti, Marie Both X 11.1.14

Dupuis, Amiee N-95 X 11.4.14Ferdinand, Tanya Both X 11.13.14

Fleisig, Abby N-95 X 11.4.14Gagnon, Jason N-95 X 11.1.14Gilmore, Kristin Both X 11.3.14Halliday, Kerri Both X 10.31.14Healy, Caitlyn Both X 11.14.14Holland, Karen N-95 X 11.1.14Hughes, Sarah Both X 11.14.14Johnson, Diane Both X 11.4.14

Lamontagne, MaryAnne N-95 X 10.31.14Laskey, Amanda N-95 X 11.4.14Levinson, Hilary Both X 11.16.14

Liszanski, Elizabeth N-95 X 11.4.16Lordan, Julie N-95 X 11.16.14

Maillet, Robert N-95 X 11.4.14Marceau, Alyssa N-95 X 10.31.14

Maynard, Jennifer Both x 11.27.14McCarthy, Kathleen N-95 X 11.1.14

McGillivray, Ines Both X 11.16.14McLauglin, Joanna N-95 X 11.1.14

Murphy, Elise N-95 X 11.1.14O'Donnell, Michael N-95 X 11.3.14

Ouellette, Sarah Both X 11.13.14Presnick, Karen Both X 11.16.14

Protesewich, Rachel N-95 X 11.16.14Rallo, Karin N-95 X 10.31.14

Reardon, Jane N-95 X 12.23.14Reguera, Adriana Both X 11.13.14

Simpson, Beth N-95 X 11.4.14Sinclair, Elizabeth Both X 11.16.14

Stubbs, Kelly N-95 X 11.1.14Vareschi, Maria N-95 X 11.4.14

Vissering, Victoria Both X 11.13.14Wellen, Lisa Marie Both X 11.16.14

Wynn, Kerry N-95 X 11.4.14Zachary, Tracy N-95 X 11.4.14Zinni, Jairah N-95 X 11.1.14

MICU STAFF NamePPE Type

(N95, PAPR, or Both) Ebola 101 PPE Training #1

DateAdams, Ryan N-95 X 11.10.14 Bailey, Peter BOTH X 11.16.14

Calef, Cameron BOTH X 11.3.14Coyne, Gillian N-95 X 11.10.14Davis, Asheley PAPR X 11.22.14

de la Hoz, David BOTH X 11.19.14Diamond, Sarah PAPR X 11.14.14Dunbar, Coleen N-95 X 11.7.14Gaglione, Caitlin PAPR X 11.19.14

Hunter, Tom N-95 X 11.7.14 Mantia, Jennifer PAPR X 11.22.14

McCarthy, Christine N-95 X 11.4.14Merry, Nick PAPR X 12.3.14

Meyer, Shenley BOTH X 11.20.14Mover, Liz PAPR X 11.19.14

Navarro, Stephanie PAPR X 12.3.14Paschal, Kayla PAPR X 12.4.14 Perfetti, Kelly PAPR X 11.19.14

Politano, Stphanie PAPR X 12.4.14 Pratt, Neil N-95 X 11.8.14

Riley, Lauren N-95 X 11.3.14 Robertson, Valerie N-95 X 11.16.14

Ross, Kerri BOTH X 11.14.14Shell, Emily BOTH X 11.19.14

Tady, Michael PAPR X 11.19.14 Trahan, Robin BOTH X 11.14.14Voelkl, Kerri BOTH X 11.14.14

Wachter, Krista BOTH X 11.16.14

PICU STAFF NamePPE Type

(N95, PAPR, or Both) Ebola 101

PPE Training#1

DateBielinski, Jillian N-95 X 11.16.14Buck, Sarah PAPR X 11.19.14Carroll, Cristin N-95 X 11.6.14Cataldo, Jennifer N-95 X 11.5.14Chandler, Ashley N-95 X 12.02.14Cleary, Colleen PAPR X 11.5.14Cole, Rachel PAPR X 11.5.14Croll, Elizabeth PAPR X 11.5.14DeBarbrie, Caitlin N-95 X 11.6.14Gallagher, Barbara N-95 X 11.6.14George, Danielle N-95 X 11.6.14Holman, Cheryl N-95 X 11.13.14Huesgen, Debra N-95 X 11.19.14Kenney, Laura PAPR X 11.21.14King, Jeanette N-95 X 11.19.14Limone, Anna N-95 X 11.17.14McLaughlin, Dawn N-95 X 11.7..14Murphy, Kim N-95 X 11.5..14O'Gara, Kathy N-95 X 11.5..14Ogden, Lisa PAPR X 11.17.14Palumbo, Melissa PAPR X 12.02.14Paquette, Ellen N-95 X 11.19.14Ratto, Karen N-95 X 11.11.14Reardon, Jenna N-95 X 11.11.14Rothstein, Amy N-95 X 11.5.14Ryan, Jill PAPR X 11.21.14Samiotes, Jennifer N-95 X 12.8.14Simonds, Erin N-95 X 11.19.14Tavares, Nicole N-95 X 11.7.14Titus, Diana N-95 X 11.21.14Welch, Megan N-95 X 12.7.14Whalen, Kim PAPR X 11.12.14Woods, Allison N-95 X 11.11.14

Email to Leadership re: PPE Training (Nursing Leadership of PICU, MICU & ED highlighted)

From: Staples, Monica G., R.N. Sent: Tuesday, November 18, 2014 2:39 PM To: Nally, Jacquelyn M.; Fahey, Todd B. Cc: Bajwa, Ednan K.,M.D.,M.P.H.; Cummings, Brian,M.D.; Poznansky, Mark,M.B.,Ch.B.,Ph.D.; Warren, H. Shaw,M.D.; Drain, Paul K.,M.D.; Davis, Benjamin T.,M.D.; Robbins, Gregory K.,M.D.; Pasternack, Mark S.,M.D.; Nelson, Sandra Bliss,M.D.; Gelfand, Jeffrey A.,M.D.; Basgoz, Nesli,M.D.; Calderwood, Stephen,M.D.; Velmahos, George,M.D.; Fagenholz, Peter J., M.D.; DeMoya, Marc A.,M.D.; Wylie, Blair; Barth Jr., William H.,M.D.; Ecker, Jeffrey L.,M.D.; Riley, Laura Elizabeth,M.D.; Peccei, Alessandra,M.D.; Boatin, Adeline A.,M.D.; Hughes, MaryFran, R.N.;McIntryre, Joyce, R.N.; Harris, Catherine, R.N.;Kelleher, Arlene,R.N.; Beauchamp, Kathryn,R.N.;Livelo, Jeanette N.,R.N.; Ananian, Lillian, R.N.; Wright, Paula J.,R.N.; Keady, Susan,R.N.; Shenoy, Erica Seiguer,M.D.,Ph.D.; Nally, Jacquelyn M.; Biddinger, Paul,M.D. Cc: Whitney, Kevin, R.N.:Gallivan, Theresa, R.N.; Burke, Debra, R.N. Subject: PPE Training Schedule Importance: High

Thank you for your patience as we coordinate end user training. We are making great progress thanks to your engaged staff!

As always, the Infection Control website infectioncontrol.massgeneral.org/icu/ has the most current Ebola information for your review. In the training session, we will focus on donning and doffing personal protective equipment.

Please see the attached PPE training schedule. • The most up-to-date schedule (will be dated) is found on the SharePoint site:• sharepoint.partners.org/mgh/emergencypreparedness/EVD%20PPE%20Tr

aining%20Planning%20Group/Forms/AllItems.aspx • We are updating sessions as faculty become available.

Some notes:

• N95 training should be completed before attending a PAPRsession.

o Sessions that are marked OPEN can be attended by all staffhowever MICU/PICU staff should not attend sessions directedtoward the ED and vice-versa as PAPR equipment varies.(MICU/PICU using BULLARD and ED using ILC-Dover)

Please remember to:

• Send approximate number of attendees for each session toMonica Staples and Todd Fahey. This helps us to forecast thenumber of faculty members we need at each session.

Thank you. Please send questions and comments.

Monica