Testimony of Debbie White, RN, President, on the recent outbreak at the Wanaque Center for Nursing and Rehabilitation

Senate Health, Human Services and Senior Citizens Committee

Monday, December 3, 2018

Good afternoon Chairman Vitale and Members of the Senate Health Committee. My name is Debbie White and I am the President of Health Professionals and Allied Employees (HPAE). Thank you for inviting HPAE to testify today regarding the outbreak of the adenovirus at Wanaque Center for Nursing and Rehabilitation. HPAE represents over 13,000 health care professionals including nurses, mental health clinicians, research scientists, and professionals providing patient.  On behalf of the nearly seventy registered nurses and licensed professional nurses represented by HPAE Local 5107 at The Wanaque Center for Nursing and Rehabilitation I am here today to share their experience in caring for the children at the facility.

HPAE members, as the primary caregivers for the children at Wanaque, are deeply saddened by the loss of life and grave illness that has infected so many children at the facility. Since this outbreak HPAE has held weekly meetings to provide a safe place for workers to grieve and connect with their colleagues who are struggling to continue to treat their patients while working to stop the spread of the virus. Tears are shed at every union meeting as members share their memories of times spent with the children.  The care they provide is personal because for every child, Wanaque is not just a place where they receive medical care rather it has become their home.

The priority of our nurses is to provide the best care for their patient.  Yet without the appropriate policies and resources, the nursing staff struggle to provide the kind of care they know patients need. We are dedicated to fighting for solutions that prevent viral, and now fatal, outbreaks from claiming the lives of patients in the future, whether at Wanaque or any facility in the state.

The 34 adenovirus cases that were found in patients and one staff member at Wanaque highlight three specific needs:

• the need for safe staffing legislation
• The need for enhanced quality improvement initiatives
• the need for increased oversight and transparency

Safe Staffing Legislation

Members at Wanaque, which is owned by the for-profit corporation, Continuum Healthcare LLC, have consistently reported short staffing. Because Wanaque’s pediatric patients are a fragile population, meaning they have compromised immune systems and require an intense level of care, the need for safe staffing is all the more highlighted. Research shows that higher staffing levels are linked to lower rates of patient falls, infections, medication errors, and even death. And when unanticipated events happen in a hospital resulting in patient death or injury, inadequate nurse staffing often is cited as a contributing factor.[i] Many public health experts have concluded that understaffing in periods of increased work load can result in outbreaks of nosocomial infections, otherwise known as hospital acquired infections, and should be avoided.[ii][iii]

When nurses are assigned too many patients, their ability to respond quickly and adequately to patient needs and to provide safe and quality care diminishes. When safe staffing levels are implemented, nurses are better able respond to patient needs, and patient care and safety are improved.

Under the leadership of Commissioner Elnahal, the NJ Department of Health has taken steps to ensure staffing levels at Wanaque are meeting the needs of the current crisis situation. The need to quickly staff up in a time of crisis, however, is reactionary and highlights the need for a more proactive, state mandated, safe staffing legislation or a revision of current regulations.

Nurses at Wanaque must provide frequent observation to ensure patients are stable, but since these particular patients can decline quickly and may require a higher level of care, it is especially important to always have adequate staff present.[iv]  Adequate staffing is essential to detect any early changes in status.

As the Legislature considers passing bills to improve staffing levels in healthcare facilities, HPAE asks that the Department of Health evaluates the regulations (N.J.A.C. Chapter 39) which establishes Standards for Licensure of Long Term Care Facilities to consider revisions to mandatory nurse staffing requirements.

Enhanced Quality Improvement Initiatives

As already mentioned, the pediatric patients infected by the outbreak had severely compromised immune systems. Because these patients are at high risk for infection, there are additional precautions the Wanaque facility should have taken to protect the children from exposure. HPAE recommends the following CDC guidelines [1]:

• Strict Isolation: Pediatric patients on Strict/High-Risk Isolation, such as the patients at the Wanaque facility, require a private room[v] with dedicated staff.
• Oversight by specialists: Once this deadly infectious disease was identified in the facility, an infection control specialist should have been onsite. Their scope of work includes the oversight and monitoring of employee infection prevention practices, implementation of prevention measures and planning for outbreaks.[vi]
• While these practices are currently in place, it is clear that these steps occurred only after the NJ Department of Health intervened. Therefore, it is imperative that the government officials review and continue to monitor Wanaque’s compliance with infection prevention and control practices, in accordance with New Jersey State Law and CDC Guidelines.

The Department required Wanaque to hire a certified Infection Control Practitioner (ICP) and a Department-approved physician or practice certified in infectious disease. It appears that the plan in place was not adequate plan to address and contain the infection. We recommend that Wanaque and all facilities create a plan to address this moving forward.

The Wanaque Center has a responsibility to provide training to all health care professionals in the facility on infection control. We believe current trainings are inadequate. We suggest that facilities provide ongoing trainings at appropriate intervals, so all workers stay abreast of proper infection prevention protocol.

Increased Oversight and Transparency

During the Christie Administration, NJ DOH experienced a reduction of inspection staff.  This can make it more difficult for the state to ensure that adequate infection control procedures are being followed before a time of crisis. After inspections are conducted, there must be follow up on the plan of corrections to enforce and monitor conditions in facilities. We encourage the NJDOH to prioritize hiring a substantial number of staff to ensure the plan of correction is being followed.

Thank you for the opportunity to speak to you all today and I welcome any questions that you may have for me.

[1] Guidelines for Care of the Immunocompromised Patient and Guidelines for Isolation Precautions

[i] https://www.infectioncontroltoday.com/occupational-health/rn-safe-staffing-bill-introduced-congress

[ii] Harbarth  S, Sudre  P, Dharan  S, Cadenas  M, Pittet  D. Outbreak of Enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices. Infect Control Hosp Epidemiol. 1999;20:598–603.

[iii] https://wwwnc.cdc.gov/eid/article/10/11/04-0253_article#r22

[iv] https://degree.astate.edu/articles/nursing/high-acuity-nursing.aspx

[v] https://infectioncontrol.ucsfmedicalcenter.org/41-guidelines-care-immunocompromised-patient

[vi] https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf