As state and local health agencies wrestle with Ebola preparedness policies, members of National Nurses United (NNU) gathered at their Oakland headquarters last week, calling for uniform protocols to protect healthcare workers as they care for patients with the lethal virus.

While the U.S. Centers for Disease Control and Prevention (CDC) is sending rapid response teams to hospitals with a potential case, both the CDC and the California Occupational Safety and Health Administration (Cal/OSHA) have set blood-borne pathogen guidelines prescribing proper care for a possible Ebola case. But NNU Co-President Deborah Burger said guidelines aren’t enough; they need enforcement.

Union organizers met October 21 with Governor Jerry Brown and representatives from state agencies such as the California Department of Public Health (CDPH) before the nurses’ latest press conference.

Katy Roemer, a registered nurse at Kaiser Permanente in Oakland, is calling on Brown to mandate that hospitals use “the highest level of personal protective equipment and have interactive trainings.”

After negotiations with Brown, NNU Executive Director RoseAnn DeMoro said she saw prospects for improvement, adding, “I think Jerry Brown will lead the nation in terms of figuring out how to protect nurses and patients and other healthcare workers.”

The nurse’s union also sent a letter to President Barack Obama listing the preparedness measures they say hospitals are lacking, DeMoro said. On the list were: HAZMAT suits, two registered nurses to every one Ebola patient, better one-on-one nurse training, and a requirement to meet or exceed University of Nebraska Medical Center standards.

“California’s workplace safety and health standards go further than national standards in protecting workers from hazards such as Ebola,” Acting Cal/OSHA Chief Juliann Sum said in a statement.

State standards already include personal protection equipment (PPE) requirements like gloves, impermeable body coverings, face shields, and respiratory protection. The standards also mandate a buddy system and dedicated areas for donning and doffing equipment.

Though the implementation of uniform guidelines has been slow-moving, DeMoro said the governor seemed to understand the nurses’ concerns. “I do believe his agencies are staying up overnight, they’re listening … they’re working with the nurses,” she said.

On October 24, the CDPH issued a statement announcing that all five University of California Medical Centers—in San Francisco, Davis, Los Angeles, Irvine and San Diego—were in position to provide treatment for confirmed cases of Ebola.

In light of that move, Dr. Erica Pan, deputy health officer of the Alameda County Public Health Department said at a gathering of communicable disease experts on October 27 that local hospitals also are doing their best to get ready. “I think we’re all doing a great job preparing,” she said, and pointed out that medical professionals are always encountering new issues “as we exercise our protocols, and as the hospitals and healthcare facilities exercise their protocols and plans.”

East Bay hospitals themselves say they are working to meet both updated Cal/OSHA guidelines and NNU requests. At UCSF Benioff Children’s Hospital Oakland, a multidisciplinary group has been meeting daily to prepare the hospital for the possibility of a patient with suspected Ebola, said Melinda Krigel, media relations manager.

Children’s will provide personal protection equipment that meets or exceeds CDC/OSHA recommendations, a cold room for donning equipment and a warm room for doffing contaminated gear adjacent to negative pressure isolation rooms, and provide specialized training to frontline staff, Krigel said.

Alta Bates Hospital in Berkeley said through a spokesperson that its parent organization, Sutter Health, had an Ebola Virus Response Planning Team monitoring the situation. Revised Sutter Health protocols call for no skin exposure for anyone treating a patient with the Ebola virus, and included a personal protection equipment monitor, buddy and checklist system.

The hospital is training all clinical personnel to identify and isolate a potential patient with Ebola, a fact sheet on the revised protocols noted. Alameda Health System, which operates Highland Hospital in Oakland and other public facilities in the county, didn’t respond to requests for comment on Ebola preparedness.

Some nurses say potential confusion first came to light when California’s first suspected Ebola patient was admitted to South Sacramento Kaiser on August 18.

The response highlighted the discord between health officials and frontline workers. Charu Bahuguna, chair of Northern California Kaiser’s infectious control committee, said South Sacramento followed strict isolation protocols developed just three days before the arrival of the patient—who ultimately tested negative for Ebola.

“There was an abundance of caution,” said Bahuguna. A dedicated monitor trained in infection control oversaw the donning and doffing of protective gear in an anteroom, and the staff elected to use universal shoe and leg coverings, as well as “chemo gloves” which are longer than traditional gloves, she said. “The staff repeatedly told us they felt very safe and very comfortable.”

“This patient was quickly identified, appropriate infection control procedures were implemented, and public health authorities were notified,” said CDPH Director Ron Chapman. “The system is working.”

But that sentiment wasn’t shared by all. Diane McClure, a registered nurse at Kaiser South Sacramento, said the patient sat in the ER for 40 minutes before he was looked at. She said he was in regular clothes and could have exposed everyone in the waiting room.

Nurses assigned to the patient were “not given anything close to proper equipment,” McClure said, but instead used standard gowns. She said they should have worn full HAZMAT gear, and said that some staff learned of the suspected case through word of mouth or the media.

Kaiser Permanente of Northern California said in a statement it was continuing negotiations with the California Nurses Association, which is part of NNU, and shared the union’s concern that necessary steps be taken to “protect their colleagues and our patients from infection with Ebola virus.”

And while University of California officials have said that their hospitals are ready —joined by UCSF CEO Mark Laret, who is also board chair of the California Hospital Association—registered nurses at the medical centers tell a different story.

“We are not prepared, not equipped, not staffed for even one Ebola patient,” Erin Carrera, an RN at UCSF Medical Center, said at a meeting of several hundred RNs with California regulatory officials last week. “We know that the communication to direct care RNs in every area is deficient,” added UCSF RN Maureen Dugan, who is also a CNA board member.

The nurse’s union wasn’t the only group left with questions about its preparedness. UCSF recently drilled for Ebola and still “had some learning to do,” said clinicians on a September 26 call hosted by the CDPH. Amy Nichols, director of epidemiology and infection control at UCSF, said it took time for the staff to remove supplies stored in the anteroom to the hospital’s only negative pressure Airborne Infection Isolation Room (AIIR), where Ebola patients would be treated.

She said the drill’s mock Ebola patient was never masked, and it took longer than she’d hoped for the emergency staff to triage the patient and notify her— about fifteen minutes.

Lab director Steve Miller also said blood samples could not be bedside tested for Ebola. They had to be carried to the lab in a neighboring building.

UCSF issued a statement on October 24 saying that an isolation unit was being constructed in one of the existing intensive care units on its Mount Zion campus, based on the bio-containment units at Emory University, and Nebraska Medical Center.

The NNU says it will continue to negotiate for nationally enforced guidelines, training, and equipment.

In the meantime, some union members said that California hospitals continue adhering to their own interpretations of preparedness. “We do not have standards,” said Zenei Cortez, a registered nurse at Kaiser Permanente. “One facility says … ‘Stay away three feet, you’ll be fine.’” But, she continued, “Nursing care cannot be provided from three feet away. There’s another facility that says ‘As long as the suspected Ebola patient stands within the green square until we figure out if they really have it … then you’re fine.’ We cannot provide nursing care like that. Because nursing care is hands-on.”