Lessons Learned from SARS: The Hospital Perspective

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Lessons Learned from SARS The Hospital
Perspective
Brian Schwartz, MD. CCFP(EM), FCFP Sunnybrook and
Womens College Health Sciences Center Assistant
Professor, Faculty of Medicine, University of
Toronto Vice-Chair, Ontario SARS Scientific
Advisory Committee
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City of Toronto

• Canadas largest city
• 2.5 million residents
• 5 million people most business days
• 632 square kilometers
• Financial capital of Canada

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City of Toronto

• One-third of Canadas population is located
  within 120 miles of Toronto
• One-half of the population of the United States
  is within a 1 days drive
• Canadas 1 tourist destination with 21 million
  visitors in 1999
• 48 of residents were born elsewhere
• Canadas gateway to international marketplace

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City of Toronto home of famous celebrities!
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Ontario
Popn 829, 800
Popn 10, 839, 500
Total Population of Ontario 11, 669, 300 in the
Year 2000
Metropolitan Areas 8, 339,
500 Non-Metropolitan Areas 283, 400
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Outline

1. What happened and what we found out
2. Safety Personal protection
3. Containing the Outbreak
4. Maintenance of Services
5. Lessons for the future

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What happened? Demographics

• 375 probable/suspect cases (40 HCWs)
• 44 deaths (3 HCWs)
• Mortality higher with age (3lt60, 53gt60), and
  comorbidity
• Transmission associated with sicker patients,
  less protection, aerosol-
  generating procedures

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Impact of SARS on Toronto Hospitals

• 3 Toronto hospitals closed to admissions for
  varying periods
• 2/3 of hospitals had SARS patients
• Services affected in all hospitals
• Minimal surge capacity
• Some capacity in LTC

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Toronto Hospitals
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Toronto Hospitals affected by SARS
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What we found out

• We were neither prepared for communicable
  diseases nor a major emergency event
• Providing ED care was a huge challenge due to
  staff illness, quarantine and protection issues

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What we found out

• Our weaknesses were exposed
• Overcrowding
• Poor infection control
• Lack of emergency preparedness
• Staffing and resource vulnerability

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2. Safety Personal Protective Equipment

• Evidence vs. Emotion

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April 13, 2003
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April 13, 2003
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April, 2003

• 9 HCWs contracted SARS after caring for a
  patient, despite using PPE
• 6/9 were present during intubation
• Led to
• widespread concern about and increase in levels
  of PPE worn, and
• Recommendation for higher level of protection
  for high risk procedures

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PPE Evidence?
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Standards Levels of Evidence

1. Positive RCTs
2. Neutral RCTs
3. Prospective, nonrandom
4. Case series
5. Animal studies
6. Extrapolations
7. Rational conjecture

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Level of Evidence 1
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Level of Evidence 6/7
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Best Evidence for PPE April 2003

• Expert opinion
• Anecdotal lessons learned
• Extrapolation to other venues

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Emerging Evidence Seto et al, Lancet, May 2003

• Lower risk of HCW acquiring SARS with
• Gown P.006
• Gloves OR 0.5 (.14,1.6)
• Handwashing OR 0.2 (.07,1)
• Masks OR 0.08 (.02,.33)

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Seto et al Conclusions

• Droplet precautions (handwashing, masks, gowns
  and gloves) are effective in reducing the risk of
  infection after exposure to patients with SARS
• Reduction significant only for masks
• No caregiver who practiced all 4 measures became
  infected

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PPE Recommendations 2003

• Droplet precautions (surgical mask eye
  protection) for Febrile Respiratory Illness
• N95s, face shield, gowns, gloves, for suspected
  SARS patients during outbreak

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Exposure Risk in ICU

• Loeb et al. Emerg Inf Dis Feb, 2004
• 8/32 ICU nurses entering room vs 0/11 others
  (P0.09)
• Risks
• assisting with intubation RR4.2 (1.5, 11.1)
• suctioning before intubation RR4.2 (same)
• Nebulizer Rx RR 3.24 (1.1, 9.4)
• manipulation O2 mask RR9.0 (1.3,65)

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Aerosol-generating High-risk Procedures

• Intubation
• Airway suction
• Nebulized therapy
• Positive pressure ventilation

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What happened?

• It became clear that even if SARS was not
  transmitted by airborne spread, aerosol
  generating procedures were very high risk and
  needed special precautions

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Effectiveness of Precautions Loeb et al.

• Lower risk with
• Gloves OR 0.45 (0.4, 4.5)
• Gown OR 0.36 (0.1,1.2)
• N95/surgical mask OR 0.23 (0.07,0.78)
• Surgical mask OR 0.45 (0.07, 2.7)
• N95 OR 0.22 (0.05, 0.93)

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But

• There were still a few HCWs who wore appropriate
  protection during these high risk exposures and
  still contracted SARS!

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April 13, 2003
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Use of PPE During High Risk Procedures

• Inadequate protection or improper use of adequate
  protection?
• Other factors
• No fit testing as yet
• Incomplete education on donning and removal of PPE

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This? - Mask and Face Protection
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Or This? - PAPR
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PAPR

• Positive
• Airway
• Pressure
• Respirator

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PPE Recommendations forHigh-risk Procedures -
2003

• Droplet precautions for all (Seto, Loeb)
  including Febrile Respiratory Illness (FRI)
  patients
• N95s, eye protection (goggles and face shield)
  gowns, gloves for FRI during outbreak (Loeb)
• PPS/PAPRs for SARS patients

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Environmental needs for High-risk procedures
during outbreaks

• Negative pressure rooms
• Appropriate isolation, disinfection and disposal
  of equipment
• Protection of patients during transport within
  and outside of hospital

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PPE Education is Imperative!
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Personal Protective Equipment

• Basic infection control measures must be learned
  and applied consistently
• PPE must be used based on best evidence/best
  practice
• PPE must be applied properly
• This message must be universal

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3.Containing the Outbreak
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Containing the Outbreak

• Hospital IMS
• Screening
• Provincial Transport Authorization Center

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Hospital IMS
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Incident Manager
Executive Officers
Public Information Officer
Health Safety
Liaison
Operations
Planning
Logistics
Finance
Med Director
Supplies
Med. staffing
Security
Triage
Material
Accommodation
Nsg. staffing
ED/OR/CrCU
Costing
Communication
Volunteers
Pharmacy
Nutrition
Med/Surg
Investigations
Facilities
Lab
Strategies
Imaging
Morgue
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Hospital Screening
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Hospital Screening
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Hospital Screening
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Screening tool

• Universal screening used in
• Hospitals
• Patients
• Staff
• Visitors
• Community health settings
• Mission critical areas
• Government agencies
• Private industry

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Provincial Transfer Authorization Center
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PTAC Developed By
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SARS Facility Screening
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SARS Transfer Approved
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PTAC results (MacDonald et al. PEC, 2004)

• 13 SARS patients identified from acute care and
  LTC facilities
• No reported spread of SARS during interfacility
  transfer
• Approved for continued operation as of December
  2003

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4. Maintenance of Services

• Impact on hospitals
• Working quarantine
• Staff support
• Patient care issues

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Impact on hospitals
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Sunnybrook Womens

• 350 beds
• University of Toronto teaching hospital
• Lead Trauma and Burn Center
• Orthopedics, PG, Oncology, Cardiac
  Neurosciences
• Base Hospital for paramedics of Toronto EMS
  Ontario Air Ambulance

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SARS at Sunnybrook

• Principal tertiary referring hospital
• Admitted 71 SARS patients March 14 May 24, 2003
• 1000 patients seen at SARS assessment clinic

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SARS Screening Clinics
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SARS Screening Clinics
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Avg. Daily ED Census
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SARS at Sunnybrook

• ICU closed April 19-30
• Left 1 adult trauma unit open in the city
• Isolation of dozens of patients
• PPE issues
• Staffing issues

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Trauma/ICU Issues

• Due to cancellation of elective cardiac, cancer
  and neurosurgery, emergent critical care services
  were maintained
• Isolation negative pressure resources were
  limited
• Still short staffed due to quarantine!

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Maintenance of Services

• A network of SARS hospitals (the SARS alliance)
  was considered in SARS I and created during SARS
  II with mixed reviews
• Capacity was created with movement of long stay
  patients to ALC facilities
• Working quarantine was created

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Paramedics on Quarantine
Days on Quarantine 2035 Ave Days on Q 7.8
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Home quarantine

• Confined to home
• Mask while in same room as others
• Separate towels/drinking cups/cutlery
• Sleep in separate rooms if possible
• Temp twice daily and report to Public Health if
  gt380 C

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Working Quarantine

• Same as home quarantine, except
• PPE at all times en route to work (no public
  transit)
• PPE at all times at work except on breaks
• Keep 6 feet away from others if no PPE

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Working Quarantine
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Staff support
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Hospital Disaster Staffing If You Call, Will
They Come?

• Survey to hospital employees at 8 hospitals in 5
  states
• 1874 surveys sent 1612 responses
• 86 willing to come in after MCI
• 58 willing after CBR event

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Hospital Disaster Staffing If You Call, Will
They Come?

• Support needs identified to increase response
• Long-distance phone service (41)
• Email access (34)
• Pet care (33)
• Child care (30)
• Adult / elder care (7)

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Provider support

• Child/dependent care
• Food/shopping/other supports while in quarantine
• Transportation
• Psychological support
• Not adequate in most instances

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Patient care issues

• Access to care
• Restrictions on care of individual patients

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Access to careQuestions

• What was the effect on morbidity and mortality in
  populations of patients with
• Cardiac disease
• Cancer
• Arthritis
• Did the psychological stress of staff and lack of
  visitors affect mortality?

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Access to careQuestions

• Determining the Population Health Impact of the
  Healthcare System Response to the SARS outbreak
  Stukel et al
• Stay tuned..

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b) Individual patient care

• How did protection against SARS impact the care
  of critically ill patients?

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CMAJ August 19, 2003
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Critical Care issues

• Response to cardiac arrests
• Airway management in trauma patients with no
  history available
• Resuscitation of known SARS patients

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Should paramedics intubate patients with
SARS-like symptoms?

• Risks
• Safety of provider
• Safety of bystanders / other patients
• Cross-contamination
• False sense of protection afforded by protective
  systems if not used correctly

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Therefore

• Research is needed to evaluate the impact of
  protective measures on non-SARS populations
• The use of high risk procedures must be evaluated
  based on risk/benefit
• Protection of practitioners is paramount

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5. Lessons for the Future
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Components of Emergency Response

• Preparation
• Recognition
• Containment
• Protection/decontamination
• Treatment
• Recovery

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Hospitals Need IMS

• Incident Management System is a method of
  coordinating parts of one agency or many agencies
  in a unified command structure to use all
  available resources in the effective and
  efficient response to an emergency.

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ExpectationsHospital Standard-2003

• A baseline level of protection for all potential
  exposures
• A baseline level of preparedness
• Immediate activation of hospitals emergency
  response plan
• Plans for staff call back and personal maintenance

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Expectation - System

• A better system of communication and coordination
  within the Health Care sector centers of
  excellence / leadership
• Data management, collection and analysis

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SARS - Summary
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SARS Lessons learned

• Infection control
• Disaster management

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a) Infection control

• Baseline infection control is essential at all
  times
• Higher levels for aerosol-generating high risk
  procedures
• Screening and protection must be universal during
  an outbreak

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b) Disaster Management

• Continuous preparation and vigilance
• Incident Management Systems in our ED/hospitals
• Integration among hospitals, emergency services,
  Public Health and government
• Staff organization and support

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Our Heroes
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Questions?