Strategies for coping with SARS in the ED

1. Strategies for coping with SARS in the ED • Part 2; • Challenges and Lessons

2. Overview • Controversies and challenges • SARS today • Lessons for the future • Conclusions

3. General Comments on Infectivity (WHO) • Basic R0 (reproductive value) ~2-4 • Estimate of R0 for influenza = 10 • 83% of SARS patients did not transmit to anyone • Primarily transmitted in acute care hospitals (77%) and in HCW’s (44%) • 20% attack rate for ED RN’s with unprotected exposure WHO/CDS/CSR/GAR/2003.11

4. General Comments on Infectivity (WHO) • Primary mode of transmission • Large droplet and direct mucous membrane (eyes/nose/mouth) • Transmission enhanced by close prolonged contact • Aerosolizing procedures seems to amplify transmission • Other? • Airborne? -occasional case that may be associated with large number of cases • Fomites? • Amoy Garden outbreak; enteric/airborne WHO/CDS/CSR/GAR/2003.11

5. Clinical Outcome • 20% admitted to ICU • 15% required mechanical ventilation • ~10% died • Influenza~0.1-0.2% • Avian influenza 15 to 70% • Increased risk of death or ICU admission if: • Increased age • Comorbidity Tsui et al. EID 2003; 9: 1064-1069; Fowler et al. JAMA 2003; 290: 367-373; Lew et al. JAMA 2003; 290: 374-380

6. Controversies and Challenges • Lack of transmission in ED’s after Mar 22- why? • natural history of disease; • able to tolerate masks • few required airway procedures • short stay • high compliance

7. Controversies and Challenges • Effectiveness of PPE? • Transmission in the setting of any precautions; • SARS-1 - 260 patients • 22 HCW infected (1 for every 12 patients) • primarily airway care in critical care areas • SARS-2 – 129 patients • 3 HCW infected (1 for every 43 patients)

8. Differences between SARS-1 and SARS-2 • Added barriers • Double gloves, hair & foot covering, greens • Enhanced protection during intubation/cardiac arrest, etc. • HCW training and awareness • Practice issues • Minimize time in room • Minimize contact with patient • Medical therapy to reduce cough/vomiting • Minimize procedures that increase risk of droplets

9. Controversies and Challenges • Transmission “through” precautions often associated with unrecognized or “low risk” case - ? Compliance • Intubation; • perception of ineffectiveness of ppe led to recommendations for use of powered air purifying respirators (“PAPR”) hoods • much debate, conflict over who should perform procedures

12. Controversies and Challenges • Of ~ 50 SARS intubations (or bronchoscopy) 5 led to transmission to ~ 20 HCW’s • Several involved only partial precautions, unrecognized case and/or problems in practice • Clearly high risk procedure

13. Approach to Intubation/Airway Care • Performed by most skilled/experienced team available • Performed in the best available room • Anticipate and plan • Minimize cough, suction, using RSI if possible • No +ve pressure therapy, scavenge exhaled gases • Careful use of PPE especially undressing • Consider use of PAPR if available and familiar with it’s use

14. ED Design and Operational Issues • Implications for visitor policy and bed flow policies – avoid excessive crowding especially in corridors and curtained areas (consider max occupancy?) • Design implications – space and barriers, ventilation

22. Mask-Fit Testing

23. Staff Training and Communications • Infection Control training • Awareness, cultural shift; • not just for rare events like SARS • ARO, c. difficile, TB • Can SARS do for resp droplets what HIV did for bodily fluids? • Receiving and distributing alerts and info 24/7 esp. with shift workers • Multiple points of reception • Use of Electronic comm, AND bulletin boards, word of mouth

24. Controversies and Challenges • Appropriate level of preparedness; • one travel case walking into an unprepared ED can set off an outbreak with billion $ impact • excessive measures are costly and encourage non-compliance • should we place everyone with fever and cough into droplet precautions? • should triage nurse be in ppe? • for how long?

25. SARS Today • Eliminated from global popn • Reservoirs in animals and lab sources • Much greater surveillance in China and HK make unannounced arrival unlikely • Vaccines in development • Therefore small but real risk of return, however most important as a prototype for other outbreaks (influenza) or bioterror

26. Conclusions • ED’s provide fertile ground for disease transmission • Require attention to system issues; • Overall ED design • hand-washing • individual care rooms and spacing • Adequate isolation rooms • en suite BR, resuscitation room with airborne protection • Avoid crowding due to excess pt’s/visitors

27. Conclusions • Adequate staff training in infection control policy and procedure, use of ppe • Focus on triage, case recognition • Communications vital; • receiving of disease alerts • transmitting info to staff

28. What do we do differently? • (Virtually) No Hallway stretchers • Equipment reviewed, changed • Selected use of open area stretchers • Strict visitor policy, control of WR • Better awareness and adherence to infection control practices • Reno to increase isolation resources • Challenges; • maintain vigilance!!! • Baseline precautions

34. The Future • Lessons learned; • 4 Canadian provincial and federal expert panel reports • Some investments in public health • Staff training improvement spotty • System issues related to crowding unaddressed

37. Questions or more info howard.ovens@utoronto.ca www.sarswatch.ca