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Strategies for coping with SARS in the ED Part 2; –Challenges and Lessons
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Overview Controversies and challenges SARS today Lessons for the future Conclusions
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General Comments on Infectivity (WHO) Basic R 0 (reproductive value) ~2-4 Estimate of R 0 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
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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Mask-Fit Testing
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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
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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?
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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
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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
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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
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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
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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
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Questions or more info howard.ovens@utoronto.ca www.sarswatch.ca
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