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 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

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