Strategies for coping with SARS in the ED

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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 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 HCWs (44)
• 20 attack rate for ED RNs 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
• Influenza0.1-0.2
• 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 EDs 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 HCWs
• 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 its 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

• EDs 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 pts/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_at_utoronto.ca
• www.sarswatch.ca