CLINICAL AND PUBLIC HEALTH SYSTEMS ISSUES ARISING FROM THE OUTBREAK OF SARS IN TORONTO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Throughout its deliberations, the Committee appreciatedthe importance of understanding the response to SARSwithin a clinical and local public health context. Whilewe recognize that these matters are primarily a provincialresponsibility, viruses do not respect borders or jurisdictions,and lessons from Ontario are almost certainly applicableto other provinces. We have indicated that BritishColumbia was both fortunate and in some respects betterprepared to deal with SARS. We also speculated that hadSARS touched down somewhere other than Toronto, theresults could have been more devastating, although it ispossible that some of the jurisdictional tensions wouldhave been less.

Based on the SARS experience, this chapter discusses thesteps that key informants believe might be taken toenhance the readiness, efficiency and effectiveness of theresponse to a future outbreak. It also provides anassessment of the deferred service and disruption duringSARS and actions that might be taken in future to reducethe degree of disruption to ‘normal’ services.

This chapter draws heavily on work by the Hay Group.The Committee gave a specific mandate to theseconsultants and interacted with them on study design.Their conclusions were extraordinarily consistent withthose that arose from stakeholder submissions and fromthe Committee’s own experiences, interviews, reading,and deliberations.

The consultants used a combination of surveys, interviews,focus groups and data analysis. These activities focusedon a sample of organizations and individuals in thepublic domain significantly affected by SARS and/or whowere actively involved in the management of the response.Given the time frame available, the consultants establishedfirm schedules for participation and requested that partici-pants make themselves available. The organizations and

individuals contacted made every effort to provide inputwithin the schedule and the Committee greatly appreciatestheir efforts.

We have dealt elsewhere with the readiness of HealthCanada to respond in support of those at the local andprovincial levels fighting SARS. Health Canada’s responseswere seriously confounded and limited by the lack ofjurisdictional clarity about roles and responsibilities andthe lack of what can be termed ‘a receptor function’ inthe provincial system. However, it should be emphasizedhere that, during the consultants’ work, multiple infor-mants indicated disappointment with the role played byHealth Canada in dealing with the outbreak in Toronto.

The chapter also draws strongly on a series of roundtablesconvened by Health Canada’s Office of Nursing Policy tosolicit the perspectives of front-line nurses and supportstaff affected by the SARS outbreak in Toronto. Regulatorycolleges, professional bodies, and unions affiliated withthese two groups were also invited. Two Committeemembers attended the sessions.

In framing our perspectives and recommendations, theCommittee was also guided by input from several organi-zations. Among these were briefs from the Victorian Orderof Nurses, Ontario Association of Medical Laboratories,the Ontario Hospital Association, the Ontario Council ofTeaching Hospitals, and the Association of NursingDirectors and Supervisors of Ontario Health Agencies.

In general, a striking congruence of perspectives emergedin the responses of administrators, specialist physicians,front-line nursing and support staff, and unions repre-senting the latter groups. The chapter focuses on areasfor improvement; the consultants specifically solicitedinput on the strengths and weaknesses associated with theresponse to the outbreak and steps that might be takento improve that response in the future. Most informants

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Chapter 8S A R S a n d P u b l i c H e a l t h

indicated that most participants indicated that the aspectof the response that allowed the system, in the end, tosuccessfully contain the outbreak of SARS was theincredible effort made by front-line staff. This reportfocuses on opportunities for the future and thus is unableto give a full accounting of the valiant and sometimesheroic efforts of many of the public health and healthcare workers in the Greater Toronto Area [GTA] as theybattled to aid those infected and contain the spread ofthe disease.

Last, we have deliberately kept our recommendations at afairly high level of generality. This reflects considerationsof mandate, time constraints, and the existence of twoother processes to learn lessons from SARS in Ontario.We anticipate that more detailed recommendationsapplicable to the Ontario experience will be forthcomingfrom a provincial panel chaired by David Walker, Dean ofthe Faculty of Medicine at Queen’s University and fromMr. Justice Archie Campbell’s public health investigation.

8A. Scope and ApproachIn total, the consultants conducted 25 focus groups and21 interviews with organizations and individualsrepresentative of those that were most directly involvedin treating people infected with SARS and containing the spread of the disease. This included staff of ninehospitals, four public health units, Community CareAccess Centres [CCACs] in Toronto, representative primarycare providers, and officials of the Ontario Ministry ofHealth and Long-Term Care [OMHLTC].

They surveyed all acute care, rehabilitation and complexcontinuing care hospitals in the GTA regarding theirreadiness and experience with SARS. They receivedresponses from all Toronto and GTA hospitals included inthe survey1.

The survey collected activity volume data for March,April, May, and June of 2002 and 2003. The four monthsin 2003 were selected to cover the period of the SARSoutbreak. The data for the same four months in 2002were collected to provide an approximate activity baseline,with the simplifying assumption that any major changesin activity levels could be attributed to the impact of SARS.

Much of the analysis of the hospital survey activity datafocused on comparing the 2003 activity levels with thevolumes for the corresponding month in 2002. Onlyhospitals with complete data for all eight months wereincluded in the analyses.

Daily Census Summary [DCS] data were provided by theOMHLTC. These are records of the number of inpatientstreated, patient days and type of service delivered inOntario hospitals each day. These data supportcomparisons of changes in acute care hospital occupancyrates during the SARS outbreak.

Detailed, patient-specific records of inpatient and ambula-tory procedure activity for the GTA and Toronto hospitalpatients receiving care during the SARS outbreak will notbe available until late 2003. This means that there canbe no direct analysis of the impact of SARS on hospitalcase mix and specific clinical groups. However, to providesome information about the normal case mix and clinicalcharacteristics of the patients treated in Toronto hospitals,the Hay Group used the 2001/02 Canadian Institute forHealth Information [CIHI] records for Toronto hospitalsobtained previously for a benchmarking study. Thesedata were then used to estimate the expected distributionby program of Toronto hospital activity during theperiod of the SARS outbreak and to support the estimateof the volume and cost of deferred surgical activity.

The Committee had hoped to examine physician servicevolumes but approvals from the OMHLTC to access thenecessary data set had not been obtained at the time ofpreparation of this report. Researchers at the Institute forClinical Evaluative Sciences will be undertaking analysesof physician practices as part of a broader assessment ofprocess and outcome impacts from the outbreak.

As to the four roundtables convened by the Office ofNursing Policy, attendance follows:

• sixteen front-line nurses from eight organizations;

• nine participants from organizations representingnurses;

• six front-line support staff from three organizations;and

• four participants from organizations representingfront-line staff.

Participants included full-time, part-time, and casual staff from various sectors. Categories of staff included:registered nurse, registered practical nurse, infectioncontrol practitioner, nurse manager, environmental services,dietetic attendant, porter, and patient service aide.

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1 Some multi-site hospitals provided separate responses for each of their sites, while others provided a single response for the corporation.

8B. Readiness of the HealthSystem

8B.1 BackgroundKey dates in the outbreak have already been presented in Chapter 2. To recapitulate, the index patients withatypical pneumonia were seen at the Grace Site of theScarborough Hospital the week of March 10, 2003 andidentified as potential SARS cases on March 14. PremierErnie Eves declared SARS a provincial emergency onMarch 26. On or about March 28, under direction fromthe Provincial Operations Centre [POC], all GTA andSimcoe County hospitals restricted access to critically illpatients and necessary staff only. On March 29, thesehospitals were also directed to “initiate full Code Orangeemergency response plans.” The Premier lifted theprovincial emergency as of May 17, 2003.

A ‘second wave’ of SARS cases was confirmed on May 23, 2003. On May 27, the provincial governmentannounced, “four hospitals, working with all GreaterToronto Area hospitals, will use their expertise andleadership in a coordinated fight against Severe AcuteRespiratory Syndrome (SARS).” The four hospitals wereNorth York General Hospital, St. Michael’s Hospital, The Scarborough Hospital, General Division, and theEtobicoke site of the William Osler Health Centre. TheMinister stated that “We are concentrating the treatmentand expertise of SARS at four key sites around the GreaterToronto Area to ensure we quickly identify and containthe disease during this current wave of cases… This willhelp us protect the capacity of the health care system aswell as ensure that the health care system in the GTAkeeps running safely and efficiently2.” These fourhospitals are collectively referred to as the “SARSAlliance” hospitals.

For the purposes of this chapter, SARS I refers to thetimeframe of approximately March 10 to May 17, 2003.This timeframe corresponds to the initial identificationof SARS in Ontario and the response characterized by thedeclaration of a provincial emergency and oversight ofoutbreak management by the POC.

SARS II refers to the period beginning on or about May 18, 2003 and ending approximately June 30. Thistimeframe corresponds to the second cluster of SARSpatients and the date of the final new case underinvestigation. Characteristics of the SARS II response

include the SARS Alliance announced May 27 and theSARS Operations Centre [SOC] established by theOMHLTC.

8B.2 Roles and ResponsibilitiesDuring the initial stages of the outbreak, betweenapproximately March 10 and March 26, 2003, variousrespondents were unclear on the roles and jurisdictionalresponsibilities of Health Canada, the provincial Ministryof Health and the regional Public Health Units. Fromtheir perspective, it was unclear, for example:

• who was to be the contact with the World HealthOrganization [WHO];

• who was responsible for keeping the system informed;

• who had the jurisdiction/role to issue press releases;

• who was to provide advice on proper infection controlprocedures and to whom; and

• whose definitional frameworks were to be used.

Respondents observed that these issues appeared to be asource of debate between the OMHLTC and Health Canada.The province assumed responsibility for communicationwith the public initially through the Public HealthCommissioner and later through a subset of members ofthe Executive Committee of the POC. It became clearthat Health Canada had responsibility for contact withWHO. However, respondents were concerned that it wasnot until May 29 that Health Canada announced a fullalignment (or re-alignment) of its criteria for diagnosis ofSARS with those of WHO.

Respondents felt that clarity in jurisdiction and role andmore communication between Health Canada, theOMHLTC, and regional public health units would haveeliminated some of the early confusion in addressing theoutbreak. Front-line roundtable participants spoke of“fragmentation” in the system, “silos”, and “chaos”during SARS I.

Provincial GovernmentCommand and control for the operational response wassomewhat clarified when the Premier declared SARS aprovincial emergency on March 26, 2003 under theauthority of the Provincial Emergency Plans Act. Thisactivated the POC, made up of representatives from allnecessary provincial ministries. Concurrently, eachMinistry activated its own Ministry Advisory Group

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2 Ontario Ministry of Health and Long-Term Care Press Release, “Eves Government announces four hospitals to lead coordinated fight against SARS,”Toronto, May 27, 2003, Canada News Wire.

[MAG] to advise the POC and manage the emergency onbehalf of its respective Ministry. Pre-selected individualspopulated the POC and the MAGs. The consultantsinterviewed a number of individuals who had contactwith the POC during SARS I. Most indicated that themultiplicity of participants, and the advice being providedby the MAGs (most of whom had little understanding orinvolvement with SARS), led to a perception of confusionand dysfunction at the centre.

Public Health UnitsThere was also confusion regarding the roles andresponsibilities of public health units and their relation-ship to other parts of the system. The reporting relationshipof Regional Public Health Units through local govern-ments was perceived to be a source of uncertainty andconflict in their relationship with the OMHLTC PublicHealth Branch. Respondents widely reported that therewas a lack of coordination of information and overlap of roles.

Public health units and hospitals alike reported that therewas inconsistency in approach and activities across thepublic health units in the GTA. Respondents attributedthe inconsistencies to the absence of a clear linkage androle for the units in the clinical sphere, the weak link ofthe units to the OMHLTC Public Health Branch, and a lackof leadership from the OMHLTC Public Health Branch.

A number of respondents criticized the municipalreporting relationship of the regional public health units.They acknowledged that a number of the current respon-sibilities of Public Health benefit from a local emphasis(health promotion, smog alerts, etc.), but argued that areassuch as infectious diseases would benefit from a broader,provincial approach and responsibility. Health careproviders suggested that government should undertake areview of Public Health activities with the goal of redis-tributing and clearly identifying responsibilities of localpublic health units and the provincial Public HealthBranch of the OMHLTC. Respondents felt that roles,responsibilities, and accountabilities needed to be clearlydefined and understood.

HospitalsAs one CEO indicated, the management of any newinfectious disease in the absence of a scientific consensuson diagnostic criteria, etiology or treatment creates bothapprehension and new challenges for hospitals andhospital staff in responding to the illness.

None of the hospitals contacted for this study hasidentified infectious diseases as a priority program; thereis also no regional infectious disease program designatedby the OMHLTC. Further, there is no formal network ofinfectious disease specialists and there is no regionalmechanism to design or implement strategies to respondto an outbreak of infectious disease. It was reported thatinfection control specialists from hospitals have developedan informal network and some hospitals reported learningabout the outbreak through that source. A regionalinfectious disease network and strategy is clearly needed.

Many respondents indicated that being prepared requiresanticipation of a potential event and the availability of a planned response should it occur. The increasingprevalence of infectious disease outbreaks and challengesrequires that surveillance be an ongoing hospital function,and that a planned response to an outbreak be availableon both a routine and emergent basis.

Community Care Access Centres CCACs are Ontario’s clearinghouse for access to a rangeof home-based health and social services. They reportedthat the OMHLTC and hospitals did not use the expertiseof CCACs to the extent that was possible. The CCACscould have provided greater support in the discharge anddecanting of patients, particularly in the SARS Alliancefacilities that were attempting to create the capacity toaccept SARS patients. In some instances hospitals/physicians simply signed patients out without notifyingthe CCACs for tracking purposes, for arrangement ofappropriate home support, or for appropriate protectionof community workers.

Conversely, the Committee has learned that the CCACsin the GTA did not have ready access to infection controlexpertise or standardized protocols for dealing with SARS-like situations. The Victorian Order of Nurses took anumber of steps that enabled home care nurses to partici-pate effectively in the outbreak response. However, thehome care system in general was not adequately integratedor prepared for an outbreak of this nature.

During SARS II, the OMHLTC announced that theLeisureworld Brampton Woods facility would provideservices for patients, particularly from the SARS Alliancehospitals, that no longer required hospital care. Someinformants felt that the same result could have beenachieved with better outcomes (patients in facilitiescloser to home and more appropriate settings) if theMinistry had utilized the resources of the CCACs.

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Inter-Organizational InteractionRespondents reported that no system existed prior to theSARS outbreak for communication of routine infectiousdisease alerts from Health Canada to the operationallevels of the health system (i.e., to hospitals, long-termcare [LTC] facilities, CCACs, ambulance services, familyphysicians). Hospitals indicated that they had no directcommunication from Health Canada regarding SARS.

Respondents also indicated that there was a lack ofclarity regarding responsibility for alerting the variouscomponents of the health system to infectious diseaserisks when they are identified. Virtually all informantsidentified the need for a clear statement and assignmentof responsibility for providing infectious disease alerts toeach of the components of the health system including:

• regional public health units;

• family physicians;

• ambulance;

• hospitals;

• CCACs; and

• LTC facilities.

Several individuals suggested that such alerts must be ina format that is readily digestible by the different audiencesthat receive them. Further, the recipients themselvesrequire a process to receive and appropriately disseminatesuch alerts. A number of individuals identified theCoroners’ reports as an example of dissemination thatworks reasonably well: clearly labeled reports, identifyingparticular professionals who would have an interest inthe specific findings and recommendations, and a processto disseminate results.

Feedback regarding interaction with WHO was unequivocal:Health Canada has responsibility for liaison with WHOand provinces and Health Canada must collaborate tomeet our international obligations. Health Canada shouldcommunicate relevant WHO information to provincialPublic Health Branches and local public health units. IfHealth Canada is departing from international recommen-dations (as in the SARS diagnostic criteria), it must followa process that builds consensus and credibility withunambiguous explanations to all concerned.

Communication protocols regarding infectious diseasesmust include information flow in both directions: fromlocal to provincial to federal levels and from the federallevel back. Although local public health units have theresponsibility to collect infectious disease information for

reportable diseases at the individual case level, andproviders are required to report such information to thepublic health units, Public Health does not have clearenough responsibility to report this information back toproviders. Front-line workers expressed concern thatPublic Health focused on community contact tracing andquarantine to the exclusion of closer interaction withhospitals to identify how their processes and practicesmight be contributing to nosocomial infections.

Respondents believed that Health Canada should establisha surveillance role that enables it to accumulate and analyzethe locally-collected information, and establish a communi-cation process that alerts provincial public health unitsabout unusual patterns in an appropriate form fordissemination back to providers. Finally, relevant WHOinformation should be analysed in concert with thelocally collected information in the surveillance ofunusual patterns.

In sum, post-SARS, clinical and public health leaders inthe Toronto area were unambiguous in supporting anintegrated and regional system of surveillance, reporting,and outbreak management for infectious diseases. Front-line roundtable participants similarly urged the establish-ment of coordinated outbreak management under asingle authority.

8B.3 Emergency Structure/PlanningDue to the nature of the SARS emergency, there wassome initial confusion/frustration between the POC,populated by individuals prepared broadly for emergencyresponse, and the OMHLTC MAG with the contentknowledge to address the SARS emergency. The POC,which had not previously been activated, had notdeveloped a process to share responsibility. The POC andthe OMHLTC MAG ultimately amalgamated and situatedthemselves in the same physical location. Respondentsstated that this accommodation by the POC to thegreater expertise of the OMHLTC significantly improvedthe functioning of the POC. This occurred within 72hours of the declaration of the emergency.

The command-and-control structure of the POC, however,had not anticipated sharing responsibility/authority witha lead Ministry. There was perception that the roles ofthe Commissioner of Public Safety and the Commissionerof Public Health/Chief Medical Officer of Health overlapped,and it was unclear which position was ultimately respon-sible for the management of the emergency. Respondentsreported that this lack of clarity in leadership led toconfusion in the field.

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It was also noted that the various areas within eachMinistry had identified only one individual per area topopulate the POC and the MAGs; there were no alternates.This quickly proved inadequate given a 24/7 workload.Below the level of the POC and the MAG, there appearedto be little infrastructure to assist in the workings of theMAGs in support of the POC or to support the POC itself.

Further, areas of expertise were missing. Insufficient inputfrom the acute care sector meant that some of the earlydirectives demonstrated a lack of understanding of theworkings of either the health care system as a whole or theindividual components of the system. Hospital respondentsreported frustration with early directives that wereunrealistic and often not possible to implement.

Consistent with findings and recommendations inChapter 5, respondents suggested that a process beestablished to share the authority vested in the POC witha lead Ministry with content knowledge of the particulardisaster. This process should include a clear statement ofthe position/person that has ultimate authority for agiven emergency. Most recommended against a sharedresponsibility during a crisis. It was also noted that morethan one individual from each Ministry should beidentified to support the POC and the MAGs.

Several respondents also raised the question as to whetheror not a provincial emergency actually needed to bedeclared in the SARS outbreak. They felt that the POCwas a cumbersome structure for this particular emergencygiven that the response mostly required the efforts of asingle Ministry. Others noted, however, that the declarationof the emergency was necessary to provide the governmentwith the authority to make decisions and issue neededdirectives. As an alternative, informants suggested thatkey Ministries might develop their own individual emer-gency plans that provided the government with relevantauthority to act and that such Ministry-specific plansneed not involve the entire POC apparatus. If criteria foridentifying Provincial versus ‘Ministerial’ emergenciescould be set, this would allow for a more graded responserooted in sectoral expertise. Many felt that the SARSOperations Centre functioned more effectively than didthe general Provincial Operations Centre.

It was also widely suggested that both the provincial andministerial emergency plans consider closely the expertisethat would be required in various emergency situationsand identify ahead of time individuals with such expertise.As the SARS Scientific Advisory Committee demonstrated,such experts need not be employees of the provincial

government. Rather, experts from across the provincecould be identified in advance and take part in exercisesto pre-determine relevant emergency protocols.

Emergency plans should also consider compensationissues. Respondents noted that neither at the provincialnor ministerial level had emergency planning madeadvance provisions for compensation of those individualsrequired to respond to the emergency, as well as thoseaffected by the particular emergency.

Again consistent with recommendations in Chapter 5, it was also suggested that the federal government beinvolved with the emergency planning of provincialgovernments to ensure that the federal role in variousemergency situations is identified ahead of time.

Respondents identified the lack of any formal process orprevious human resource planning for recruiting or sec-onding staff to public health units in the event of an emer-gency. It was almost universally felt that there is insufficientcapacity in local public health units to address emergencysituations. Respondents were grateful that London andHamilton provided teams to assist the GTA public healthunits and noted that individuals were re-deployed internallyto provide additional focus on the SARS situation. Publichealth units reported a lack of physicians with appropriatepublic health training, and some of those with this typeof training were not available to the local units, as theyhad been seconded to the OMHLTC for the emergency.

A number of individuals suggested that there should be theability to dispatch a team of professionals to the epicentreof a major outbreak if requested to do so. Such a teamwould be specifically trained to assess the outbreak and ifnecessary identify additional resources that could be accessedto contain the situation. The services provided by this teammight range from infection control advice and specific staffeducation to actual patient care staffing. However, severalrespondents felt that sufficient health human resources donot exist for such an approach. It was suggested that anassessment of the expertise required to deal with infectiousdiseases be made and specific policies put in place toencourage the training of a sufficient number of suchprofessionals.

Many hospital respondents noted that emergencypreparedness policies and procedures are developed andtested at the level of the individual institution. Noregional policies exist and there is little evidence ofconsistency of protocols among institutions.

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There was a sense among focus group participants andinterviewees that cooperation among hospitals was inade-quate to the needs of the SARS emergency. A number ofindividual examples of sharing (non-union) staff withparticular expertise were identified as positive exceptions.Participants noted a particular need for greatercooperation among hospitals in the following areas:

• transferring/accepting non-SARS critical care patients;and

• sharing staff (and physicians) with particular expertise.

Many suggested that the absence of a pre-existing plan orapproach to cooperation among hospitals in an emergencysituation was an impediment to effective action duringthe SARS outbreak. This was identified by several respon-dents both within and external to the hospitals.

In sum, it was clear that the Toronto public healthsystem could not manage both the SARS crisis and carryon its day-to-day business. It was also clear that Torontocould not deal with more than one crisis at a time andthat the system would crash if faced with one additionallarge-scale crisis. Without a pre-existing mechanism toshare resources within the system and no surge capacity,Toronto was overwhelmed.

Managerial and front-line respondents alike urged thatall levels of government invest in front-line public healthcapacity, in addition to, and not at the expense of,existing resources and core services. Both clinical teamsand outbreak teams are needed when dealing with ahealth emergency. An adequate and consistent surgecapacity across Canada must be developed and requiresthe collaboration of provincial/territorial and municipalgovernments to ensure that investments are made andneeds met.

Code Orange is the internationally recognized code foran external disaster/emergency. Each hospital hasdeveloped its own policies and procedures to addressCode Orange situations. A number of hospitalscommented that Code Orange was not intended to dealwith an outbreak of infectious disease; nor was it themost appropriate response for all hospitals in the system.

The survey conducted as part of this study requested thathospitals state whether there were formal protocols foroutbreak management in place prior to the SARSoutbreak. Almost 90% of the acute care hospitals and78% of the non-acute hospitals reported having a formaloutbreak policy in place (Exhibit 8.1).

Two of the three Toronto hospitals that reported no formaloutbreak policy were SARS facility level 3 (the highestlevel) hospitals during the outbreak, while the third waslevel 2.

The survey also asked hospitals to provide a copy of theirprotocols for outbreak management. Eighteen facilitiessubmitted copies out of the 32 facilities that reported theexistence of such protocols.

The protocols received were of variable detail, clarity,quality and length. There are very different policies andprocedures for dealing with outbreaks of infectious diseaseamong the hospitals. In most cases, the protocols did notappear to provide sufficient information or instruction todefine how to manage severe outbreaks. Most protocolshad not been recently revised. Front-line respondentsparticularly emphasized the need for standard protocolsand practice algorithms in outbreak management.

Some respondents indicated in interviews and focus groupsthat SARS showed that many hospitals, especiallycommunity hospitals, are unprepared to deal with seriousoutbreaks of infectious disease. They have relatively weakinfection control functions and processes. Finally, somerespondents urged that basic standards of cleanliness andstandardized infection control practices and protocols bemandated across the health care system, includinghospitals, LTC, home care, and the offices ofindependent health professionals. Some suggested that

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Hospital Acute Care with Non-Acute with Location Formal Outbreak Formal Outbreak(County) Policy Policy

Yes No % Yes Yes No % Yes

Durham 4 0 100% 0 1 0%

Halton 5 0 100% 0 0

Peel 3 0 100% 0 0

Toronto 11 2 85% 7 1 88%

York 2 1 67% 0 0

Total 25 3 89% 7 2 78%

E X H I B I T 8 . 1Hospital Survey Responses re Existence of FormalProtocols for Outbreak Management

there be requirements, particularly for hospitals, toprovide continuing education on basic precautions forphysicians, nurses and other health professionals.Analogies were drawn to basic fire training required onan annual basis.

The lack of any regional hospital planning for emergencypreparedness was also heavily criticized. It was stronglysuggested that the emergency response plans of hospitalsshould include regional planning and cooperation. Suchplanning must include both inter-hospital participationand other providers and stakeholders as appropriate (i.e., CCACs, LTC facilities, Public Health, etc.).

A number of hospitals reported making use of existingnetworks, such as the Toronto East Emergency Networkand the Child Health Network, to assist with communi-cations and in some cases patient transfer.

CritiCall3 was essential for a number of required patienttransfers. Many hospitals, however, suggested that thepowers of CritiCall to enforce acceptance of patients byfacilities with open beds needed to be strengthened.Numerous situations were reported wherein hospitals had difficulty transferring patients both with andwithout SARS.

8B.4 Hospital FacilitiesThe hospital survey included questions regarding thepreparedness of the hospital facilities to accommodateSARS patients. Exhibit 8.2 shows the number of singlepatient rooms with anterooms and/or negative pressurein the GTA and Toronto acute care hospitals. Overall,3.8% of Toronto and GTA acute care hospital beds are insingle negative pressure rooms. Only 1.0% of Torontoand GTA non-acute care hospital beds are in singlenegative pressure rooms.

Toronto hospitals have the highest percent of rooms withnegative pressure (4.6% of acute beds, 1.0% of non-acutebeds). The range in the percent of acute care bedsequipped with negative pressure for individual hospitals(shown in Exhibit 8.3) is from 0% to 12%.

Of the 28 Toronto and GTA hospitals with emergencydepartments, 6 reported in the survey that they do nothave an infection control area. The hospitals withoutinfection control areas in their emergency departmentsare distributed as follows:

• two in York;

• three in Toronto; and

• one in Durham.

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3 The Ontario CritiCall Program facilitates emergency patient referrals by assisting physicians in community hospitals with access to the resources of larger tertiary care hospitals in their regions. Management of the program is provided by Hamilton Health Sciences (HHS).

Acute Hospital Location (County)

Anterooms? Negative Durham Halton Peel Toronto York Grand Pressure Total

Yes No – 8 31 7 12 58

Yes Yes 11 14 22 147 20 214

No Yes 3 13 2 140 2 160

Total Beds: 552 830 1,445 6,254 800 9,881

% Beds w/ Anterooms 2.0% 2.7% 3.7% 2.5% 4.0% 2.8%

% Beds w/ Neg. Press 2.5% 3.3% 1.7% 4.6% 2.8% 3.8%

% Beds w/ Both 2.0% 1.7% 1.5% 2.4% 2.5% 2.2%

E X H I B I T 8 . 2Hospital Survey Responses re Anterooms and Negative Pressure Rooms in Acute Care Hospitals by Hospital Location

The survey results show that 18% of monitoredintermediate/critical care beds are equipped for infectioncontrol. The percent equipped for infection controlranges from 10% in Halton to 28% in Peel.

Only 30% of hospitals with autopsy suites reported thattheir suites conformed to CDC guidelines.

All hospitals as well as front-line workers commented onthe lack of capacity to accommodate the surges indemand that often accompany emergencies. If it needsto operate regularly at 90% to 95% of capacity (as is thecase for acute medical beds), the system is unable toabsorb a large influx of patients associated with anemergency while still maintaining normal activity levels.In addition, the rest of the system lacks capacity toabsorb volume if some hospitals have to reduce volumesto deal with an emergency, as occurred during SARSwhen some hospitals’ ICUs became compromised. Somehospitals did indicate that the elective elements ofnormal activity could be temporarily suspended, if needed,to provide sufficient resources to deal with the emergentsituation. However, such interruptions would have to bebrief and accompanied by provision for catch-up capacity.

The SARS Alliance facilities noted that, with no regionaldisaster planning in place or previously identifiedmethods for cooperation between facilities, it was verydifficult to transfer non-disaster (non-SARS) relatedpatients to other facilities. The concept of designating

entire facilities as ‘level 3’ on the Ministry’s SARS scale,rather than specific units of a hospital where a breachhad occurred, led to confusion and a transient stigmati-zation of entire institutions. A number of patients wererefused, despite the transfer protocols, simply becausethey were coming from a level 3 facility.

Given the impact and potential increase in prevalence ofinfectious disease outbreaks, a number of suggestionsregarding appropriate infrastructure were also broughtforward. Specifically, respondents suggested that eachemergency room be equipped with isolation facilitieswith appropriate air handling and anterooms. They alsosuggested that the number of negative pressure rooms inhospitals be expanded. These facilities would, in theevent of an outbreak, be temporary treatment areas priorto transfer to a regional facility (or facilities) withresponsibility for caring for and isolating patients withthe infectious disease. If patients could be congregatedin regionally-designated institutions, the rest of thesystem could carry on in addressing the other health andhealth service needs of the population.

It was suggested that one or more institutions in eachregion of the province should have the necessaryinfrastructure to isolate a large number of patients in anemergency situation. These institutions would requireboth the facilities to accommodate a large number ofpatients suffering from infectious disease, and the staffrequired to treat them.

If regional programs in infectious diseases were established,the institution(s) with the facilities for addressing theoutbreak should also be the locus for the program. Manysuggested that it would be unrealistic to expect a singleinstitution to be home to sufficient infectious disease andinfection control expertise to deal with a crisis. Rather, anetwork of providers should be created that couldcollectively focus on each outbreak and realign themselvesto ensure that the needed resources are available to theregional facility in the event of an outbreak.

8B.5 Communications Structures and Processes

As noted, respondents reported that there was not aseamless and effective system prior to the SARS outbreakfor communication of routine infectious disease alertsfrom Health Canada to the operational levels of thehealth system (i.e., to hospitals, LTC facilities, CCACs,ambulance services, family physicians).

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A B C D E F G H I J K L M N O P Q R S T U V W

E X H I B I T 8 . 3Variation in Percent of Toronto and GTA Hospital AcuteBeds in Single Negative Pressure Rooms (onlyhospitals with at least 100 acute beds)

The interviewees and managerial/physician focus groupparticipants indicated that communications related toSARS came from various components of the health caresystem, with no clearly identified source and often withconflicting and/or out-of-date advice. Communicationscame from:

• Public Health Commissioner;

• Regional Public Health Units;

• Provincial Operations Centre;

• SARS Operations Centre;

• Ontario Hospital Association;

• Ontario Medical Association;

• Ministry of Health and Long-term Care;

• Public Health Branch, OMHLTC;

• Institutions Branch, OMHLTC;

• Ministry of Public Safety and Security; and

• Health Canada.

There was neither the mechanism nor the disciplinerequired to consolidate and control communicationswithin the POC. Theoretically, the POC should have beenthe single source for communications for all providers.This was not the case. Various reasons for this werepostulated; chief among them was a lack of clarity of roleand jurisdiction and a need for organizations to be seento be active in supporting their constituencies.

As noted above, the field also heavily and repeatedlycriticized both the process of issuing directives and thecontent of directives from the POC. Front-line staffemphasized that, especially early in the outbreak, itappeared that those formulating directives were notsufficiently knowledgeable about the practicality ofimplementing these practices in the clinical setting.

Criticisms also included:

• lack of clarity around who the POC was and who wasdirecting its activities;

• frustration that teleconferencing did not allow partici-pants to know who was participating in the POC, andwhether the participation was informed by science orpolitical necessities;

• length of time required to issue directives, which inturn was attributed to delays occasioned by the internalreview and approval process;

• inconsistency in directives;

• initial directives not numbered or signed; and

• lack of a pre-defined process to clarify directives.

Some of these criticisms are not entirely consistent withothers; speed in issuing directives may lead to lack ofclarity while delays led to criticisms about lack of leader-ship. Regardless, the criticisms speak to an opportunityfor improved performance.

Respondents had a mixed response to the mechanism/media used for communications by the POC. Manystakeholders expressed frustration with the length andfrequency of teleconferences. However, many also statedthat this was a timely method of disseminating quicklychanging information. After the first few days,respondents reported that the effectiveness of theteleconferences improved.

Some respondents felt that the difficulties associated withthe communications process could have been alleviatedif the OMHLTC had its own emergency preparedness planseparate from that of the POC. It was overwhelminglysuggested that regardless of the emergency situationdeclared, responsibility for communications should beidentified clearly in the various scenarios and that mechanisms be established to enforce a single communi-cations source.

Numerous comments were received highlighting theneed to ensure that all interested stakeholders receiveappropriate communications. Clearly, interested stake-holders will vary depending on the situation. However,many respondents suggested that appropriate contactsheets could be prepared ahead of any particular emergencysituation to ensure, for example, that family physiciansand local Public Health Units4 receive information at theinitiation and throughout an outbreak situation.

Finally, almost all respondents felt that a process must bein place to attempt to minimize frequent changes toinformation and conflicting information in an emergency.

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4 It is curious that initial directions from the POC were not made available to public health units. CCACs reported providing information to public healthunits that the public health units did not seem to be receiving directly.

In sum, the overwhelming sense obtained by the consultantswas that SARS demonstrated the importance of effectivecommunication during an emergency, both domesticallyand internationally. Poor communication during theSARS outbreaks may have contributed to the impositionof a travel advisory by WHO, harming Canada’s economyand reputation. The use of a myriad of spokespeoplespeaking to the media at the same time with messagesthat sometimes conflicted did nothing to instillconfidence in the public health system and underminedthe credibility of those at the helm. Respondents notedthat uneven communication to other affected sectors,such as the travel sector, created confusion and fear forboth the public and people working in those othersectors. The travel sector, severely affected by SARS,should have been kept better informed and betterutilized in disseminating information and easing publicanxiety. Pharmacists as front-line health careprofessionals also could have been better utilized toconvey important messages.

Public HealthThere was no effective mechanism for medical officers of health [MOH] to communicate amongst themselvesand to coordinate their actions during the outbreak.Conference calls among the MOH were arranged but notconsistently attended by all units. Many clinical leaderscommented that the MOH in the various regions weredisconnected from each other.

Participants also expressed frustration that communicationsfrom the public health units were non-existent orsporadic; in their view, much information was providedto Public Health, but little information came from PublicHealth. Hospitals reported receiving inquiries frommultiple public health units for the same informationregarding the same patient. When notified that the infor-mation had already been provided to a different publichealth unit, hospitals were told that the units did nothave mechanisms to share the information amongstthemselves and that it was easier to collect it again fromthe hospital.

Some hospitals anticipated that the role of Public Healthwas to consolidate, analyze and communicate back insome useful fashion the information that it was collecting.Public Health informants felt that they could not shareinformation because of confidentiality restrictions, becausethey did not have sufficient resources to share informa-tion, or simply because it was not their responsibility tocommunicate back to providers. It is unclear, thereforewhose role this was. Either expectations must be modifiedor mechanisms found to close the communications gap.

The role assumed by most public health units was focusedon front-line containment of the outbreak. As notedearlier, along with their front-line staff, several hospitalleaders had expected advice from the public health unitson infection control and quarantine procedures andenforcement; these expectations were not consistentlymet. Providers were unsure if this was or should be arole for provincial or regional level Public Health.

Confidentiality concerns raised by Public Health wereshared by health care providers who argued that they,too, have a responsibility and tradition of maintainingconfidentiality. Hence, some sharing of informationshould have been possible.

Family PhysiciansThere was no regular connection between Public Healthand family physicians during the outbreak. The role ofPublic Health in relation to physicians’ offices is notclear. Those contacted for this study indicated that theyhave no relationship with Public Health and received nocommunication from their local public health unit.Family physicians were unaware of the outbreak untilafter it had occurred and were unclear what precautionsshould be taken in their practices and unclear whoseresponsibility it was to provide them with suchinformation.

Family physicians were also largely unaware of HealthCanada infectious disease alerts. They did not knowwhose role it is to provide such alerts to family physicians.

Most family physicians reported learning of the outbreakinitially through the media. Formal communicationswith the SARS emergency infrastructure were non-existent.Initial communications (such as the location of SARSclinics) came from the media; subsequently, the OntarioMedical Association provided communications thatrespondents found useful and effective. Those activelyinvolved with a hospital received information and advicefrom the hospital. There was no direct communicationfrom Public Health to physicians’ offices.

Community Care Access CentresCCACs were not receiving any official infectious diseasecommunications from any source prior to the Torontooutbreak. Like others in the system, CCACs have nodirect relationship with Health Canada, although they domonitor Health Canada information for product alerts.It was unclear to CCACs whose role it is to alert themabout emerging infectious diseases or outbreaks.Respondents reported that Public Health and the CCACssometimes provided conflicting information to CCAC

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clients. These members of the public were accordinglyunclear if the CCACs or Public Health were the appropriatesource for information.

HospitalsNo hospital reported receiving infectious disease alertsfrom Health Canada or having a formal system in placeto receive or scan for such alerts. A number of hospitalsreported awareness of Health Canada product alerts andbulletins, but they had no formal link to Health Canada.Hospitals reported that they became aware of the TorontoSARS outbreak through the media and communicationsfrom the Public Health Branch of the OMHLTC. One CEOstated that in the UK public health is more integratedwith other elements of the health system. He had learnedthat in the UK, public health informed hospitals aboutthe emergence of a new respiratory illness from China inFebruary 2003, whereas in Toronto, hospitals did not knowabout SARS until the patients contracted the disease atThe Scarborough Hospital, Grace Division in March 2003.

Virtually all hospitals commented that throughout SARSI, it was not clear who was sending directives to thehospital. Early directives were unsigned. Later directiveswere signed by both the Commission of Public Health/Chief MOH and the Commissioner of Public Safety andSecurity. In either event, some hospitals were not initiallyclear how to get clarifications of the directives or raiseconcerns about them.

All hospitals commented on confusion arising from:

• receipt of information from different sources;

• conflicting information;

• frequent changes to information and directives;

• conflicts between directives and expertise andexperience of staff; and

• impracticality of directives in the hospital situation.

Administrators and staff at all levels expressed frustrationwith an inability to implement the directions received.The most common reasons for failing to implementdirectives were:

• unavailability of supplies identified in directives; and

• timing of receipt of directives (i.e., insufficient noticeto allow implementation).

A number of respondents felt that more input from thefront-line staff actually dealing with SARS patients mighthave improved the practicality of the directions from thePOC and the SOC.

Front-line respondents also commented on internalcommunications. They appreciated the effort made byinstitutions to communicate creatively by formal andinformal channels, but, consistent with comments inChapter 5 on risk communication, urged that spokes-people acknowledge ‘the unknowns’ rather than holdback information.

Many indicated that there is a need to strengthen therelationship and communication between public healthand hospitals. Although there is a statutory requirementthat representatives of the MOH sit on infection controlcommittees in hospitals, these individuals often lack astrong clinical background and may therefore have littleunderstanding of hospitals. As a result, they are unableto effectively liaise between the hospital and publichealth or provide useful advice to the hospital. Mosthospitals in particular felt that they had little access toregional public health officials. And when they did haveaccess, hospitals were concerned that public health staffmay not have the necessary knowledge, skills orexperience to provide appropriate advice to the hospitalsregarding infection control.

Exhibit 8.4 shows the responses from the hospital surveyregarding liaison with Public Health. While mosthospitals (89%) reported regular liaison with PublicHealth, in some instances the liaison appeared to be littlemore than the mandatory communication regardingreportable communicable diseases or having representativeson Infection Control Committees. Despite the statutoryrequirement, 35% of hospitals did not mention PublicHealth representation on committee structures whenasked to describe how they kept in contact with PublicHealth. These findings emphasize the need to ensurethat there is close liaison between local public healthunits and hospital infection control.

Also, hospitals and clinical leaders commented criticallyon the number of requests for information from PublicHealth regarding SARS patients. Hospitals reportedreceiving requests for information from more than oneregional health unit, the Public Health Branch of theOMHLTC as well as from the Ministry per se.

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8B.6 SurveillanceSurveillance emerged as another area of diffusedresponsibility. Local public health was geared towardsoutbreak containment; provincial Public Health did nottake on the role of the collection point for assemblingand facilitating the analysis of the cumulating data.There is no body with the jurisdiction at the overallsystem level to:

• accumulate and analyze information definitively orfacilitate such analysis by others;

• identify and communicate findings of the analysis ofpatterns of occurrence;

• identify and communicate alerts of unusual patterns;and

• develop contingency plans.

Although some public health units reported that theywere assisting hospitals with syndromic surveillance toidentify patients with SARS-like symptoms, hospitalsindicated that these cases were not confirmed by publichealth if an epidemiologic link to a confirmed case wasnot present. Some hospitals felt that the focus onepidemiologic links blunted their vigilance.

8B.7 Health Human Resources A number of hospitals identified insufficient numbers of specialized staff as a challenge in dealing with theoutbreak. The most commonly cited deficiencies wereinfectious disease specialists, infection control physiciansand hospital epidemiologists.

While 71% of acute care hospitals reported having accessto a physician trained for infection control, one quarterof these hospitals reported that the position was not paidand protected, leaving 46% of acute care hospitals withouta paid and protected infection control position. Only 1of 9 (11%) non-acute hospitals had a physician trainedfor infection control (this position is not paid andprotected). Collectively, the consultants' survey suggestedthat the Toronto and GTA hospitals have at most 7 FTEpaid and protected specialized infection control physicians(or 0.7 FTE positions per 1,000 acute care beds). This maybe an over-estimate based on the Committee’s own tally.The number of fully-trained hospital epidemiologists iseven lower.

These observations clearly reinforce findings from Chapter 7about the state of infection control human resources and theneed for action as regards accreditation standards or regional/ministry regulations to strengthen infection control.

Numerous individuals noted that the nature of thecollective agreements makes it virtually impossible tohave full-time employees of one institution work acrossmultiple organizations, unless each of the organizationsemploys the person directly. Sharing of staff in emergencycontravenes existing collective agreements. Front-linestaff and their organizations signaled a high degree ofdedication and a willingness to engage in planning foremergencies, along with dissatisfaction with ad hoc andpost hoc human resource practices during the SARSoutbreak.

Several hospitals identified that the high percentage ofnursing staff working part-time or casual hours throughagencies was a problem during SARS, a point echoed byfront-line focus groups. These types of employmentpractices provide a flexible workforce for the peaks andvalleys in demand inherent in hospitals, but result in staffbeing employees of several institutions simultaneously.Front-line workers highlighted the importance of a stableand permanent workforce, rather than reliance on morecostly agency personnel. Although a great deal ofpublicity centred around the potential increased risk ofinfection being transferred across organizations arisingfrom this practice, respondents were not aware of a single case of SARS transmitted from health care workers

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Hospital Hospitals Reporting Hospitals ReportingLocation Regular Liaison Public Health on(County) with Public Health Infection Control

Committee

Yes No Yes No

Durham 4 1 3 2

Halton 4 1 4 1

Peel 3 0 3 0

Toronto 20 1 13 8

York 2 1 1 2

Total 33 4 24 13

% Yes 89% 65%

E X H I B I T 8 . 4GTA and Toronto Hospital Survey Responses reRegular Liaison with Public Health

working in multiple institutions (in fact, it appears therewas only one such case). Restrictions on movement ofstaff during the outbreak may have mitigated thispotential problem. However, the challenge associatedwith such arrangements arises from:

• staff needing to be familiar with the different infectioncontrol policies and procedures of multiple organizations;

• difficulty engendering the level of commitment to an organization that is required to respond toemergencies; and

• difficulty for a hospital to secure additional shiftswhen employees have commitments to work atmultiple organizations.

There were various issues identified with compensationthroughout the SARS experience. Some hospitals reportedbeing ‘required’ to pay physicians additional stipends toinduce them to work with SARS patients. The OntarioMedical Association and the OMHLTC, working throughthe Physicians Services Committee, have developed twoprograms for physicians whose incomes were affected bySARS. These programs are the SARS Advance PaymentProgram and the SARS Income Stabilization Program.Details of these programs were made available tophysicians on the Ontario Medical Association website in a series of communications dated June 26, 2003.

In the SARS Advance Payment Program, physicians mayapply for advance payment against future billings toaddress current shortfalls in income due to service reduc-tions as a result of SARS. In this program, a physicianwhose income is less than 80% of average monthlybillings may receive payments to make up the differencebetween the earned amount and the threshold of 80% ofaverage billings. These advances will be deducted fromfuture payments. This program applies to the periodfrom March 14, 2003 to June 30, 2003.

The SARS Income Stabilization Program applies tophysicians whose incomes were reduced because ofquarantine, reductions in hospital operating capacity orreduced practice volumes in and/or outside the hospitalsetting. All physicians affected by SARS are eligible toreceive payments equivalent to the difference betweenthe amount earned and 80% of average annual billings.Physicians who worked in hospitals that were specificallytreating SARS patients are eligible for payment of thedifference between the amount earned and 100% ofaverage annual billings. Top up to 80% applies to theentire SARS emergency period. Top up to 100% appliesto the period from May 23, 2003 to June 30, 2003.

The SARS Alliance hospitals chose to provide double-timepay to those individuals working in SARS affected areas/SARS units. The OMHLTC did not sanction this action.It was heavily criticized from an equity perspective sinceother hospitals that treated SARS patients did not providethe same benefit to their staff. Further, staff were providedthe additional salary whether or not the SARS unit theyworked on actually treated SARS patients. As a result, insome cases staff treating SARS patients received no addedcompensation benefit, while others who did not treatSARS patients did receive additional compensation.

The lack of intensive care nursing professionals, and thecentralized response to this challenge, resulted in compen-sation practices that were also heavily criticized. A contractbetween the province and Med-Emerg was established toprovide critical care nursing staff to hospitals upon theirrequest. Respondents noted that the nurses employed byMed-Emerg were compensated at rates up to three timesthat of ‘regular’ hospital-based critical care nurses, causingequity concerns. Front-line representatives expressedconcern about both differential compensation and incon-sistent perquisites. Because of uneven pay scales, somehospitals felt compelled to offer their own staff the samepremium that the OMHLTC was paying to agency stafffrom Med-Emerg. Further, a number of hospitals reportedthat nurses who would otherwise have been regularlyavailable to the institution were recruited by Med-Emerg.Finally, hospitals reported limited flexibility in the staffingoffered by Med-Emerg; the hospital was unable to modifystaffing requirements and consequently, they sometimesfound themselves in the uncharacteristic position of havingtoo many staff. Despite these criticisms, as indicated inChapter 2, Med-Emerg was understood to have filledserious gaps in staffing in a very difficult period.

During the outbreak, nurses were restricted from workingin multiple institutions to control the risk of SARSmoving from one hospital to the next. This provisionserved to reduce the incomes of nurses who relied onincome from multiple organizations. Respondents notedthat the OMHLTC has not volunteered to compensatethese nurses in the same way that it has guaranteed theincomes of most physicians who work in hospitals.

These findings all highlight the need for regularizedprocesses for sharing and compensating staff duringemergencies.

Occupational health and safety concerns emerged clearlyfrom focus groups with front-line workers. Existingoccupational health and safety committees were notengaged; necessary equipment was sometimes unavailableor suboptimal, and some administrators liftedprecautions prematurely. The Committee understands

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that ambulance personnel and paramedics also hadserious concerns about protective equipment during theSARS outbreak.

8B.8 Psychosocial Implications of SARSMany respondents also discussed the significant psychosocialimplications of SARS and related stories that illustrated thepalpable fear among both health workers and the public.The impact of SARS on individuals working within thehealth system should not be underestimated. It included:

• people afraid to go to work in hospitals;

• people afraid to care for SARS patients;

• people afraid to associate with health care workers, oreven spouses of health care workers, particularly thosefrom SARS units;

• lingering resentment of colleagues who might nothave contributed what was expected;

• people feeling helpless, angry, and guilty; and

• people experiencing acute social isolation and ostracism.

Many who participated in the interviews and focusgroups suggested that the fear was engendered both bythe sensationalism of the media coverage andinconsistent information coming from the provincial andmunicipal public health officials. Front-line focus groupparticipants emphasized the need for formal crisiscommunications protocols suited to the unique needs ofeach institution and its staff (e.g., remote workers, shiftworkers). Much of the fear was simply a reasonablereaction to an unknown but extremely virulent disease.In spite of these fears, the focus groups yielded manyaccounts of heroic efforts of health workers to supporteach other and to ensure that all patients received thebest care possible.

8C. Services Impact and BacklogEstimates

All focus group participants and interviewees referred tothe impact of the SARS outbreak on hospital activityvolumes, and the challenges posed in attempting to clearbacklogs. Hospital activity data from 2002 and 2003were used to document the impact of SARS on the GTAand Toronto hospitals and to estimate the cost to thehospital system to clear the backlog.

The primary impacts on hospital service volumes werethe result of the directives to GTA and Toronto hospitalsat the end of March that required that they restrict accessto only critically ill patients. Because most surgical patients

are elective, this restriction had the greatest impact onsurgical volumes. The physical limitations on access tohospitals and the increasing public awareness of the risksof SARS in health care facilities meant that visits toemergency departments [ED] were also greatly reduced.

8C.1 Impacts on Emergency DepartmentVisit/Admission Volumes

Exhibit 8.5 shows the year-over-year percent change from2002 to 2003 in ED visits, by month and hospitallocation (GTA and Toronto).

During the first full month of the outbreak (April 2003)visits to the ED were 28% below the April 2002 levels forboth the Toronto and the GTA hospitals. After April, ED visits to the GTA hospitals recovered to levelsapproximately 15% below the prior year’s level. Visits tothe ED in Toronto hospitals increased slightly in May (to24% below the prior year), but fell to 31% below theprior year in June with SARS II. The hospitals assigned tothe SARS Alliance had a 50% reduction in their ED visitvolumes in June (after the Alliance had been established).

Exhibit 8.6 shows the overall changes in ED volumes byCanadian Triage Acuity Scale [CTAS] scores.

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E X H I B I T 8 . 5Reduction in ED Visit Volumes in 2003, Compared to2002, for Toronto and GTA Acute Care Hospitals, byMonth

Overall, during the four-month period, the volumes ofED visits with CTAS score 1 (the most urgent cases)increased by 3% in the GTA hospitals and 12% in theToronto hospitals. The volumes of ED visits with CTASscore 5 (the least urgent cases) decreased by 35% in GTAhospitals and by 39% in Toronto hospitals.

As would be expected, the ED visit volumes fell the mostfor the visits that would most likely be considered to bedeferrable. There is no way to determine whether thesepatients who would normally attend and receive care in an ED received care elsewhere, e.g., in a familyphysician’s office or drop-in clinic, or went without care.Lack of access to OHIP physician service data precludedthis analysis.

For medical and mental health patients, the most commonroute of entry to the hospital is via the ED5. It would beexpected that the most critically ill patients, who requireadmission to hospital for definitive treatment, wouldcontinue to visit the ED and would continue to beadmitted as inpatients. Exhibit 8.7 shows that althoughthere was an 11.2% decrease in admissions via the ED inthe four months in 2003 compared to the same fourmonths in 2002, the decrease was exclusively due todecreases in admission of the least urgent patients.Admissions of CTAS 1 (resuscitation) patients increased by8% and admissions of CTAS 2 (emergent) patientsremained constant.

The reduction in admissions through the ED is progres-sively greater for the CTAS score 3, 4, and 5 visits. Thissuggests that the SARS outbreak and the restrictions onhospital services led to changes in inpatient admissionthresholds, and that patients who would have beenpreviously admitted were not admitted.

This study does not assess the impact of the reduction ofED visit volumes on the health of the population nor canit determine whether patients who would otherwise haveattended the ED were able to receive appropriate careelsewhere. The sustained reductions in ED visit volumesduring the outbreak suggest that the Toronto and GTAEDs have traditionally accommodated a large number ofambulatory care visits that might be handled by areformed primary care system, and that when disincentivesto visit the ED were introduced, these visit volumesdropped.

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E X H I B I T 8 . 6Reduction in ED Visit Volumes in 2003, Compared to2002, by CTAS Score, for Toronto and GTA Acute CareHospitals, by Month

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E X H I B I T 8 . 7Reduction in Admissions of Patients via the ED in2003, Compared to 2002, by CTAS Score, for Torontoand GTA Acute Care Hospitals

5 In 2001/02 68% of medical admissions and 81% of mental health admissions for GTA and Toronto hospitals entered via the ED.

8C.2 Surgery VolumesThe hospital survey asked that hospitals report theirsurgical volumes (ambulatory procedures, inpatientelective cases, inpatient non-elective cases) for March,April, May, and June of 2002 and 2003. The analysespresented here compare 2003 volumes with 2002volumes for the four months.

Of all Toronto and GTA hospital ambulatory procedurecases, 98.2% are considered to be elective. When thedirectives to restrict activity to critically ill patients werepublished, ambulatory procedures and ambulatory clinicvisits would be the first services to be reduced or elimi-nated. Exhibit 8.8 shows the reduction in ambulatoryprocedure volumes from 2002 to 2003.

In April 2003, ambulatory procedure volumes dropped by56% in the GTA hospitals and by 70% in the Torontohospitals, compared to April 2002. In May 2003, GTAhospital ambulatory procedure volumes rebounded to alevel 3% above the prior year. Toronto hospital ambula-tory procedure volumes in May were only 7% below theprior year. SARS II appears to have had very limitedimpact on ambulatory procedure volumes, with the GTAhospitals only 1% below, and Toronto hospitals 5% below,the prior year. The majority of the ambulatory procedurebacklog was caused in April.

Exhibit 8.9 shows the impact of the SARS outbreak oninpatient elective surgery volumes in the Toronto andGTA hospitals. In April, the reductions in surgery weregreatest for the Toronto hospitals, but for both the GTAand Toronto hospitals, the percent reduction was not asgreat as it was for ambulatory procedures.

Although GTA inpatient elective surgery volumes for May showed a significant increase over April, they stayed13% below the level from the previous year. In June, thedrop in volumes for inpatient elective surgery for theGTA hospitals was even greater, at 21% below the prioryear. The Toronto hospitals followed a similar pattern,with inpatient elective surgery volumes 15% below theprior year in May, and then further below (24%) in June.

Thus, during the initial outbreak (in April), the drop inambulatory surgery activity was greater than the drop ininpatient elective surgery, whereas during May and June,ambulatory surgery volumes returned almost to normalwhile the volume of inpatient elective surgery remaineddepressed. One explanation is a lack of critical carecapacity in the hospitals, since complex inpatient electivecases (e.g., most cardiac surgery, most thoracic surgery,most neurosurgery, etc.) are more likely to require acritical care stay.

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E X H I B I T 8 . 8Reduction in Ambulatory Procedure Volumes from2002 to 2003 by Month and Hospital Location

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E X H I B I T 8 . 9Reduction in Inpatient Elective Surgery Volumes from2002 to 2003 by Month and Hospital Location

The inpatient non-elective surgerypatients would be expected to fallinto the category of critically illpatients, who would be givenpriority with little reduction involumes caused by the activityrestrictions imposed as a result ofSARS. Non-elective surgeryvolumes for each of the fourmonths were generally within10% of the previous year’svolume. For the GTA hospitals,non-elective surgery volumes wereactually higher than the prior yearfor three of the four months (andonly 1% lower in May). For theToronto hospitals, non-electivesurgery volumes were higherduring SARS I, but lower duringSARS II. The higher non-electivesurgery volumes could be a resultof hospitals re-categorizingpatients from elective to non-elective, year-over-year growth involumes, or random variation.

8C.3 Patient Days andOccupancy

The OMHLTC provided daily census and bed numbers,by bed type, for GTA and Toronto hospitals for March,April, May, and June of 20036. Exhibit 8.10 shows thechange in occupancy of medical, surgical, and mental healthbeds from the beginning of March to the end of June.

The vertical bars on Exhibit 8.10 show the date that theCode Orange directive was published and the date thatthe SARS Alliance hospitals were assigned.

In early March 2003, medical bed occupancy averaged95%. High occupancy (over 90%) in medical beds isassociated with off-service placement of patients andmore frequent transfers of patients between services.This can present infection control challenges as patientsare moved from one unit to another, sometimestemporarily placed on units where the staff may beunfamiliar with their care requirements.

During SARS I, medical bed occupancy dropped to 80%.It recovered to almost 85% by mid-May, but droppedagain to 80% during SARS II.

In early March 2003, surgical bed occupancy was 88%,with a drop to 80% during the March school break. Itdropped from 85% just prior to the declaration of CodeOrange to 68% immediately following the declaration.From late April until the end of June, surgical bedoccupancy stayed between 75 and 80%.

Occupancy of mental health beds dropped from 80%prior to SARS I to 62% in mid-April. It rose to 75% bymid-May and stayed close to 75% until the end of June(when it dropped slightly to 73%). The drop in mentalhealth bed occupancy is surprising since most mentalhealth admissions (94.5%) are considered non-elective.This drop is likely related to the reduction in ED activity,since most mental health inpatients are admitted via theED. There was no way, with the available data, to assessthe impact of the reduction of mental health inpatientactivity on mental health patients (or potential patients).

The occupancy data show that the introduction of CodeOrange had the most immediate and greatest impact onsurgical beds. There was also a large occupancy reductionfor mental health beds, particularly in Toronto

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6 At the time that this report was prepared, not all Toronto and GTA hospitals had reported their occupancy data for June 2003. Only hospitals withcomplete data for all four months are included in the analyses. Data were missing for June 2003 for four acute care hospitals—Toronto East General,St. Joseph’s Health Centre, Sunnybrook and Women’s, and St. Michael’s Hospital (which was a SARS Alliance hospital).

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E X H I B I T 8 . 1 02003 GTA and Toronto Hospital Bed Occupancy for Medical, Surgical, and MentalHealth Beds by Week

community hospitals. Thereduction in occupancy for medicalbeds was not as rapid or as large.

Exhibit 8.11 shows that prior tothe establishment of the SARSAlliance the hospitals that wouldbecome Alliance members main-tained overall bed occupancy ratesbetter than the other hospitals.We speculate that this is becausetwo of the hospitals (St. Michael’sand Sir William Osler) had verylimited SARS volumes in SARS I,and the Scarborough General sitewould have taken on overloadfrom the closure of the Grace site.After the Alliance was established,overall bed occupancy in theAlliance hospitals dropped to 50%. However, this figure may besomewhat misleading. A majorcontributor to the drop in occupancy in SARS Alliancehospitals was the virtual closure of North York General Hospital.Furthermore, data from one of the four SARS Alliance hospitals,St. Michael's Hospital, were notavailable for analysis. At the sametime, the non-Alliance hospitalswere able to maintain an overalloccupancy rate of 85% duringSARS II.

Exhibit 8.12 shows that duringSARS II (and after the establish-ment of the SARS Alliance) theoverall hospital acute care bedoccupancy was approximately 80%,much lower than the above 90%rate in early March, but higherthan the 75% rate during SARS I.

The attempt to confine the impact ofSARS to the SARS Alliance hospitalsduring SARS II appears to haveinsulated the non-Alliance hospitalsfrom further large reductions inactivity, but the non-Alliancehospitals were still unable to returnto pre-SARS occupancy levels.

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E X H I B I T 8 . 1 22003 GTA and Toronto Hospital Overall Acute Care Bed Occupancy by Week

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E X H I B I T 8 . 1 12003 GTA and Toronto Hospital Overall Acute Care Bed Occupancy by HospitalSARS Alliance Status by Week

8C.4 Elective Surgery BacklogAs noted, most medical admissions to acute care hospitalsare non-elective and occur via the ED. The majority ofsurgical admissions are elective (as are almost all ambula-tory procedures). This analysis of the service backlog inToronto and GTA hospitals accordingly focuses on electivesurgery cases (both ambulatory and inpatient).

If Toronto and GTA elective surgery activity in March,April, May, and June 2003 had been equal to the activitylevels in the same months in 20027, then we estimatethat there would have been 6,641 additional inpatientcases and 17,828 additional ambulatory procedure cases.More than half of the inpatient elective surgery backlogoccurred in April 2003, during SARS I and Code Orange.The ambulatory procedure backlog was even moreconcentrated, with 85% occurring in April.

For purposes of calculating the cost to eliminate thisbacklog, we have assumed that all of the elective surgicalcases that could not be accommodated during the SARSoutbreak were deferred and will have to be accommo-dated some time in the future. It may not be necessaryto address the entire backlog since:

• some patients may no longer require surgery (havingopted for non-surgical treatment instead) or may nolonger be suitable candidates for the surgery;

• some patients may have sought and received theircare in hospitals outside Toronto and the GTA; and

• some physicians and patients may reassess theappropriateness of the planned surgery (given therestricted access), leading to removal of some patientsfrom the waiting lists.

Using the 2001/02 CIHI/Hay Group annual benchmarkingstudy data for Toronto and GTA hospitals, we establishedclinical program profiles for elective inpatient andambulatory procedure activity. By applying averagedirect cost per weighted case values to the weighted casedata, we estimated the direct cost of the deferred surgicalactivity to be $32.1 million.

The program areas with the estimated greatest backlog(in terms of cost) are:

• general surgery (including much of the cancer surgery,$6.3 million);

• orthopaedic surgery ($5.2 million); and

• cardio-thoracic ($5.2 million).

The analysis above is based on direct costs only. Someoverhead costs (excluded from the direct cost calculation)could be considered to be partially variable, or at leastaffected by changes in direct care volume (e.g., laundry,housekeeping, materials management). If 50% of overheadcosts were added to recognize variable overhead costs,the total estimate of the cost of deferrable surgical activitywould increase from $32.1 million to $37.9 million.However, as explained above, it is unlikely that the entirecalculated backlog will need to be cleared.

While this calculation focuses on deferred electivesurgical activity, there will be various other backlogs,such as deferred elective medical admissions and deferredambulatory diagnostic tests.

The OMHLTC has made $25 million available to hospitalsfor clearing deferred cases arising from the SARS outbreak.This funding will go some distance towards the estimatedcosts of the backlog, but not cover all estimated costs.

Funding will not be the only limiting factor on thecapacity of the Toronto and GTA hospitals to furtherincrease their activity levels to clear the backlogs. Otherpossible constraints include:

• hospital physical capacity (e.g., OR theatres, beds);

• staffing shortages (e.g., ICU nurses, respiratorytherapists); and

• impact on efficiency and productivity ofaccommodating the post-SARS “new normal” practicein Ontario hospitals.

In addition, if overtime payments are required to ensurethat staff is available to support the expanded activity,the unit costs per case will also be higher.

8D. RecommendationsA number of the issues raised by these interviews, focusgroups, surveys, and analyses have already been addressedin earlier chapters, viz. strengthening public healthinfrastructure, better F/P/T coordination, clarity aboutoutbreak management at a systems level, emergencypreparedness and response and its relationship to health

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7 We have assumed that without SARS, the 2003 activity levels would have been equal to the 2002 activity levels. This might not have been the casesince some hospitals facing funding constraints may have planned to reduce activity anyway in 2003, while others were planning for increasedactivity consistent with program expansions arising from Health Service Restructuring Commission directives.

emergencies, surveillance, systems of alerts, andcommunication challenges. However, additional issues,many specific to health care and local/regional publichealth, also emerged. The Committee’s members live,work, and pay taxes in several different provinces ofCanada. Several of us are active as administrators and/orpractitioners in the health field. As the tenor of theforegoing chapters has illustrated, we see our mandate asnational, aiming at building all levels of public healthcollaboratively. We therefore have no hesitation inoffering recommendations that bear on health care andlocal/provincial public health matters. Accordingly, theCommittee recommends that:

8.1 The CEOs of hospitals and health regions shouldensure that there is a formal Regional InfectiousDisease Network that can design and overseeimplementation of hospital strategies forresponding to outbreaks of infectious disease.These Networks should map out programs ofhospital surveillance for infectious diseases thatcross-link institutions and connect in turn to anational surveillance program so as to integratehospital and community-based information.

8.2 As part of its activities, the F/P/T Network forEmergency Preparedness and Response shouldexamine provincial and federal emergencymeasures with a view to ensuring that allemergency plans include a clear hierarchy ofresponse mechanisms ranging from the responseof a single ministry to a response from the entiregovernment, with appropriate cross-linkages.

8.3 Provincial/territorial ministries and departmentsof health should ensure that emergency plansinclude provisions for appropriatecompensation of those individuals required torespond to and those affected by the emergency.

8.4 Provincial/territorial ministries and departmentsof health should revise their statutes andregulations to require that every hospital orhealth region has formalized and updatedprotocols for outbreak management. Theseplans must include mechanisms for gettinginformation and supplies to those outside theinstitutional sector, such as primary carephysicians, ambulance personnel/paramedics,and community care providers.

8.5 The CEO of each hospital or health region shouldensure that each hospital’s protocol for outbreakmanagement incorporates an understanding ofthe hospital’s interrelationships with local andprovincial public health authorities.

8.6 The CEO and relevant clinical chiefs of eachhospital or health region should ensure thatthere is continuing education for hospital staff,particularly front-line health care workers, toenhance awareness of outbreak/infectiousdisease issues and institutional/clinicalinfection control.

8.7 Provincial/territorial ministries and departmentsof health should ensure that all key health leadersare trained in crisis communications. Hospitaland health region CEOs in turn should ensurethat clinical leaders and key administrators arealso trained in crisis communications and thatthe organization has a clear cut protocol forproviding all relevant information to staff andhearing their concerns in a timely, respectful,and participatory fashion.

8.8 Provincial/territorial ministries and departmentsof health should require through regulationand provide funding to ensure that emergencydepartments have the physical facilities to isolate,contain and manage incidents of infectiousdisease. Emergency departments should also beequipped with appropriate infostructure toenable their participation in infectious diseasesurveillance networks, including receipt of allnecessary national and international alerts.

8.9 Provincial/territorial ministries and departmentsof health should provide the necessary fundingfor renovation to achieve minimal facilitystandards for infection control in emergencydepartments.

8.10 Provincial/territorial ministries and departmentsof health should ensure that each hospital hassufficient negative pressure rooms for treat-ment of patients with infectious disease.

8.11 Provincial/territorial ministries and departmentsof health should ensure that, for emergencysituations, at least one hospital in each ‘region’of a province/territory has sufficient facilitiesand other infrastructure to serve as a regionalcentre to anchor the response to outbreaks ofinfectious disease.

8.12 Provincial/territorial ministries and departmentsof health should ensure that systems are devel-oped to ensure that providers and the publicreceive timely, accurate and consistent infor-mation and directives during an outbreak ofinfectious disease.

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8.13 Public health managers and facility/regionalhealth authority CEOs, in collaboration withrelevant unions, professional associations andindividuals, should create a process/mechanismto include front-line public health and healthcare workers in advance planning to preparefor related outbreaks of infectious diseases andother health emergencies. Occupationalhealth and safety issues should be givenprominence in this process.

8.14 Provincial/territorial ministries and departmentsof health should engage the Canadian Councilfor Health Services Accreditation to work withappropriate stakeholders to strengthen infectioncontrol standards, surveyor guidelines andtools that are applicable to emergency servicesas well as outbreak management within healthcare institutions. The standards should alsoinclude descriptors of the appropriate expertiserequired to maintain hospital infection control.

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