strategies for coping with sars in the ed part 2; –challenges and lessons
TRANSCRIPT
Strategies for coping with SARS in the ED
Part 2; – Challenges
and Lessons
Overview
Controversies and challenges SARS today Lessons for the future Conclusions
General Comments on Infectivity (WHO)
Basic R0 (reproductive value) ~2-4
Estimate of R0 for influenza = 10 83% of SARS patients did not transmit
to anyone Primarily transmitted in acute care
hospitals (77%) and in HCW’s (44%) 20% attack rate for ED RN’s with
unprotected exposure
WHO/CDS/CSR/GAR/2003.11
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
Clinical Outcome
20% admitted to ICU 15% required mechanical ventilation ~10% died
– Influenza~0.1-0.2%– Avian influenza 15 to 70%
Increased risk of death or ICU admission if:– Increased age – Comorbidity
Tsui et al. EID 2003; 9: 1064-1069; Fowler et al. JAMA 2003; 290: 367-373; Lew et al. JAMA 2003; 290: 374-380
Controversies and Challenges
Lack of transmission in ED’s after Mar 22- why?– natural history of disease;
able to tolerate masksfew required airway procedures
– short stay– high compliance
Controversies and Challenges
Effectiveness of PPE? Transmission in the setting of any
precautions;
– SARS-1 - 260 patients22 HCW infected (1 for every 12 patients) primarily airway care in critical care areas
– SARS-2 – 129 patients3 HCW infected (1 for every 43 patients)
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
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
Controversies and Challenges
Of ~ 50 SARS intubations (or bronchoscopy) 5 led to transmission to ~ 20 HCW’s
Several involved only partial precautions, unrecognized case and/or problems in practice
Clearly high risk procedure
Approach to Intubation/Airway Care
Performed by most skilled/experienced team available
Performed in the best available room Anticipate and plan Minimize cough, suction, using RSI if possible No +ve pressure therapy, scavenge exhaled
gases Careful use of PPE especially undressing Consider use of PAPR if available and familiar
with it’s use
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
Mask-Fit Testing
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
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?
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
Conclusions
ED’s provide fertile ground for disease transmission
Require attention to system issues;– Overall ED design
hand-washingindividual care rooms and spacing
– Adequate isolation roomsen suite BR, resuscitation room with airborne protection
– Avoid crowding due to excess pt’s/visitors
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
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
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
