key: cord-0720043-kmfx4l8s
authors: Holden, Ann C.; Mogck, Isabelle
title: Severe Acute Respiratory Syndrome: SARS: One Toronto Hospital Experience
date: 2003-10-31
journal: AWHONN Lifelines
DOI: 10.1177/1091592303259516
sha: 2a9e20d98b0a2a7cb8650bee40ed02cab6f1fbb0
doc_id: 720043
cord_uid: kmfx4l8s

nan

In late March 2003, health care workers in the greater Toronto area, in Ontario, embarked upon a new era in health care. Severe acute respiratory syndrome (SARS) had been identified as a trend in several hospitals.

To deal with the increasing crisis, a Code Orange was declared by the Ministry of Health. A Provincial Operations Centre (POC) was established to centralize management of the SARS outbreak province-wide.

It was not long before the inadequacies of current hospital emergency measures manuals became apparent. The manuals were developed to assist hospital personnel in dealing with "one time" sentinel types of events. There was an immediate need to develop and implement procedures and guidelines specifically relevant to SARS. All the new guidelines were focused on containment of the disease and protection of all patients, health care workers and visitors. The great challenge was to manage a disease about which very little was known, and about which knowledge would be constantly emerging.

Door screening was implemented for everyone entering the hospital. Specific entrances were identified for use and all others were sealed off, thus securing the perimeter and ensuring that no one entered who did not pass through screening. All nonurgent procedures and clinics were cancelled, and visiting restrictions were implemented.

Volunteers, salespersons and delivery personnel weren't permitted to enter the hospital. screeners' role involved promoting public relations, communicating policies, de-escalating resistance, and offering solutions or options. Isolation rooms and units were identified and prepared for patient use. The Women and Children's Health Program prepared protocols to manage care of SARS patients in the Maternal Newborn areas, as well as in Pediatrics. Since the programs consist of services at two sites, it was decided that the higher risk unit would become the triage and isolation unit for birthing patients. When other local hospitals had to close their services due to SARS, women were redirected to this unit to receive care. The nurses assumed the added workload with caring and stamina.

Planning for the care of a woman with SARS requiring a cesarean birth and/or care of ill newborns presented additional challenges, as minimal patient movement and contact with others was desirable. The plan of care for women who have been contacts of SARS patients, and who remain asymptomatic, includes providing LDRP care in a birthing room using respiratory isolation precautions. If a mother and her newborn are stable, they are discharged 24 hours postpartum to complete their quarantine period at home with Public Health follow-up. A woman requiring cesarean birth will remain with her healthy newborn in the birthing isolation room, where she will receive all needed nursing care, to decrease the potential for exposure in other areas of the hospital. Women who require isolation would be managed in the birthing unit and then transferred to a designated SARS Alliance hospital. Transfer protocols for women and newborns requiring tertiary-level care and retro-transfer procedures were developed at the provincial level and implemented locally.

Neonatal and pediatric patients are transferred and treated at the Hospital for Sick Children. The Toronto area hospitals with maternal, newborn, and pediatric services are members of a local, collaborative network, which proved to be an enabler and an advantage when the network took a lead role in providing scientific and practical guidelines for managing services for women and children during the outbreak.

Strict infection control principles were adhered to based on the current understanding that transmission is primarily through droplet infection. Disposable equipment and protective coverings for nondisposable items were obtained. Carts containing disposable patient care supplies were filled and placed outside the door of the isolation rooms. The rooms were blocked from use by other patients to ensure immediate availability. The nursing staff were provided with frequent education updates as information became available.

Staffing presented another unpredictable challenge. Many nurses and other health care personnel work at more than one hospital in the Toronto area. When hospitals were closed and the staff sent home for a 10-day quarantine period, those staff members were not able to go to work at other locations, leaving gaps in schedules and units short-staffed. Nursing agencies were also affected, which further limited the availability of nurses.

Initially, directives from the POC were being received frequently throughout the day, seven days per week. The administration team, including the infection control practitioners and educators, provided 24-hour coverage onsite and by pager. The need to communicate changes frequently and effectively requires significant teamwork, as the directives must be put into a user-friendly format for staff and then communicated to all. There have been frequent modifications made to procedures and guidelines to ensure their consistency with the most recent directives. It became apparent quickly that every document had to include the date and time of generation to ensure that staff were always working from the most recent information. Yellow paper was used to distinguish SARS-related information.

Protective wear for nurses includes N95 masks, goggles or face shields and gowns and gloves. While providing protection, the garb has also presented some challenges, including:

• patients having difficulty understanding the nurse when she or he was speaking through the mask • skin reactions among the staff related to wearing the masks and the frequent use of alcohol-based hand sanitizer

• respiratory difficulties, such as shortness of breath • headaches and discomfort from being hot while in the protective clothing

Family-centered care has been a consideration through the SARS experience. Birthing women have been permitted to have one support person with them throughout their hospital stay. This was increased to two support persons when the restrictions were relaxed. Babies in the NICU and pediatric patients may have two parents with them (plus two significant oth-ers). Asymptomatic women have been encouraged to breastfeed in the absence of evidence to the contrary. The lessons learned from this experience have included an increased appreciation for the level of integration that exits within the health care system as evidenced by the impact on all hospitals when one or two hospitals are closed and their staff are placed on quarantine. The present system for emergency codes doesn't address a situation such as SARS; a code for a nonsentinel event such as "infectious disease" would be useful.

It's essential to place the date and time on every piece of paper generated during an ongoing crisis, as there are frequent updates and changes made as more information becomes available. The value and contribution of families and significant others of health care workers must not be underestimated or taken for granted. Staff burnout is a risk factor with any ongoing crisis.

The mother-baby nurses have found that new mothers seem to have more teachable moments and are more attentive to the teaching that is provided during these times. They reported observing improved breastfeeding outcomes and attribute those observations to the lack of visitors and other distractions.

The impact of SARS on a hospital community is multifaceted. Families of health care workers have been affected by quarantine, longer than usual hours and stress and illnesses related to wearing the protective apparel. The Public Health units have been stretched to the limit, and access to health care usually associated with a hospital (e.g., prenatal, postpartum and lactation clinics) has been more challenging. Misinformation has created public reactions that require time and energy to address.

Health care delivery in Toronto has been changed forever by SARS. Organizations are reviewing once liberal visiting policies, ongoing screening at entrances, alternatives for off-site provision of out-patient services and numerous other strategies that will support the ability of the hospital to continue to provide inpatient acute care and emergency services when the next crisis occurs.

Throughout this experience, the nurses have demonstrated understanding when new information did not always seem to make sense, caring when in great personal discomfort, commitment when the hours of crisis became days, weeks and then months, and a sense of humor to help everyone cope with a new, complex infectious disease.

Ontario Ministry of Health and Long-Term Care: www.health.gov.on.ca • Health Canada: www.hc-sc.gc.ca/pphb-dgspsp/sars-sras/index.html • World Health Organization: www.who.int/csr/sars/en/ • SARS Reference (online medical textbook): www.sarsreference.com • Centers for Disease Control & Prevention: www.cdc.gov/ncidod/sars/ • Food and Drug Administration