Strategies for coping with SARS in the ED - PowerPoint PPT Presentation

1 / 37
About This Presentation
Title:

Strategies for coping with SARS in the ED

Description:

83% of SARS patients did not transmit to anyone ... most important as a prototype for other outbreaks (influenza) or bioterror ... – PowerPoint PPT presentation

Number of Views:54
Avg rating:3.0/5.0
Slides: 38
Provided by: mmed
Learn more at: http://www.uic.edu
Category:

less

Transcript and Presenter's Notes

Title: Strategies for coping with SARS in the ED


1
Strategies for coping with SARS in the ED
  • Part 2
  • Challenges and Lessons

2
Overview
  • Controversies and challenges
  • SARS today
  • Lessons for the future
  • Conclusions

3
General Comments on Infectivity (WHO)
  • Basic R0 (reproductive value) 2-4
  • Estimate of R0 for influenza 10
  • 83 of SARS patients did not transmit to anyone
  • Primarily transmitted in acute care hospitals
    (77) and in HCWs (44)
  • 20 attack rate for ED RNs with unprotected
    exposure

WHO/CDS/CSR/GAR/2003.11
4
General Comments on Infectivity (WHO)
  • Primary mode of transmission
  • Large droplet and direct mucous membrane
    (eyes/nose/mouth)
  • Transmission enhanced by close prolonged contact
  • Aerosolizing procedures seems to amplify
    transmission
  • Other?
  • Airborne? -occasional case that may be associated
    with large number of cases
  • Fomites?
  • Amoy Garden outbreak enteric/airborne

WHO/CDS/CSR/GAR/2003.11
5
Clinical Outcome
  • 20 admitted to ICU
  • 15 required mechanical ventilation
  • 10 died
  • Influenza0.1-0.2
  • Avian influenza 15 to 70
  • Increased risk of death or ICU admission if
  • Increased age
  • Comorbidity

Tsui et al. EID 2003 9 1064-1069 Fowler et
al. JAMA 2003 290 367-373 Lew et al. JAMA
2003 290 374-380
6
Controversies and Challenges
  • Lack of transmission in EDs after Mar 22- why?
  • natural history of disease
  • able to tolerate masks
  • few required airway procedures
  • short stay
  • high compliance

7
Controversies and Challenges
  • Effectiveness of PPE?
  • Transmission in the setting of any precautions
  • SARS-1 - 260 patients
  • 22 HCW infected (1 for every 12 patients)
  • primarily airway care in critical care areas
  • SARS-2 129 patients
  • 3 HCW infected (1 for every 43 patients)

8
Differences between SARS-1 and SARS-2
  • Added barriers
  • Double gloves, hair foot covering, greens
  • Enhanced protection during intubation/cardiac
    arrest, etc.
  • HCW training and awareness
  • Practice issues
  • Minimize time in room
  • Minimize contact with patient
  • Medical therapy to reduce cough/vomiting
  • Minimize procedures that increase risk of droplets

9
Controversies and Challenges
  • Transmission through precautions often
    associated with unrecognized or low risk case -
    ? Compliance
  • Intubation
  • perception of ineffectiveness of ppe led to
    recommendations for use of powered air purifying
    respirators (PAPR) hoods
  • much debate, conflict over who should perform
    procedures

10
(No Transcript)
11
(No Transcript)
12
Controversies and Challenges
  • Of 50 SARS intubations (or bronchoscopy) 5 led
    to transmission to 20 HCWs
  • Several involved only partial precautions,
    unrecognized case and/or problems in practice
  • Clearly high risk procedure

13
Approach to Intubation/Airway Care
  • Performed by most skilled/experienced team
    available
  • Performed in the best available room
  • Anticipate and plan
  • Minimize cough, suction, using RSI if possible
  • No ve pressure therapy, scavenge exhaled gases
  • Careful use of PPE especially undressing
  • Consider use of PAPR if available and familiar
    with its use

14
ED Design and Operational Issues
  • Implications for visitor policy and bed flow
    policies avoid excessive crowding especially in
    corridors and curtained areas (consider max
    occupancy?)
  • Design implications space and barriers,
    ventilation

15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
(No Transcript)
22
  • Mask-Fit Testing

23
Staff Training and Communications
  • Infection Control training
  • Awareness, cultural shift
  • not just for rare events like SARS
  • ARO, c. difficile, TB
  • Can SARS do for resp droplets what HIV did for
    bodily fluids?
  • Receiving and distributing alerts and info 24/7
    esp. with shift workers
  • Multiple points of reception
  • Use of Electronic comm, AND bulletin boards, word
    of mouth

24
Controversies and Challenges
  • Appropriate level of preparedness
  • one travel case walking into an unprepared ED can
    set off an outbreak with billion impact
  • excessive measures are costly and encourage
    non-compliance
  • should we place everyone with fever and cough
    into droplet precautions?
  • should triage nurse be in ppe?
  • for how long?

25
SARS Today
  • Eliminated from global popn
  • Reservoirs in animals and lab sources
  • Much greater surveillance in China and HK make
    unannounced arrival unlikely
  • Vaccines in development
  • Therefore small but real risk of return, however
    most important as a prototype for other outbreaks
    (influenza) or bioterror

26
Conclusions
  • EDs provide fertile ground for disease
    transmission
  • Require attention to system issues
  • Overall ED design
  • hand-washing
  • individual care rooms and spacing
  • Adequate isolation rooms
  • en suite BR, resuscitation room with airborne
    protection
  • Avoid crowding due to excess pts/visitors

27
Conclusions
  • Adequate staff training in infection control
    policy and procedure, use of ppe
  • Focus on triage, case recognition
  • Communications vital
  • receiving of disease alerts
  • transmitting info to staff

28
What do we do differently?
  • (Virtually) No Hallway stretchers
  • Equipment reviewed, changed
  • Selected use of open area stretchers
  • Strict visitor policy, control of WR
  • Better awareness and adherence to infection
    control practices
  • Reno to increase isolation resources
  • Challenges
  • maintain vigilance!!!
  • Baseline precautions

29
(No Transcript)
30
(No Transcript)
31
(No Transcript)
32
(No Transcript)
33
(No Transcript)
34
The Future
  • Lessons learned
  • 4 Canadian provincial and federal expert panel
    reports
  • Some investments in public health
  • Staff training improvement spotty
  • System issues related to crowding unaddressed

35
(No Transcript)
36
(No Transcript)
37
Questions or more info
  • howard.ovens_at_utoronto.ca
  • www.sarswatch.ca
Write a Comment
User Comments (0)
About PowerShow.com