SARS in Toronto! - page 11

Hey I just saw on the news that a thousand people have been quarentined at a hospital in Toronto! Do you all know anything about this? I hope our Toronto members are alright. Is this virus... Read More

  1. by   Trishrpn
    Thanks for your reply epaminondas, I'll try to answer some of your questions and give you some thoughts to ponder ... hopefully some of the others who are in affected hospitals will also reply.

    Masks- I haven't found a Mask that I prefer. We don't have much choice in the matter- we get what we are given when we check in each day. Occasionally there is a choice of two or three masks but most often there is only one type. I haven't seen the N100's, we've been working mainly with the N95's and N99's. Only those of us working in Emerg, Sicu or CCU get N99's when they are available. Otherwise we use N95's.

    Anyone working in patient care area's must wear an N95 mask (or higher depending upon the area that they work in). They have changed the regulations slightly now so that hospital workers that don't work in patient care areas do not have to wear a mask (but everyone still does). Staff that don't work in patient care areas can wear standard surgical masks or the duck bill masks, and anyone that is even just walking through a patient care area must wear a mask of some type. Anyone working in a patient care area wears the masks that are valved, although the valveless variety are available as well. All patients are given standard surgical masks to wear, and any patients with respiratory symptoms are given N95's.

    Patients entering through Emerg are given a mask when they are screened outside the hospital prior to entering the hospital. On the rare occasion when a relative is allowed in with them (ie critically ill patient or someone who can't speak English at all, or the parent of a sick child) this person is also screened and given a Mask. Basically no one gets into the hospital unscreened or unmasked, although as I've said, staff that do not work in, or walk through patient care areas do not have to wear masks at this time.

    We are given a new mask each shift. If that mask becomes soiled or damp we can replace it, but if it remains intact they consider it good for the whole shift. When working with patients in Isolation we put a standard surgical mask over or N95 or higher mask. Originally they said we had to change the N95 mask but now they say that we should just protect the mask with a surgical mask and only discard the surgical mask after working with an isolation patient. Many of us are not convienced that this will protect us so we often change our N95 masks too. (provided that there is a good enough supply to do so! That's another problem!)

    As far as I know no one is using the HEPA head gear in our hospital.

    We've been told to try to keep our goggles and to bring them back to the hospital for each shift, not to throw them out after a shift. We've been told to wash them with soap and water.


    I really don't know what percentage of Ontario Sars victims are health care workers.

    Just a little history here ... Our first case of Sars visited China in Febuary, she and her family returned to Canada near the end of Febuary (24th?) and she began to develop symptoms of the illness on Febuary 27th and I believe she was hospitalized on March 1st, however she died at home on March 5th. By this time her husband and her son were also exhibiting symptoms and I believe the hospital where they were cared for was beginning to suspect that this was a contagious disease but they might not have fully known at that time what they were dealing with. The World Health Organization didn't put out it's Global Alert until March 12th which was a full 7 days after we'd had our first death here. I believe that almost all of the cases that we have here in Toronto with the exception of a couple of other Sars victims who had also travelled to Asia can be traced back to these first three cases (the first family). Now, because the hospital and health care workers didn't know what they were dealing with when these first cases occured in Toronto no isolation measures were taken during the initial stages, which means that numerous health care workers and likely patients in the emerg and other patient care areas of the hospital were exposed to the SARS virus. Affected members of this family also visited a doctors office or medical clinic and I believe that some of the people there were affected too. Not everyone who was exposed has become ill with SARS but most were definitely affected on that they had to be quarantined once we knew what we were dealing with. It's that initial two week period from the families return from China until the WHO Global alert that has caused the majority of our SARS cases here in Toronto. Once that initial hospital knew what it was dealing with isolation precautions were put into place, but by that time there were many people exposed to the infection. Still, I'm not certain at this time how many health care workers have actually become ill with SARS like symptoms, I believe that the numbers will still end up being on the low side when all is said and done.

    This article from the New England Journal of Medicine has a breakdown of the intial cases here in Toronto:
    http://content.nejm.org/cgi/reprint/NEJMoa030634v1.pdf


    I realize that you are happy to hear that so far only 3% of US health car workers have been affected by SARS but there are a few things to consider with that figure. your population is about 10 times higher than the Canadian population ... so how many health care workers exactly is 3% of your health care workers?

    In an article in the New York Times I read today that the US is now reporting only the probable figures on the world health organization website (I don't see that change the numbers still reflect your total probable and suspect cases) which is now supposedly only 36 cases. We have 126 probable cases across the country and we've had Sars here since the end of Feb. From what I've found it seems that Sars really didn't hit the US until two or three weeks later than it hit us ... so we've been fighting it or working with it almost twice as long.

    It's unfortunate that Sars hit us in Toronto so hard, but once we knew what we were dealing with we went into high gear. As I've described in my two posts to this forum today everyone is wearing masks in the hospitals- patients and staff, and we are screening everyone who enters the hospital before they even get inside. I'm 100% convinced that if we weren't taking this so seriously that things would be much worse here.

    From what you've said and from what I've gathered from reading posts and articles about SARS in the US it doesn't sound like the hospitals there are taking this infection quite as seriously as I think they should be. I've seen several posts that state no protective or isolation measures are being taken until the patient is actually in the hospital and presents with symptoms and states they've had recent travel to an affected area. Only then are they given a Mask and put into isolation. This is scary!!!!!

    We've just had a whole church congregation of 500 people put into quarantine because of a slip up. A gentleman passed away here in Toronto on the first of April. This man had orginally gone to the hospital on March 16th (the hospital where this all started in Toronto). His son was present in the emerg with him. Shortly after their visit to emerg on march 16th, health officials here in toronto decided that anyone that had been in the hospital emerg and other specific areas needed to go into a 10 day quarantine because of possible exposure to another Sars victim that had been there at that time. I'm not sure if the man that I'm discussing was admitted to the hospital on his visit to emerg or was released, but either way the son voluntarily quarantined at home for 10 days. Then the father died and 5 days after his death and 2 days after his funeral it was decided that his dealth was caused by SARS. What wasn't known at that time was that another son had briefly visited the father and son in Emerg on March 16th. The second son was never quarantined because it wasn't known he was in emerg that day, and I suppose he never put two and two together and realized he'd had an "at risk" exposure on that brief visit. Well to shorten this story ... the second son who was never quarantined was a member of the Church congragation that just had to be quarantined earlier this week. This son is now sick with Sars like symptoms as are 28 other members of that congragation (BTW the people that visited the funeral home on April 3rd also had to be quarantined).

    The point I'm trying to make in all this is that the father and sons became ill because they were exposed to another person who happened to have Sars symptoms at the time they were all in the emergency dept. Now remember one son was only in the hospital briefly.

    I just think the fact that your hospitals in the US are not giving out masks and that the health care workers are not at least wearing masks in "at risk areas" at all times, is simply asking for trouble. From our experience here it doesn't seem like it takes are very long unprotected exposure to possibly cause illness. That's why were are protected at all times and why we have masks on every patient coming into the hospital.

    Yes everyone in my hospital seems to be showing up for work. No one seems to be too scared to come in. We are protecting ourselves and we *should* be safe. I do know that no health care worker that has been wearing protective gear has been infected ... any health care workers who have been affected had unprotected exposures (ie prior to the WHO global alert). That's the main reason why I'm concerned that there might not be enough preventative protective measures being taken in the US.

    If people in your hospital are saying already that they will not come in if SARS hits the hospital that is possibly due to the fact that not enough measures seem to be being taken at this point to protect health care workers and patients from exposure to this illness. If those measures were in place already as they are here I would hope that you would be hearing less statements like that.

    As I said the US has the advantage of watching how we deal with this disorder. I would hope that your hospitals would learn from what we are doing, and any mistakes that were made in the beginning by us due to our not knowing what were werer dealing with initially. By the time this hit the US you knew what it was, and it's still a hard disease to diagnose, it's not always easy to spot ...

    The staff that are expressing concern are likely very worried. You ask "why declare cowardice in advance- particularly if you may never need to act on it?" But if no preventative protective measures were being taken here I would be afraid too.

    As long as I feel like the measures we are taking are effective I plan on continuing on and working. I love my job and hope this resolves itself in the near future ... but I also fear that I'll be wearing a mask for a long time to come because I don't think this disease is going to settle down any time soon. I don't feel that I really have a choice in the matter ... I mean all the hospitals here are chronically short staffed, and now with this health care disaster in the works it's even worse ... how could I not work? They need me.

    It's an unusual situation and one that I hope we never have to face again. Here in Toronto we are comparing this to how we would react if there were an act of biological terrorisim in the city. What we've found is that in some ways we were prepared ... when we knew what were wre dealing with we went into full alert (our hospital is in Code Orange which is our external disaster code), and for the most part all the plans made in advance of such a disaster have been effective. I do know that we have learned that we need to have triple the amount of supplies stored away though (ie MASKS!).

    Sorry to wander off like that - but watching SARS head towards us with all the speed of a twenty foot high wave of molasses gives us a lot more time to think about it than you probably have on the front lines.
    And that's why I'm trying to ring the warning bells. That wave is coming and if you don't treat it like the health care disaster it is (or as you would a biological threat for example) you might end up in even worse shape than we are here in Toronto. I'm not trying to be an alarmist, I just fear that if you don't start wearing masks and also putting masks on everyone that comes through your hospital doors soon this will really get out of hand. I think what we have been doing here with the masks and isolation gowns is really all that has kept this from getting totally out of control ... some fear that even with the measures that we've taken that it might be becoming out of control.

    The article that you linked in your post http://www.pilotonline.com/news/nw0326che.html
    was interesting. It's great tht that doctor was really up to date on his information, and that he took action as quickly as he did. It was a lucky call. I also wonder how long that patient sat in the waiting room etc ... you have to wonder, if it really was SARs, just how many people were exposed to that patient before she was placed in isolation.

    Here we are thinking about what to do. But there is a strong desire to not look silly, to not be paranoid. To not get ready.
    Yeah On March 27th when we all started wearing masks and gowns and gloves all the time the media started to wonder if we were overreacting, and I guess some of us health care workers did too ... but believe me, no one thinks we are overreacting now.

    Our trigger point is when the first case hits the state. Then things will start to get moving.
    It will be too late by then ... this is a global illness.

    It's like the article that someone posted earlier about the fact that they will start wearing Goggles in British Columbia when dealing with Sars isolation patients because Sars infected droplet molecules might have infected a nurse through her unprotected eyes. Duhhhh! We've been wearing Goggles here in Ontario when caring for suspect SARS cases for three weeks! British Columbia is in Canada ... they know very well what we are going through and what we are doing here in Ontario ... if that nurse did become infected because she wasn't wearing goggles it wasn't due to lack of knowledge, it was because her hospital or province hadn't recommended/demanded that goggles be worn. What I'm trying to say is that they saw what was going on here and they must have watched and waited ... and now perhaps a nurse is paying the price for their lack of action.

    Thanks for the information from Hong Kong- it's interesting to find out what's happening on the front lines there too. Are health care workers all wearing N95 masks there too- all the time I mean?

    Ok gotta go to bed! I have to work in the morning. Hopefully tomorrow is a better day at work than Tuesday was.

    Trish
  2. by   sixes
    Trish thank you for the wonderful post . i have printed the Identification of SARS in Canda link you provided I was having a hard time reading all 11 pages.
    I think everyone should read this article it is a wealth of info.
    I hope you have a good day at work, Hoping everyone has a Happy Easter. To those in quarantine my heart goes out to you. God will forgive you and love you all the ore if you stay home and pray instead of breaking your isolation.

    Here are some more links

    It'll be a long weekend
    http://www.canoe.ca/TorontoNews/ts.ts-04-18-0004.html

    The selling of TO
    http://www.canoe.ca/TorontoNews/ts.ts-04-18-0005.html

    Tourism workers reeling
    http://www.canoe.ca/TorontoNews/ts.ts-04-18-0006.html

    Economy may feel chilly touch of scare
    http://www.canoe.ca/TorontoNews/ts.ts04-18-0007.html

    SARS in sewer
    http://www.canoe.ca/TorontoNews/ts.ts-04-18-0038.html

    Kuala Lumpar lifting ban on Canada
    http://www.canoe.ca/TorontoNews/ts.ts-04-18-0039.html

    Tests to help pinpoint virus
    http://www.canoe.ca/TorontoNews/ts.ts-04-18-0041.html

    Tory convention will stick with Toronto
    http:www.canoe.ca/TorontoNews/ts.ts-04-18-0044.html

    Help on the way for city's beleguered Docs
    http://www.canoe.ca/TorontoNews/ts.ts-04-18-0046.html

    System at surge capacity
    http://www.canoe.ca/TorontoNews/ts.ts-04-18-0047.html

    Beijing visa office shut
    http://www.canoe.ca/TorontoNews/ts.ts-04-18-0048.html

    PS Keep up the wonderful posts. I live only about a 7 hour drive from Toronto. but I feel like I'm a million miles away
  3. by   fergus51
    We are using the n95 masks and gowns and gloves (have to change the mask every 8 hours). The province has something like 80 000 nurses so, it certainly isn't like a large percentage of nurses get sars (even 1% of our nurses would outnumber the total cases of sars almost 3 to 1 and that's not counting RPNs). Everyone seems to still be showing up for work, and we're using precautions. So far I don't know any of the health care workers who contracted SARS and don't think any have from my hospital.

    I would be extremely concerned if people just refused to show up for work at this point for a reason like "I have children". To date Canada has had approximately 300 SARS cases and 13 deaths (of the deaths one person was in their 40s, one in their 50s, one in their 60s and all the rest were over 70). It is something that should be taken seriously (which is why we use our precautions religiously) but I don't think it is a reason for complete and uneducated panic.
    Last edit by fergus51 on Apr 18, '03
  4. by   fergus51
    There you go, health care exposures are broken down in the graph if you hit April 17 for the most recent one.

    For those interested at good link:

    http://www.hc-sc.gc.ca/pphb-dgspsp/...ras/prof_e.html
  5. by   JMP
    Originally posted by fergus51
    We are using the n95 masks and gowns and gloves (have to change the mask every 8 hours). The province has something like 80 000 nurses so, it certainly isn't like a large percentage of nurses get sars (even 1% of our nurses would outnumber the total cases of sars almost 3 to 1 and that's not counting RPNs). Everyone seems to still be showing up for work, and we're using precautions. So far I don't know any of the health care workers who contracted SARS and don't think any have from my hospital.

    I would be extremely concerned if people just refused to show up for work at this point for a reason like "I have children". To date Canada has had approximately 300 SARS cases and 13 deaths (of the deaths one person was in their 40s, one in their 50s, one in their 60s and all the rest were over 70). It is something that should be taken seriously (which is why we use our precautions religiously) but I don't think it is a reason for complete and uneducated panic.
    Agree with you Fergus.
    Uneducated panic is one of the worst things we could have now/
    We wear the N95's. We also wear googles-gowns-gloves.
    No ONE has refused work and if anything our sick calls are down. Which is a relief for many I am sure, since it was thought in the beginning sick time would climb. It has not.
  6. by   zumalong
    Hello to my friends across the lake (Ontario). Wendy---how are you--you haven't posted in several days. When I started reading about SARS in Toronto I thought of you first. (no offense to everyone else but I haven't posted for many months due to total hip replacement and lack of money for internet connection and Wendy is an ole timer who I remember when I last posted)

    Did anyone see or read the book, "...and the Band Played On" I see some eerie parallels with the HIV virus and this one. I agree that we are seeing a new era in healthcare. Any of us who were nurses before HIV remember that gloves were not available and if they were you would never use them because it "decreased your tactile sensitivity etc."

    As someone with severe asthma (which consequently led to my need to have hip replacement) I can say I am petrified to return to acute care.

    Living so close to Niagara Falls I ponder a scary scenario: One person with SARS. Coughs etc. near the mist: how many people will be infected? (if you have ever been to the Horseshoe falls you know that there is continual mist from the water)

    I do have a question about the masks though. If you wear a surgical mask--won't this risk more moisture building up on protective masks???? I have been trying to imagine having to wear a mask for my whole 12 hour shift. I get short of breath thinking about it.

    Does anyone wonder if this might not have been biological warfare that was released by accident (or worse--on purpose)

    It does not matter how it arrived on the planet, it is not going to go away easily. Take care all my nursing colleagues--both in acute care and in all areas of patient care. We may be nurses but we are still humans with families who need us around for a long time.
  7. by   RNonsense
    There is a second nurse here now from the same hospital who as SARS. I'll post a link as soon as it hits the web.
  8. by   sixes
    Good morning all. I am a little concerned that I haven't heard from Wendy. Hope you are well. I hope alll nurses working and coping with SARS are doing OK. Keep up the good work your are truly are front line defense.

    Faithful Fight Fear
    http://www.canoe.ca/TorontoNews/ts.ts-04-19-0004.html

    2 Stricken Hospital to reopen in days
    http://www.canoe.ca/TorontoNews/ts.ts-04-19-0005.html

    No help for stab victim
    http://www.cnaoe.ca/TorontoNews/ts.ts-04-19-0027.html

    SARS 'prisoner'
    http:www.canoe.ca/TorontoNews/ts.ts-04-19-0029.html

    Man's fight to visit in hospital pays off
    http://www.canoe.ca/TorontoNews/ts.ts-04-19-0031.html

    No Insurance
    http://www.canoe.ca/TorontoNews/ts.ts-04-19-0036.html

    450 Quarantine
    http://www.canoe.ca/TorontoNews/ts.ts-04-19-0037.html

    Leafs wary in midst of playoffs
    http://www.canoe.ca/TorontoNews/ts.ts-04-19-0038.html

    B.C. Translates SARS internet bullitens to Chinese, Pinjabi, Vietnamese
    http://www.canoe.ca/CNEWS/Canada/200.../68380-cp.html
  9. by   epaminondas
    "It was involuntary. They sank my boat."


    Remark when asked how he became a hero.
    John Fitzgerald Kennedy


    _______________________________


    I have been concerned about Wendy, too, but I see that she is posting elsewhere on this board as of today. So it looks like she is doing OK.

    I am happy to see it.

    I wonder if perhaps Wendy became uncomfortable with the degree that the discussion here was becoming centered on people debating her own situation.

    Or maybe Wendy just got bored . . .


    It is interesting to hear that everyone in Toronto is showing up for work.

    Perhaps the sort of conversations in which I have been participating are just a local anomaly.

    Perhaps an artifact of waiting instead of doing.

    Or - I wonder if it may reflect a difference in Canadian vs. American psychology.

    Perhaps Canadians are more community-minded and Americans are more what's in it for me me me.

    I don't know.

    I would guess that Canadians might be more up on the differences between Canadian and American psychology than Americans might be.

    Perhaps we will find out soon.


    Fergus wrote:

    << It is something that should be taken seriously (which is why we use our precautions religiously) but I don't think it is a reason for complete and uneducated panic. >>

    Agreed.

    That is why I am trying to learn from the Canadian experience.

    Only partial and educated panic for me! ;-)


    I have always been amused when people state "this is no time to panic!"

    I have always wondered when the proper and right time might be.

    And how one panics properly.

    No leaving footprints on the back of the person in front of you.


    I seem to be dealing with my own concerns through education and preparation.

    Hoping that none of this will prove to be necessary.

    _______________________________


    Trish,

    Thank you for the information. Most helpful!

    Please keep it coming.

    Possible future topics: signs and symptoms that y'all are actually seeing in your ER (i.e., is the temp of 38 degrees C actually magical) - are you seeing much general aching, dry cough - what?

    How in the world do you diagnose someone outside of a known chain of infection?

    Course of the disease, course of the recovery? How are health care workers holding up?

    Or just whatever you feel like writing.

    As to :

    <<I realize that you are happy to hear that so far only 3% of US health car workers have been affected by SARS but there are a few things to consider with that figure. your population is about 10 times higher than the Canadian population ... so how many health care workers exactly is 3% of your health care workers? >>

    OOPS! I obviously have been unclear. My apologies. To clarify:

    Only 3% of the SARS cases reported in the US have been health care workers.

    I.e., out of the 36 cases of Probable SARS reported thus far in the entire U.S., only one (1) person, a nurse, has been a healthcare worker (3%).

    Out of the approximately 220 cases of Suspected SARS reported thus far in the entire U.S., only four (4) people, all nurses, have been HCWs (2%).

    The same goes for all the other statistics I reported on percentage of Health Care Workers reported with SARS in outbreaks in Vietnam, Hong Kong, and Singapore - note, though, that those stats have included doctors, nurses, and other HCWs. Those reports are of the percentage of reported SARS cases in healthcare workers, not the percentage of an entire nation's healthcare workers. The numbers are in the ones and tens and hundreds of healthcare workers affected, not in the thousands or tens of thousands.

    To repeat - only one (1) U.S. nurse with probable SARS, out of 36 cases of Probable SARS reported in the entire U.S.

    Again - my apologies for the confusion.


    Happily, SARS does NOT seem to be growing out control: the increase in cases has generally been graphed as linear growth, not exponential. Perhaps this means that human beings are not merely blood agar on a Petri dish, after all. It looks like public health measures - quarantines and contact tracing - are succeeding in putting a major dent in the spread of the disease.

    As a diagnostic test becomes available, control has the potential for becoming even better, even in the absence of a specific treatment: please recollect that TB cases were reduced to one quarter by public health measures alone, in the absence of vaccine usage, via tracing and quarantine prior to the advent of any specific antimicrobial treatment for TB.

    It all now comes down to being a bit of a race between public health measures and the virus.

    I am betting on -

    I don't know.

    Looks like one could reasonably put one's money on either side of the bet.


    Current SARS growth rate graphs.

    World:

    http://www.sars-spread.com

    Note the graph at the bottom of the page - without the aberrant mainland Chinese data - gives the most accurate overall worldwide trend.

    Linear, not exponential.

    Country specific:

    http://www.sars-spread.com/country_breakdown.htm

    The mainland Chinese curve does not fit any growth curve known to nature: it appears to be more political than real. And it distorts any other graphs containing the Chinese data, which is why many analyses exclude the Chinese data at present.

    The data from Hong Kong, Singapore, and Canada all looks reasonable.

    The U.S. data has been reported in its own way . . .

    Any surprise in that?


    Note that the Canadian graph was flattening out over the last week or so, suggesting that Canada was on the verge of having this thing licked.

    I was beginning to feel pretty optimistic. Sigh of relief time.

    There is no way yet to know if the recent Canadian blip is significant. We'll just have to see how this thing plays out over time.

    Of course - that is assuming that the Canadian data is being reported accurately.


    Another graph page:

    http://www.charlesplatt.com/sars/

    __________________________________________________ _________

    RN4ev'r wrote:

    << The hospital I work in is one hospitals in Toronto. We have had 50% of the SARS patients admitted to hospital in our facility, according to what we have been told. To date, there has been no staff members contracting SARS. >>

    Excellent!

    __________________________________________________ _________


    << There you go, health care exposures are broken down in the graph if you hit April 17 for the most recent one. >>

    Fergus,

    Thanks for the link.

    Overall trends on that graph certainly look good.

    Unfortunately the graph lists all "healthcare exposures" together. This includes all patients and all visitors who have gotten SARS from other patients, in addition to HCW (Health Care Worker) exposures all lumped together, so it doesn't really help in pinning down the percentage of HCWs who have gotten the disease.

    I am still looking for the percentage of HCWs in Ontario who have come down with SARS. This is not a complex concept, and is widely reported for other countries. If anyone has seen this information for Canada, I would appreciate a heads-up.

    The HCW stats for SARS are a very basic part of the news coverage about SARS in other parts of the world with the exception of mainland China. In China, of course, much that might cause concern has been concealed: such is their press culture.

    So far there is better information on this issue from Vietnam, Hong Kong, Singapore and the U.S. than there has been from Canada.

    The following a typical report from overseas:

    www.abc.net.au/am/content/2003/s833427.htm

    Just curious . . . I am not familiar with newspaper culture in Canada. And I do not mean to offend. I know that this may sound really stupid, but -

    Does Canada have a "free press?"

    Or is the Canadian press of the more "responsible" variety?

    __________________________________________________ _______________

    << There is a second nurse here now from the same hospital who as SARS. I'll post a link as soon as it hits the web. >>

    RNonsense,

    Would that be this?

    << Officials confirmed two nurses at a Markham hospital got the disease, despite strict infection-control measures in place at the facility >>

    http://www.canada.com/health/story.h...D-6E3919E002CA

    Note that this follows the same pattern seen in Hong Kong and Singapore in regard to HCW's getting SARS despite strict infection control procedures in place.

    I am wondering if the Hong Kong and Singapore experiences may be a dry run for the emerging Canadian experience, with Canada running around a month behind Hong Kong and Singapore. And the U.S. running about a month behind Canada.

    I hope not.

    My hope is that Canada can show that SARS can be successfully contained.

    And that the U.S. will then follow suit.


    The Canadian press is reporting occasional stories of specific HCW exposures, but so far there has been no tracking of overall HCW percentage exposures in the Canadian press. None that I have seen, anyway.

    Some may find this reassuring.


    The whole SARS thing is proving to be quite the cliffhanger.

    I feel like I am reading the climax of an international novel which is in the process of being written even as we speak - at the rate of a few paragraphs a day.

    With vital sentences blanked out from both the Chinese and the Canadian editions.


    While I am merely reading the chapters of the novel as it unfolds -

    Some of y'all are actually living it.


    I've always preferred being the reader, thank you.

    __________________________________________________ _______________

    RN4e'r wrote:

    << The hospital I work in is one hospitals in Toronto. We have had 50% of the SARS patients admitted to hospital in our facility, according to what we have been told. To date, there has been no staff members contracting SARS. All the precautions everyone else is taking, gowns, gloves, masks and googles, are being used. We are also screened before entering. I do not understand why staff in other hospitals have contracted SARS. Is there more contamination in the community or is there something else we should be doing for infection control as we have just been lucky so far? >>

    That is the question, isn't it?

    The only way we will know the answer in your situation is to see what happens over time.


    The answers to that question from both the Hong Kong and Singapore experiences may be of concern. In those countries, attempts to stop spread among health care workers via strong infection control measures have not proven to be overly successful.

    However, I think that we should remain optimistic that Canada will succeed where others have failed.

    In both Hong Kong and Singapore, efforts to focus SARS treatment in one or two hospitals while getting other hospitals back to treating regular patients have also been unsuccessful.

    Again, I think it best to remain optimistic that Canada will succeed where others have failed.


    The comments that I have seen from Hong Kong were initially optimistic. Health care workers were putting appropriate measures into place, and hospitals other than the original affected hospital were not seeing HCWs affected.

    For example, Prince Margaret Hospital is the Infectious Disease (ID) hospital for Hong Kong. At one point I saw a report that they had 90 SARS patients, without one PMH Health Care Worker affected. The reasons for their success in dealing with SARS were given as: as an infectious disease hospital they had an experienced hospital culture - both great breadth and depth - of being able to deal with infectious disease, they were using appropriate barrier and all other appropriate precautions, and their physical plant had appropriate negative pressure isolation rooms and such. It was also repeatedly noted that SARS is simply not that infectious a disease. Everyone calm down.

    A week or two later I noted a news report that one doctor and 20 nurses had been diagnosed with SARS at PMH. Additional reports concerning the SARS toll followed - I believe I saw a report a few days ago that 90 PMH HCWs had been affected.

    As the SARS situation continued to develop in Hong Kong, one began seeing press comments from physicians that "SARS is proving to be much more infectious than we thought." School closures. Then comments from physicians that they were concerned that things were getting out of hand. Then comments from the governments involved of concern of impending disaster.

    The same pattern has then followed in Singapore. Singapore has generally run a couple of weeks behind the Hong Kong SARS curve.

    In Singapore, there is a very controlling government - hey, I'm not being judgmental, they seem to like it that way - which early instituted fairly extreme tracing/quarantine, now with cameras outside of peoples' houses and tracing radio-wrist bands, early school closures, etc. The initial concept was to have all cases in one hospital so that one hospital could specialize in the disease and leave the other hospitals to function more-or-less normally for the rest of the population. It seemed like a pretty good idea at the time, really -

    It just did not work.

    Some ideas are just that way, I guess.

    Since then, I have watched news reports of SARS spreading in Singapore, every few days, to each of the other large public hospitals in Singapore - all six, now. With large numbers of staff affected.

    Generally the problem seems to stem from an unrecognized case or two on the general wards affecting large numbers of Health Care Workers - not so much from the known cases in the ICU.


    Nebuliser use has been particularly implicated. Nebuliser treatment has been reported to be linked to the infection of 60 Health Care Workers.

    Canadian respiratory therapists - and other Health Care Workers on wards were such therapy is taking place - might want to bear that in mind.

    Note that the concern here is with nebuliser use with unrecognised SARS patients.


    The Singapore SARS experience is currently at 172 cases, 16 dead. That is a raw mortality rate of 9% - but of course, a raw mortality rate in the midst of a growing epidemic understates the actual mortality rate - that is basic Epidemiology 101. Such is true of almost all the mortality rates that we are seeing reported in the press.

    The reports I have seen are that around 90% of the Singapore cases have been Health Care Workers - whether or not that extends to the mortality rates, I do not know.

    I found a recent report interesting. It included a quotation form a Singapore pulmonologist that SARS is the most infectious disease that he has ever seen.

    This follows the same pattern that I have earlier seen reported by other physicians out of Hong Kong.


    Again, I would like express my optimism that the Ontario situation will not become anything like the Hong Kong or Singapore situations.

    I am certain that Canada can do better than Hong Kong and Singapore have done.


    Oh - one last bit.

    A few weeks ago I saw a Hong Kong report of five family physicians and one pediatrician admitted to one of the ten admitting hospitals in Hong Kong with SARS on the same day. This was followed by encouragement for community-based physicians to wear masks in their offices.

    Within the last week I noticed that one pediatrician had died. I do not know if it was the same one, or no.

    It will be interesting to see if we see Canadian physicians reporting in with SARS from their offices.


    Well - let's all hope this is just a flash in the pan.


    To your health -

    Epaminondas

    ___________________________________________


    If someone could tell me how to post PDFs on this bulletin board, I would be happy to post the current infection control procedures being used in Hong Kong. Of course, these likely will not be entirely in synch with Canadian recommendations.

    In the meantime, someone might find the following of interest. I imagine that Canadian Health Care Workers are getting plenty of this sort of thing in their hospitals, anyway.

    Please note the learning curve between 3/26/03 and 3/28/03.

    From Hong Kong:


    << 03-26-2003

    We now have 24 Healthcare workers in PWH caring for the first wave patients with SARS, ie 41 OF 543 staff or 7.5%.

    ICU rate is 2%.

    2 RNS who admitted the first patient to ICU. Even though the N95 went on straight away compliance was obviously not good. The mask was very uncomfortable and poorly fitting. There was only one size available from one manufacturer initially.

    Health care assistant (cleaner) was exposed to ICU on 19/3/03. She had no prior training on infection control.

    Other departments report much higher staff infection rates. 68% in the medical ward where patients are housed!!!!

    Reasons give for the failure rate in order of priority include

    1. POOR FITTING MASKS, UNCOMFORTABLE
    2. STAFF NOT ATTENDED ANY BRIEFING ON SARS
    3. CONTRACT STAFF NOT EDUCATED ON INFECTION CONTROL
    4. Poor ventilation >>
    ____________________________________________

    << 3-28-03

    The number of cases continues to grow in HK. The Government has closed schools and quarantine procedures have started. The situation in the hospital has essentially been contained but we are seeing cases of HCW (24) becoming ill after isolation procedures have been instituted.

    Reasons given by these HCW for catching the disease in order of importance are:

    1. Nebuliser use
    2. No structured course on SARS
    3. Not wearing an N95 mask
    4. Poor handwashing technique and facilities
    5. Incorrect order of gowning and gloving
    6. Communal tea breaks where masks are taken off in an enclosed space
    7. No goggles when performing NPA
    8. Too many staff exposed unnecessarily
    9. No education for contract staff
    10. Poor ventilation
    11. No mask in one case

    I have previously mentioned the difference between ourselves (non infectious diseases hospital) vs PMH (infectious diseases hospital). PMH staff are well educated in infection control - it is part of their culture.

    In our cluster of hospitals (three in total) the standard of infection control in our ICU will become the standard. Only two nurses who saw the patient first admitted to ICU have become infected. They found the masks poorly fitting and uncomfortable.

    Some general points:

    1. Recognize that infection control awareness needs still to be raised.
    2. Gowning and gloving sequence needs to be thought through by all departments (includes degowning and degloving)
    3. No nebulisers
    4. Doctors as patients create problems. They want to use the ward phone, computers. They want to read their notes and handle Xrays.

    All potential sources of contamination.

    As far as ICU we have upgraded our infection control measures on a daily basis.

    PERSONAL

    1. N95 masks at all times
    2. sequence of gowning

    wash hands
    hat
    gown
    wash hands
    gloves

    3. sequence of degloving

    remove hat
    remove gown
    remove gloves
    wash hands

    4. nothing goes into or out of the unit that is not necessary - includes pens

    5. pagers are wrapped in a glove

    6. Many Chinese people wear glasses. For those of us who do not we are wearing goggles or buying glasses.

    N100 masks have gone to Iraq. We purchased them for their comfort and for the psychological boost. We have since found other manufacturers with N95 masks.

    Personal HEPA filters will not arrive until next week. Maybe not necessary because touch wood we seem to be holding our own.

    UNIT

    Clear separation of clean and dirty areas e.g. Male change room has been moved out of the unit
    Cleaning 3 x day of all surfaces with Na hypochlorite solution
    Computers etc covered with glad ward
    Decrease traffic into and out of the unit
    Control centre outside of ICU
    HEPA filters in the airconditioning system
    Portable airfilters in the ICU
    Windows closed
    Temperature control

    PATIENTS

    No unnecessary procedures
    HME on all intubated patients
    Provide lowest O2 flow to maintain sats above 90%

    >* housing the patients (negative pressure rooms - do you have any of these?, HEPA filtration systems within the rooms)

    We only have 4 negative pressure rooms with Ventilation cycles above 12/hr.

    One of the major differences between our hospital and the ID hospital is that it admits patients to single rooms on the ID wards. Viral load of these patients is high. Our general wards have bays where patients are cohorted and may be part of the problem with HCW becoming infected. Our rooms are independently ventilated.

    >* masks - what are you and your staff doing - is there any local >experience suggesting that N95 masks are enough (assuming a good fit), or >the masks with personal HEPA filtration systems (N100 variants). What do >your nursesdo when they are looking after these patients for long time >periods?

    This is a big problem. HCW becoming ill on the wards are the nurses. ICU nurses have been spared this because our infection control measures are as high as we can make them. We would like to decrease the amount of time nurses are exposed but that means more nurses and increased exposure.

    >* what are you doing with your ventilated patients wrt exhaled gas
    See above and it is a closed system

    >* It sounds as though droplet dispersal of the virus is a significant >risk. Are you using mask CPAP at all and if so what are you doing to >redirect the exhaled gas?

    No mask CPAP, no BiPAP AT ALL.

    >* I would also be very interested (if you have the time of course) to describe >the strategy that is being used to keep up the morale of the nursing and >ancillary staff, especially in the ICU environment.

    Senior nurses and myself brief honestly nurses every day
    Information is dispersed verbally by email and by notices
    Lots of encouragement
    Lots of channels for communication
    Food and drink
    Encouragement from each other
    We contact all nurses on sick leave each day
    Nurses with ATP are seen by a senior ICU doctor

    Hope this is helpful

    Regards

    XXX XXXXXXX >>
    Last edit by epaminondas on Apr 19, '03
  10. by   RNonsense
    Story hit the web today. FYI, this is not the Markham case. This is New Westminister, BC.

    New SARS case closes ward in New West
    Health authorities looking for those who had contact with Royal Columbian nurse

    Dan Rowe
    Vancouver Sun; With files from Canadian Press


    Saturday, April 19, 2003



    Fraser Health Authority officials are putting a 59-bed ward at Royal Columbian Hospital into isolation because a second nurse there is suspected of having SARS.

    The authority is trying to identify patients, hospital staff and others who may have been in contact with the nurse, the latest B.C. resident suspected to have severe acute respiratory syndrome.

    The woman was found to have a suspected case of SARS Thursday afternoon after she told co-workers she was experiencing SARS symptoms. She had already begun her morning shift at the hospital.

    She was immediately sent home, where she is in isolation and doing well, according to Dr. Roland Guasparini, the Fraser Health Authority's chief medical health officer.

    As a precaution, the health authority is putting the ward where the woman worked into isolation and 35 nurses have been asked to stay home for 10 days. Public health officials will monitor their condition and they will continue to be paid.

    Guasparini said the nurse with the suspected case came into contact with a patient with a probable case of SARS in late March. That is the same patient another nurse at the same hospital had contact with before she was diagnosed as a probable case of SARS last Monday.

    "She (the suspected case) would have been infectious when she developed symptoms and she worked part of the night shift when she developed the symptoms [April 9] and then she worked a week or so later [April 17]," Guasparini said.

    Health authority officials say they attempted to contact the nurse during the two days between the discovery of the probable case Tuesday and her return to work Thursday, but were unable to reach her.

    In order for SARS to be contagious, the carrier must be showing symptoms. Guasparini said none of the 13 patients who came in contact with the latest suspected case are showing signs of having the disease.

    Still, the Fraser Health Authority says it is being extremely conservative and cautious in treating the latest case.

    The 13 patients are being monitored closely -- nine of them remain in the hospital, three have been transferred to other hospitals and one has gone home. Friends and family members who visit the remaining nine patients will be required to wear gowns, masks and goggles.

    None of the other patients currently being cared for in that ward will be moved to another part of the hospital and no new patients will be admitted until at least April 27, by which time the disease's 10-day incubation period will be over.

    "We are, of course, following the community contacts [of the suspected case], which at this point means the household contacts, and they have put on active daily surveillance. They will be checked twice a day to see if they have developed any symptoms," Guasparini said.

    As of Friday, the Canadian SARS case count was 304 probable and suspect cases in six provinces. All the 13 SARS deaths in Canada have taken place in the Toronto area. Internationally, the World Health Organization is reporting more than 3,300 cases and 172 deaths.

    "As we've seen elsewhere in the world, this can get out of hand very quickly and I think the expectation from the public is that we do everything we can to prevent the spread of SARS and hope to contain it," Guasparini said.

    "I still think with the appropriate containment measures we can control this long enough until we at least have some diagnostic tests that will be more refined."

    Speaking before the latest suspected case was announced publicly, Dr. Perry Kendall, B.C.'s chief provincial health officer, said the response of the province's medical system to the SARS crisis has, so far, been "very good."

    But some people are upset because Kendall's office has only just issued Internet bulletins about SARS in Chinese, Punjabi and Vietnamese.

    The resources are overdue, said Victor Wong, director of the Vancouver Association of Chinese Canadians. He urged people to check daily for updates.

    "This is the gateway for thousands of travellers from Asia, the starting point of SARS, to North America every day. It seems we should have immediately been arming these people with information in their first language," said Wong, who had been lobbying for the information to be translated.

    Toronto Public Health and the Ontario government have been publishing multilingual Internet bulletins, but they provide only local updates. The Vancouver Coastal Health Authority had been providing links to health sites in Hong Kong, but Wong said it is imperative that people be able to access information about the situation in their own city.

    Kendall, said it simply took the province longer to get it done.

    Meanwhile, the University of B.C. says it has no plans to impose restrictions on dozens of students from China expected to arrive in Vancouver Monday en route to the University of Regina.

    The university suggested Thursday that the students, none of whom are suspected to have SARS, be "quarantined" at UBC, where they are to stay during a visit to Vancouver before being bused to the Saskatchewan capital.

    Spokesman Scott Macrae said UBC has no plans to quarantine the students, who will be welcomed and free to move around the city.

    Also See: SARS a grave risk to rural China, A5; Airlines trim flights to Asia, Toronto reeling over virus, C5

    http://www.canada.com/vancouver/stor...A-37D6413C02BC
  11. by   Little One2
    [QUOTE]Originally posted by epaminondas
    [B]"It was involuntary. They sank my boat."


    Remark when asked how he became a hero.
    John Fitzgerald Kennedy


    _______________________________


    " have been concerned about Wendy, too, but I see that she is posting elsewhere on this board as of today. So it looks like she is doing OK.

    I am happy to see it.

    I wonder if perhaps Wendy became uncomfortable with the degree that the discussion here was becoming centered on people debating her own situation.

    Or maybe Wendy just got bored . . . "

    I'm sure Wendy is fine. There are also other nurses here on this board who are dealing with SARS.

    "It is interesting to hear that everyone in Toronto is showing up for work."

    Why wouldn't we show up for work? What should we do?? Stay home and abandon our patients in the hospital or community. Who would look after them. Now is the time to come together and help those who need our help. Hospitals are following full precautions. Health care workers have been wearing masks, goggles, gowns, and gloves as a protective barrier.

    "Or - I wonder if it may reflect a difference in Canadian vs. American psychology.

    Perhaps Canadians are more community-minded and Americans are more what's in it for me me me.

    I don't know.

    I would guess that Canadians might be more up on the differences between Canadian and American psychology than Americans might be.

    Perhaps we will find out soon."

    When I took psychology, our books were written by american authors. I don't believe there is a difference between our psychology. We may have different values, opinions, and ways of handling worldwide issues.


    Fergus wrote:

    << It is something that should be taken seriously (which is why we use our precautions religiously) but I don't think it is a reason for complete and uneducated panic. >>

    Agreed.

    That is why I am trying to learn from the Canadian experience.

    Only partial and educated panic for me! ;-)


    Panic - Panicking will not accomplish much. It is fine to panic. But, the next step is to handle the situation. It is important to deal with it, educate people and prepare people.

    _______________________________

    The problem I have noticed is that people are not taking it seriously. Last week, someone exposed to sars goes to church. The next thing you, 600 people have to be quarantined.

    I was listening to a talk show on the radio. They had a volunteer on who delivers the kits to the individuals under quarantine. five out of ten people were not home.

    What is wrong with this picture? Does this mean there is a lack of education or a bad attitude among the citizens of this city?
  12. by   steven44121
    I am sure you have all seen todays paper. Sunnybrook in Toronto, our major trauma , centre has closed its emerg. and ICU's after four staff have begun showing symptoms of SARS.
    This despite all precautions being taken. The paper quotes the hospitals infection control person as saying, it was likely after a very difficult 4hr. intubation. (20years in ICU and I have never seen a 4hr intubation).
    So what happened? Were infection control measures not used properly, or are we all at risk despite precautions?
  13. by   Tweety
    I've never seen a four hour intubation either! You think they are including a trach procedure? After four hours what's the point?

    Still that's very scarey that they had to close. It's only a matter of time before it moves South.
    Last edit by Tweety on Apr 20, '03

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