Saturday, January 13, 2007

A tale of two cities

I remember going [to work] Saturday morning and I said to my husband… “I’m going to go, but I am so afraid”….I thought I was the next one to get [SARS]….’cause all our nurses were falling down.[1]

Those are the words of a nurse from Ontario Province as quoted in a report by a Canadian Commission that has examined the SARS epidemic of 2003. It is a cautionary tale for hospitals and governments about controlling the spread of infection.

The report focuses on two Canadian cities, Vancouver, British Columbia, and Toronto, Ontario. At 4:55 p.m. on March 7, 2003, an ambulance brought a 55-year old man to Vancouver General Hospital. About three hours later, at 7:45 p.m., a 43-year-old man went to Scarborough Grace Hospital in Toronto. Both patients had Severe Acute Respiratory Syndrome (SARS), but the course of SARS contagion was very different in the two cities.

Because the Vancouver hospital followed strict precautions, there was no SARS epidemic in British Columbia. In Toronto precautions were inconsistently used. As a result, 44 people died in Ontario and 375 became sick with SARS. “Of the…people who contracted SARS in Ontario,” says the report, “72 percent were infected in a health care setting….[and] 45 percent were health care workers.”[2] In Vancouver only one health care worker contracted SARS.

This “tale of two cities” demonstrates the importance of proper infection control procedures, including the use of personal protection equipment. It was a “combination of a robust worker safety and infection control culture at Vancouver General….[that] ensured…B.C. (British Columbia) was spared the devastation that befell Ontario.”[3]

I was recently at an out-of-town hospital with a relative, and I saw a very casual use of precaution gowns and virtually no enforcement of gowns for visitors. I was at a meeting this week where a lay person, who had been recently cared for at another hospital, told me stories to me about inconsistent infection control practices there. We know that health care people do not always follow standard precautions, as they should.

Interestingly, the spread of SARS in Canada was mostly within hospitals and not within the community-at-large. The report credits “bold public health efforts and stringent quarantine measures”[4] with stopping the infection in the general community.

At one point, when the epidemic subsided, the Ontario government officially lifted the emergency measures that had been imposed. Here’s what the Commission said happened next:

As soon as the precautions were relaxed…the disease surged back and spread…to patients, staff, visitors, and their families.

Stringent infection control and worker safety precautions, so recently relaxed, were imposed once more. Health care workers donned their N95 respirators and gowns and gloves again. As soon as precautions were reinstated, the disease again subsided.

The value of hospital standard precautions[6] has never been more clearly demonstrated. Vancouver’s precautions stopped an epidemic before it started. Ontario’s inconsistent prevention measures allowed an epidemic to get started and, even after it was brought under control, to start a second time.

Despite the infection control system failures in Ontario, SARS was ultimately stopped, and the report credits the heroism of health workers for this:

SARS was stopped by the front-line workers and the scientists and the specialists who stepped up and who were not afraid to take strong measures that worked in the end.[7]

The SARS report shows the need for a culture of safety, a culture where every hospital worker knows, respects, and follows standard precautions. SARS was not immediately recognized as a new and serious illness. We don’t know the diseases we might face on any given day.

That is why 100% compliance with standard precautions is the way we protect ourselves, our patients, and our families.

[1] Spring of Fear, Volume 1, Executive Summary, The Commission to Investigate the Introduction and Spread of SARS in Ontario. The nurse’s quote is from p. 9. All four volumes of the Commission’s report are available at this web address:

[2] Spring of Fear, Volume 1, p. 12.

[3] Spring of Fear, Volume 1, p. 4.

[4] Spring of Fear, Volume 1, p. 6.

[5] Spring of Fear, Volume 1, p. 6.

[6] Standard precautions are safety measures for all patients who receive care, regardless of a patient’s diagnosis or known infection status, such as hand washing, the use of gloves, masks, and eye protection, face shields, gowns, etc.

[7] Spring of Fear, Volume 1, p. 10

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