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Lesson of SARS: HCWs don't always use precautions
Education, early identification improve compliance
To protect health care workers during a pandemic, you'll need more than a stockpile of N95s and a fit-testing protocol. You'll need well-trained health care workers who understand how and when to use the respirators.
That is one lesson from SARS that may influence planning for pandemic influenza. Hospitals in Toronto had "an enormous trouble getting people to change their behavior in the face of what was clearly life-threatening illness," Allison McGeer, MD, director of infection control at Mount Sinai Hospital in Toronto, told the Institute of Medicine Committee on Personal Protective Equipment for Healthcare Workers During an Influenza Pandemic.
Health care workers were very fearful about becoming infected with SARS. Two nurses and a doctor died in the 2003 Ontario outbreak and 45% of the 375 probable cases were among health care workers. But often health care workers still did not consistently use and properly remove respirators and other personal protective equipment, according to a survey of 795 health care workers at 15 hospitals.
Paradoxically, health care workers caring for the sickest patients were the least likely to consistently use respiratory protection, McGeer found. The health care workers were apparently more concerned about their patients than about their own protection. "We think that's probably a hero phenomenon," she explained.
Health care workers also were less likely to adhere to proper precautions if they entered the patient's room more often. And contrary to the advice from the Centers for Disease Control and Prevention, health care workers were not more adherent to precautions if they were involved in aerosol-generating procedures.
"People's adherence was driven by what type of patient they thought they were taking care of, not what procedure they were doing," McGeer says.
What are the implications for pandemic influenza planning? Employee health and infection control professionals may need to rethink how they educate health care workers to make decisions about PPE. "We need to rethink the focus on whether procedure-driven PPE as opposed to patient-driven PPE is going to be something that is feasible in the future," she says.
Education about PPE may have a significant impact on adherence, the study indicated. Health care workers in the SARS and intensive care units had higher levels of adherence.
Identifying risk major factor
Identification of risk also was a major factor. At the beginning of the SARS outbreak, although health care workers were cautioned to use precautions with patients who had respiratory illness, only 5.6% reported consistently using PPE with patients who had not been diagnosed with SARS. In those early days, only 55.7% of health care workers caring for SARS patients consistently adhered to precautions.
Two months into the outbreak, about 95% of health care workers used precautions with SARS patients as well as patients with respiratory symptoms.
In fact, 73% of health care workers who contracted SARS were caring for patients who had not been diagnosed. "Hazard identification is the largest component of our failure in health care systems," McGeer said.
HCWs want better protections
Discomfort also may influence health care workers' adherence to respiratory protection. Bill Borwegen, MPH, health and safety director of the Service Employees International Union cited an Ontario Nurses Association survey that found that nurses developed headaches, shortness of breath, facial rashes, fatigue, or dizziness after prolonged N95 use.
"Are there better forms of respiratory protection we should be considering?" he asked the panel.
Hospitals should consider health care worker fears as they draft pandemic plans, placing an emphasis on higher levels of protective equipment, said Leonard Mermel, DO, ScM, medical director of infection control at Rhode Island Hospital in Providence and former president of the Society for Healthcare Epidemiology of America.
"I would err on the side of caution during routine care [of pandemic influenza patients] based on perception of risk and possible transmission risk," he said. "If further research shows transmission only by large droplets during routine care, then you can change the policy and use masks and eye protection for routine care and N95s for aerosol-generating procedures."