SARS legacy: Toronto ICPs enjoy teachable moment

New interest in IC — even among docs

The aftermath of severe acute respiratory syndrome (SARS) in Canada is that health care workers are paying unusually close attention to infection control inservicing and education programs, an epidemiologist reports.

Indeed, one legacy of SARS is an "unrepeatable opportunity" for infection control education, says Allison McGeer, MD, director of infection control at Mount Sinai and Princess Margaret Hospitals in Toronto. After SARS struck Toronto hospitals particularly hard in 2002, Canadian labor officials were alarmed at the threat the coronavirus posed to health care workers treating patients. Labor officials mandated infection control education programs in some hospitals, taking a regulatory foray into health care similar to the way that U.S. labor officials reacted when tuberculosis was causing nosocomial outbreaks in the early 1990s.

"All of us sat around then and said, Thank God we don’t have that problem,’" she recalls. "Well, now we do. Our Ministry of Labor has figured out that hospitals might be dangerous places and they are now very interested."

To meet a mandate for SARS infection control education, McGeer and colleagues conducted a health care worker education campaign in 2004. "We did an infection control education program rather than a SARS-[specific] education program," she says. "It certainly had respiratory etiquette and precautions built into it."

The three-hour course primarily was presented in a case study format that called for workers to show what precautions they would use (including putting barrier gear on) for patients under different types of isolation.

"Ninety-four percent of the people in the hospital did this, so this was not your usual inservice," McGeer reports. "It is also probably true that people were primed to listen post-SARS. We had their attention. Though the Ministry of Labor order applied only to employees’ technically, we also make it mandatory for physicians."

That decision was not made without some consternation since physicians can be less than enthusiastic about infection control training. "They never like it and they look at it as a waste of their time," McGeer says. "We delayed them to the end [of the program] and we gritted out teeth. And you know something? They loved it. I was speechless."

All well and good, but did the unprecedented level of staff interest translate to any meaningful infection control improvements? McGeer and colleagues looked at that question in the aftermath of the education program, focusing specifically on nosocomial transmission of methicillin-resistant Staphylococcus aureus. A longstanding policy at Mount Sinai calls for MRSA screening on admission supplemented by periodic prevalence screening. Nosocomial MRSA cases are defined as patients identified with MRSA more than 72 hours after admission. McGeer found that the education program was associated with a 60% reduction in the nosocomial transmission of MRSA, despite no change in observed hand hygiene adherence. Though the hand hygiene finding was something of a disappointment, it appears that workers were complying more rigorously with contact isolation and other infection control recommendations.

"I think the logical assumption is that the effect was in better adherence to precautions, and maybe some changes in the timing of hand hygiene that we didn’t measure," she said. "The important message is that one of the signal failures of our MRSA control program is convincing staff to do what they are told. We finally got this window where people were doing what they were supposed to be doing because of that education program. It worked like a charm."

Though SARS has, at least temporarily, vanished from the infectious disease scene, the annual inservice will continue as a mandated program.

"I think that infection control education now is the same as fire [safety] training," McGeer says. "If you do it often enough when the fire breaks you [react] without thinking about it. That’s where we need to be with infection control. You know what to do, even in the middle of the night when you are really busy and you are faced with a patient who needs to be in isolation. You don’t have to think about it. You know what to do, you know why you’re doing it, and you just do it."