SARS: Risk managers must concern themselves with details others miss

Virus could reappear next flu season; now is time to prepare

If you’re unsure what your hospital is doing to prepare for SARS, now’s the time to get involved. The worst may still be to come with severe acute respiratory syndrome (SARS), say federal health officials who warn that the deadly virus is likely to reappear and cause deaths in the United States during the next flu season. Risk managers have a key role to play in preparing their organizations for SARS cases, which can pose special liability risks unseen with most other infections.

Hospitals must prepare for potential SARS cases even if they are in an area that has not seen any infections, said Health and Human Services (HHS) Secretary Tommy Thompson. More than 7,700 people have been infected with SARS worldwide and more than 640 people have died from the virus, the HHS reports. Almost all of those cases have been in Asia so far, but the virus has spread to Toronto and other locations. Federal health officials say there have been at least 65 cases reported in the United States, though none of those cases resulted in death. Thompson recently warned that U.S. health care providers should not take those numbers as reason to let their guard down.

"I do not think SARS is going to go away," he recently stated publicly while in Brussels, Belgium, to meet with European Union officials. Thompson’s office confirmed statements made to the press there. "Even though it may level off now, it could come back in the fall, and then you can, I think, anticipate that you will have deaths in all the continents. The virus knows no borders whatsoever."

For risk managers, Thompson’s statements should be seen as reason to move forward with SARS preparations and not think the crisis has been averted. SARS poses liability risks that must be addressed by the risk manager even as your organization’s infectious disease specialists take measures to detect and prevent the spread of the virus.

When a hospital prepares for possible SARS cases, most of the responsibility clearly falls on the infectious disease specialists, with the emergency department and perhaps employee health following close behind. But the risk manager should be on the front lines as well, says risk manager Gina Pugliese, RN, MS, vice president of the Premier Safety Institute in Chicago. She says SARS is similar to recent concerns about smallpox, anthrax, and other unusual infections that may show up at the hospital without warning.

"All of those issues are so complex and have so many dimensions that the risk managers must play a role," she says. "The hospital has to look at these issues from the perspectives of infection control, cost prevention, confidentiality, and liability. You can’t look at any one of those things in isolation."

The hospital’s approach to SARS preparation should be multidisciplinary and the risk manager should be a major player at the table, Pugliese says. She compares the SARS crisis to the way hospitals responded to the early years of the HIV epidemic. There are so many complex questions and so many issues involved that the hospital must pull experts from many areas. A top priority for the risk manager should be keeping up with the latest information on SARS, available at the federal Centers for Disease Control and Prevention’s (CDC) web site, The CDC web site is updated frequently and has specific advice for SARS infection control and a link to the World Health Organization web site.

"The smaller the hospital, the more the risk manager needs to keep up with information like that. There are so many competing priorities for each professional in every area that is affected by SARS that the risk manager may have to be the one who makes sure nothing slips through," Pugliese says. "As new guidance comes out from the CDC, you have to look at it from a risk management perspective."

Infection control and epidemiology will look at SARS from their perspectives, focusing on details such as air exchanges and what masks to wear. But the risk manager has to look at topics that may not be of concern to anyone else. For instance, Pugliese suggests asking yourself these questions:

  • What kind of warnings will you post on doors warning of a possible SARS patient? What will the signs say? On which doors will they be posted? Should you have the signs printed in advance?
  • Should you post information in the emergency department so that everyone knows there is a potential SARS patient in the area?
  • What is your hospital’s potential liability for not following the CDC guidelines?
  • What do you owe to your employees in terms of keeping them up to date about the symptoms of SARS to watch for?
  • Do you have staff traveling outside the country in areas experiencing SARS infections?
  • Do you have visitors or students from another country with SARS cases?

Those were some of the questions posed by Susan Kinter, RN, JD, director of claims litigation and risk management at the University of Maryland Medical System in Baltimore. Though her organization has not yet seen any SARS cases, Kinter and the others in her office have been directly involved in preparing a response to the virus.

"Our role is to make sure that there is an infection control plan out there, meaning that if we have a patient with confirmed SARS or suspected SARS, the staff have an isolation protocol that they can put in place immediately," she says. "A major concern for us is not infecting other patients and we also worry about health care workers becoming infected."

Kinter recently was involved with deciding what to do with two University of Maryland health care workers who could have been exposed to SARS. One was visiting relatives in China and the other was doing a rotation at a hospital in Toronto. Both were headed back to Maryland soon. Before they arrived, the health system put together a team to decide what to do with them. That team was made up of Kinter and representatives from infectious diseases and human resources.

The three perspectives yielded different recommendations, with human resources being the most conservative and recommending that the workers be barred from work for a period of time. The infectious disease professionals said there was no clinical reason to assume the workers were infected (at that time, Toronto had not had a new infection in more than 20 days) and recommended that they be allowed to return to work if an initial health checkup showed no symptoms of SARS.

"My department took a middle position and said that if their initial health check was OK, they could return to work and then be checked every other day," Kinter says. "That was what we went with in the end, and they never showed any signs of infection."

Potential for major liability if infection spreads

The prime risk management concern for Kinter is the virus spreading to other patients or health care workers within the hospital. Pugliese agrees, saying there is the potential for significant liability if SARS spreads within your hospital, as has happened at hospitals in Toronto and in China. A hospital always it at risk for a lawsuit when a patient acquires an infection while being treated, but SARS ups that risk because it can spread so effectively through a hospital, Kinter says.

"I think that’s the exposure from a liability standpoint," she says. "You have a real liability exposure there. If the patient comes down with SARS, they’re going to look to your hospital and ask why you let that happen."

Kinter believes the high profile of SARS changes how the public, or employees, will view infections that originate in your facility. A more routine infection acquired in the hospital may not be seen as evidence of malpractice, but SARS probably will just because of the hype and hysteria. And SARS is potentially deadly, which could lead to claims that the patient suffered emotionally as he or she contemplated death, a claim less likely to result from common nosocomial infections. "It’s been built up into something really scary and it’s on the news every day. That always means somebody will be more likely to sue, more so than some infection they’ve never heard of."

Early detection and a quick response is crucial to prevent the spread of SARS in your hospital, says Thomas Terndrup, MD, FACEP, professor and chair of the department of emergency medicine and director of the Center for Disaster Preparedness at the University of Alabama at Birmingham. Until the SARS risk has passed, risk managers should make sure that the emergency department’s policies and procedures include monitoring for patients who may have SARS, such as a fever check by the triage nurse.

"You would not want a patient sitting in the waiting area for four or five hours before the condition is recognized and the patient is isolated," he says. "By then, the person would have exposed quite a number of people."

Terndrup also suggests that risk managers use SARS preparations as an opportunity to review the organization’s abilities to respond to all sorts of infections.

"This is an opportunity to review your policies and procedures and to establish the relationships with some departments that might not be as close as you would like," he says. "This isn’t just about SARS. Whether it’s SARS, the West Nile virus, smallpox, or anthrax, all health care organizations ought to be vigilant about readiness. Don’t look at this in terms of being ready for SARS this month, but rather that you should be ready any emerging infection."

Preparing for SARS may be different from many risk management concerns because you have to turn over so many responsibilities to others, Kinter and Pugliese say. Though the risk manager should be involved in all key decisions, you will have to rely on some other departments, such as infectious diseases, to work out the details and develop clinical strategies. But they say there are specific steps that the risk manager can take. Here are some suggestions:

Confirm that other departments have proper protocols in place.

Though other departments must take steps to prepare for the detection, isolation, and treatment of SARS patients, the risk manager must ensure that those steps are indeed being taken. Meet with the directors of infectious diseases, infection control, and employee health to review their preparations, Kinter suggests. Watch for any signs of complacency and warn that SARS still poses a risk.

Kinter cautions that you may have to be careful not to step on the toes of others. SARS is a cross-departmental issue, and you may have to exercise some diplomacy when you check to see that others are doing their jobs. Explain that SARS involves issues that overlap your departments, and that there are risk management concerns you need to address. Acknowledge that you’re not trying to tell the other department how to do their jobs, but that you do need to be aware of what they’re doing.

If the other department is not addressing SARS, however, it is your role to explain why action is necessary.

Emphasize that SARS poses more risk to employees than other infections.

Hospital employees are used to working around infectious agents and taking precautions to protect themselves and their patients, but they may not understand that SARS poses a larger risk to them than they are used to.

"Unlike some infections that really are a threat mainly to sick patients in the hospital, those who are compromised already, this is a disease that threatens the healthy health care worker just as much. It’s different in that way from a lot of diseases they’re familiar with trying to prevent in a health care setting," Kinter says. "So you have to reinforce the idea that these precautions are as much for your health as for the patients."

Make sure media relations is in the loop.

If even one suspected SARS case shows up in your facility, the local media will descend on you in droves. How you manage that media attention may determine whether your health care organization looks like the problem or the solution, Kinter says. Risk management often oversees the media relations staff, so she says you must make sure they are directly involved in SARS preparations and kept informed of any suspected cases.

"It can be very damaging if your hospital is in the news every day with a SARS story," Kinter says. "Depending on how you’re portrayed, some patients might not want to come for a while. Keep your media staff informed and encourage them get the facts out there, reassure the public that your facility is responding appropriately to make sure the story is not blown out of proportion."