Health system failed workers during SARS

Commission on Ontario’s handling of outbreak found systemic failure

Ontario’s health-care system was woefully unprepared to deal with an infectious disease such as SARS. And one of its major failures was its inability to protect its workers, a provincial commission into the 2003 outbreak has found.

Of the more than 350 people who contracted SARS in Ontario, 72 per cent were infected in a health-care setting. Of this group, 45 per cent were health-care workers. In all, 44 people died, including two nurses and one doctor.

The report released early this month was the third and final produced by Justice Archie Campbell, who was commissioned by Ontario to look into the way the province handled the virulently contagious, flu-like virus known as severe acute respiratory syndrome.

The experience was unique, Campbell noted, in that it was a new disease with no diagnostic tests, unclear symptoms and no known treatment or vaccine. Its clinical course, method of transmission, duration of infectivity and death rate were all unknown. But that’s why it was a lesson in being prepared for the unexpected.

As a point of contrast for Ontario’s experience, the report noted that when a patient infected with SARS was admitted to a Vancouver hospital, there was no further spread. Workers there adopted the highest level of precaution then scaled down as the situation was better understood.

“A combination of robust worker safety and infection control culture at Vancouver General, with better systemic preparedness, ensured that B.C. was spared the devastation that befell Ontario,” wrote Campbell.

In Ontario, however, when a man whose mother had contracted the disease on a visit to Hong Kong was admitted to the Scarborough Grace Hospital in Toronto, the chain of transmission quickly spread to 84 people.

Most of these were health workers “because occupational safety and infection control systems, which are supposed to act together seamlessly, one focused on safeguarding workers, the other on protecting patients, failed to save them from harm.”

The province declared an emergency on March 26, a little more than three weeks after that first patient went to Scarborough Grace, and stepped up infection control and quarantine measures. By late April, the measures seemed to be working and the disease subsided. The emergency was declared over on May 17.

But then nurses at another Toronto hospital, North York General, started noticing clusters of SARS-like illness.

“They were told again and again by the hospital ‘Not SARS’ when it turned out that these cases were in fact SARS,” wrote Campbell.

Campbell offered several examples of ways the system failed to protect workers. Employers and worker representatives found it difficult getting a timely response from both the health and labour departments on issues such as work refusals and policies for pregnant workers. Joint health and safety committees were effectively sidelined during the crisis, as was the Ministry of Labour. In fact, it wasn’t until June 2003, when the outbreak was virtually over, that the Ministry of Labour proactively inspected SARS hospitals. Again, in contrast, the B.C. workplace regulator took decisive action and began inspections in early April to ensure workers were protected from the start, the report noted.

Another example of the way the system failed can be seen in the debate over the N95 respirator mask. Since 1993, Ontario law has required anyone using the mask to be properly trained and fitted for it but, in 2003, few hospitals complied with this law. There were those who argued N95 masks were not necessary because they believed SARS was spread by large droplets. Although the knowledge about the disease was evolving at the time, noted the report, there were hospital leaders who thought scientific certainty took precedence over precaution.

Linda Haslam-Stroud, president of the Ontario Nurses’ Association, said the report vindicated what nurses have been saying about not feeling protected at the workplace. Haslam-Stroud said she has seen improvements in the four years since. Workplace inspections have increased and, last September, the government set up a permanent committee under the Occupational Health and Safety Act to advise on workplace health and safety issues in the health sector.

However, she’s worried the the Ontario Hospitals Association, a major health-care employer, is still not convinced precaution should take precedence over scientific certainty. She pointed to a Toronto Star story in which association president Hilary Short said: “Our perspective is you need to use the science. There’s still controversy over what piece of personal protective equipment is best.”

The hospital association did not return phone requests for an interview.

Haslam-Stroud said although most nurses still feel it’s their duty to show up to work in the face of such risks, “there are some nurses that have said to us, ‘Unless there is a process in place to protect us, I am going to look for another profession.’”

At York University’s Schulich School of Business in Toronto, Brenda Zimmerman, director of the Health Industry Management Program, said Campbell placed too much emphasis on the government’s role and not enough on the role of individual health organizations.

“If the organizations themselves are not well-managed, don’t have a rich communication system, don’t have the capacity to handle that kind of challenge, (public health policies) are not going to be enough,” said Zimmerman.

To take as an example the second outbreak at North York General, part of the reason the administrators of that hospital didn’t listen to front-line workers’ concerns “was because the organizational structure was such that their voices didn’t matter to the right kinds of ears,” she said. “Everything we know about high-risk situations like NASA, 9/11 and other kinds of disasters is we also have to understand how organizational politics, culture, decision-making — how all that have tremendous impact.”

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