MANUSCRIPT FOR A NEWSLETTER ARTICLE
Published by
Joint Commission on Accreditation of Healthcare Organizations
Environment of Care News
“Facing down a serial killer:
What Toronto hospitals learned from SARS”
Written by Catherine A. Rategan
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Facing down a serial killer:
What Toronto hospitals learned from SARS
The rampage started off innocently enough in November 2002. Striking first in
China’s Guangdong Province, the killer masqueraded as just another case of
atypical pneumonia. But the outbreak spread with terrifying rapidity, and by the
time it had run its course eight months later, what would become known as
Severe Acute Respiratory Syndrome (SARS) would afflict approximately 8,500
people around the world and kill more than 900.
Outside of Asia, Canada was the country hardest hit by SARS. From
March 2003 to the following July, Canadians counted 438 probable and
suspected cases of SARS, with 44 deaths from the disease. Most of the SARS
cases and all the deaths occurred in and around the Toronto area, where more
than 100 health care workers got sick with SARS and three died.
Canada’s National Advisory Committee charged with investigating the
SARS outbreak cited several deficiencies in the response to the disease by the
clinical and public health systems. Among these was the lack of surge capacity,
meaning the ability to handle an influx of casualties. The experiences of two
Toronto hospitals highlight the importance of facilities management in
establishing and maintaining surge capacity.
North York Hospital – Ground Zero in the SARS wars
Toronto’s North York General Hospital is a 434-bed facility positioned at
the epicenter of the second phase of SARS. What came to be known as SARS I
lasted from March 27 to April 15, 2003. At the end of five weeks, health officials
were catching their breath on the assumption that the disease had run its course,
and the hospital had begun ramping up its services once again to near-normal
levels. That’s when the disease struck again in the form of SARS II, which for this
hospital lasted from May 23 to August 19, 2003.
“We went from 30 SARS patients in the first wave to more than 90 during
the second wave,” says Bonnie Adamson, president and CEO of North York
General Hospital. Half of these were North York’s own staff. Although many have
recovered, some are still not back at work. Among the Canadians who died was
a North York General Hospital nurse who had been caring for patients later found
to have had SARS.
As the scope of the outbreak broadened, North York General Hospital had
to expand its SARS capacity – and do it fast. Hospital management reacted
almost overnight. As luck would have it, the Hospital was nearing completion of
a new hospital facility, which included a 24-bed intensive care unit and new
inpatient units. So hospital management fast-tracked completion of the ICU in
that new building and thus was able to open more than 70 beds in the ICU and in
two units dedicated to SARS patients. Most importantly, all 70 had the required
negative air pressure (see sidebar). In order to re-deploy its resources to fighting
SARS, North York General Hospital closed the Emergency Department and the
OB unit, restricted elective surgeries and shut down many of its clinics.
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By the time SARS II struck, the Hospital’s focus was on preventing health
care workers and other patients from contracting the disease. That meant
isolating SARS units from the rest of the facilities while still providing the needed
hospital services, such as housekeeping, dietary services, maintenance, and
more.
Management and clinical staff worked closely with the building services
and facilities management staff. One example was a policy inaugurated by the
Hospital of checking for negative air pressure three times a day and reporting
results to reassure staff. Finally, on August 19, 2002, North York was able to
declare itself free of SARS patients.
Sunnybrook & Women’s – Leaders in the SARS battle
One of Canada’s largest health care facilities, this 1,400-bed
tertiary/quaternary center is an amalgam of three separate hospitals located
around Toronto. During SARS l, Sunnybrook & Women’s (S&W) screened
thousands of staff and visitors daily for SARS and managed over 70 in-patients,
the largest volume of in-hospital SARS patients outside of mainland China.
Additional pressures were placed on S&W as other facilities closed due to
SARS outbreaks. As the largest trauma centre in the country, S&W ended up
treating almost all the trauma patients in the Greater Toronto area and saw a
significant increase in the number of emergency department visits.
The hospital’s director of facilities services is Harry Taylor. He recalls,
“When SARS first hit, we knew very little about the disease. But it quickly
became evident that our number-one priority had to be creating negative
pressure rooms.” The hospital chose to dedicate a general medicine floor as a
SARS unit and almost overnight turned the 22 rooms in that unit into negative
pressure rooms.
In newer isolation rooms, an automatic alarm indicates when the room
loses negative pressure. But S&W couldn’t afford the time to buy and install
those monitoring units. So facility engineers set up a testing program to make
sure that the rooms in fact were staying negative. “Each day our technicians
performed smoke testing to show which way the air was flowing,” says Taylor.
“And each day they would see smoke disappear underneath the door of the
patient rooms, indicating negative pressure.”
In their concern about ensuring negative air pressure, S&W filtered the
exhaust through HEPA filters that would screen out any harmful elements. The
hospital purchased 22 portable units from a supplier in Quebec. “When we told
them how critical the situation was,” says Taylor, “they shipped the filters
overnight, and we had them installed in less than 24 hours.”
The hospital was also the first health care facility in Toronto to set up a
SARS assessment unit where symptomatic community residents could come to
the Emergency Department to be evaluated for possible SARS. To accomplish
this, S&W set up nearly 5,000 square feet of space at its Women’s College
Ambulatory Care Centre about five miles from the main campus and staffed it
with doctors, nurses and security officers.
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The Role of the Facility Manager
Taylor points out that, in coping with an emergency such as SARS,
facilities managers play a vital role and can draw on a wealth of resources. In
addition to their own staff, they have access to engineering groups, suppliers,
and peer groups at other hospitals. Taylor’s advice to other facility management
people who might someday face a similar challenge: “Be a strategic resource for
your organization and work closely with your senior leadership team. Educate
people on the technical aspects of the building environment. Help in the
development of tactical strategies, and then execute your plans quickly.”
SARS also allowed the hospital to test its ability to respond to a largescale emergency. “S&W did an amazing job in pulling together,” says Taylor. “It
was stressful for everyone in the hospital, but the 400 people on our facilities
management team – plant operations, environmental services, security, and our
parking & transportation group – never hesitated for an instant to do what was
needed. In fact, some of our people volunteered to take on tasks that would
require them to be quarantined at work and at home.”
Recommendations
Following is a list of recommendations for hospital facilities managers culled from
suggestions by Susan Kwolek, vice president of quality and corporate
performance at North York General Hospital and by Lucy Brun, a partner in
Agnew Peckham, a Toronto health care consulting firm:
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Provide sufficient surge capacity to address emergencies
Reduce the number of entry/exit points to the facility; control access via
cameras and swipe cards
Separate the hospital’s “mission-critical” departments and access to these
areas
Increase the number of isolation rooms that include technique anterooms
and 3-piece washrooms
Implement mechanical and ventilation systems to support isolation and
separation of air intakes and exhaust
Provide adequate individual space per patient; e.g., more than four feet
from one patient/visitor face to the next patient/visitor face
Keep an adequate supply of personal protective equipment (face masks,
gloves, gowns, etc.) on hand at all times and make sure that those
supplies are readily available.
Clean patient units on every shift
Clean all facilities and equipment that are in common use; e.g., nursing
stations, computer keyboards, telephones, etc.
Use basic infection control methods as listed on the website of the
Centers for Disease Control at http://www.cdc.gov/page.do which has a
section devoted to SARS at: http://www.cdc.gov/ncidod/sars/ and
http://www.cdc.gov/ncidod/sars/guidance/I/index.htm.
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[SIDEBAR}
Preparing for the future
[TEXT]
Skip Gregory, bureau chief of the Office of Plans and Construction at Florida’s
Agency for Health Care Administration reports that the Agency is currently
investigating how to expand the surge capacity of Florida hospitals to cope with
infectious disease outbreaks. Hospitals are being alerted to deal with the
following scenarios:
 How to manipulate the hospital’s HVAC system to turn patient rooms into
negative air rooms and exhaust this negative infectious air to the outside
without returning it to the building.
 How to find products that can be affixed to walls or ceilings in order to
convert normal patient rooms into negative air rooms.
 How to set up a temporary structure within a designated area of the
community that would enable a certain segment of the population to be
isolated.
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[SIDEBAR]
Proposed guidelines for arresting or preventing a disease outbreak
[TEXT]
A working group at Tampa General Hospital has submitted the following
guidelines to the Florida Hospital Association for review by and input from other
hospitals throughout the state. The hope is eventually to enact these
recommendations in order to regulate patient placement and movement in case
of a disease outbreak:
1. The facility will accommodate 10 beds
2. The facility has negative air pressure in relation to surrounding areas; min.
of one-one-hundredth (.001) of an inch
3. The facility will provide a magnahelic gauge to insure pressure differentials
are maintained.
4. The facility is monitored continuously for negative air pressure.
5. At least 12 air changes per hour of circulation (supply and exhaust).
6. Air is exhausted to the outdoors on the roof of the facility through
monitored hepa filters; no air from this facility is circulated to other areas.
7. Supply air is conditioned for summer or winter
8. The facility will provide automatic door closers to assure door is closed.
9. The facility will provide anterooms with air supply to maintain positive air
pressure.
10. The facility will provide medical gas (oxygen, vacuum and medical air) at
each bed.
11. The facility will provide an emergency power supply to critical medical
equipment and air circulation equipment.
12. The facility will provide hand-cleaning facility and toilet facility.
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[SIDEBAR]
The other killers
[TEXT]
Public health officials consider SARS to be the first severe and readily
transmittable disease of this century. But many other diseases have been
identified in recent decades and should be considered in hospital emergency
plans. Among them:
 Bioterrorism (i.e., chemical warfare)
 Dengue fever
 Food-related outbreaks (e.g., E-coli)
 Malaria
 Methacillin-resistant staphylococcus aureus (MRSA)
 Norwalk
 Vancomycin-resistant enterococcus (VRE)
 Chicken pox
 Ebola
 Influenza
 Meningitis
 Multi-resistant tuberculosis
 Other respiratory viruses (i.e., RSV, para-influenza)
 Smallpox
 West Nile virus
[SIDEBAR]
Saving lives through negative pressure
[CAPTION FOR ILLUSTRATION OF AIR FLOW]
Goals:
 Prevent infected air from a patient room from entering the hallway.
 Exhaust air from patient room to the outside, rather than to the corridor.
Technique:
In most instances, the pressure of air in the patient’s room is greater than the air
circulating in the hallway. So opening the door to a patient room allows air from
that room to enter the hallway.
Negative Pressure:
Air pressure in the corridor is stronger than in the patient room, so when the door
opens between the two areas, air from the corridor enters the patient room.
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[SIDEBAR]
SARS timeline
[TEXT]
16 November 2002
First known case of atypical pneumonia occurs in Foshan City, Guangdong
Province, China, but is not identified until much later.
10 February 2003
World Health Organization (WHO) learns of a strange contagious disease that
has already killed more than 100 people in Guangdong Province in just one
week.
11 February
WHO receives reports of an outbreak of acute respiratory syndrome with 300
cases and 5 deaths in Guangdong Province.
22 February
A Guangdong doctor who had previously treated patients in Guangdong seeks
urgent care at a Hong Kong hospital for respiratory failure.
23 February
A 78-year-old female tourist from Toronto, Canada checks out of the Metropole
Hotel and begins her return journey to Toronto.
26 February
A 48-year-old Chinese-American businessman is admitted to a Hanoi hospital
after a trip to Guangdong Province. He is attended by a WHO official, Dr Carlo
Urbani, based in Viet Nam.
5 March
The 78-year-old Toronto woman dies at Toronto’s Scarborough Grace Hospital.
Five members of her family are found to be infected and admitted to the hospital.
13 March
The 44-year-old son of Toronto’a first case dies in Scarborough Grace Hospital.
14 March
Health authorities in Ontario, Canada alert medical professionals and public
health units of four cases of atypical pneumonia in Toronto that have resulted in
2 deaths in a single family.
15 March
Health Canada reports 8 cases of atypical pneumonia, including 2 deaths.
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25 March
Scarborough Grace Hospital in Toronto is closed to new patients and visitors.
26 March
World total of cases soars to 1,323 with 49 deaths. Ontario health officials warn
of possible health emergency.
29 March
WHO infectious disease specialist Dr Carlo Urbani dies of SARS in Thailand.
30 March
Canadian health officials close York Central Hospital to new patients and request
hundreds of its employees to quarantine themselves. Thousands of Toronto
residents face quarantine at home.
2 April
World total of SARS cases passes the 2000 mark.
8 April
A cumulative total of 2,671 cases and 103 deaths is reported from 17 countries.
16 April
WHO announces conclusive identification of the SARS causative agent: an
entirely new coronavirus.
23 April
The cumulative number of probable SARS cases climbs to 4,288 with 251
deaths.
28 April
The number of cases surpasses 5,000
14 May
Toronto is removed from the list of areas with recent local transmission.
22 May
As the cumulative global total of cases surpasses 8,000, health authorities in
Canada inform WHO of a new hospital-based cluster of five cases of acute
respiratory illness in Toronto.
18 June
The global outbreak enters its 100th day as the number of new cases reported
daily dwindles to a handful.
2 July
Toronto is removed from the list of areas with recent local transmission.
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5 July
WHO declares that SARS outbreaks have been contained worldwide but calls for
continued vigilance.
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