The Ontario SARS Commission Interim Report: What Went Wrong for Health Care Workers
By Shaun O'Brien
On April 15, 2004, Mr. Justice Archie Campbell of the Ontario Superior Court released The SARS Commission Interim Report: SARS and Public Health in Ontario (the Interim Report). At the time of the Interim Report's release, the SARS Commission had conducted over 300 interviews and held six days of public hearings. While the Commission's work continues, Justice Campbell released the Interim Report "because government decisions about fundamental changes in the public health system are clearly imminent". The Interim Report was released just over a month before the tabling of the Ontario government provincial budget on May 18, 2004.
The focus of the Interim Report was on "public health renewal". Justice Campbell examined various aspects of the public health system, including what he described as a "dysfunctional" Public Health Branch of the Ministry of Health and Long-Term Care (PHB). While the Interim Report leaves for the Final Report many of the issues directly pertaining to health care workers, such as health care worker protection and occupational health and safety in hospitals, the Interim Report addresses two issues which are of particular interest to health care workers and their representatives. These are the lack of links between the PHB and both hospitals and health care workers and the resulting lack of adequate infection control and protection for health care workers.
The Interim Report states that, prior to the SARS outbreak, the PHB in theory had an important role to play in preventing hospital infections. In particular, pursuant to mandatory guidelines issued under the Health Protection and Promotion Act, the PHB was supposed to provide input into hospital infection control. However, in many cases this input did not occur. The Interim Report notes, for example, that before SARS, Toronto Public Health did not play much of a role in hospital infection control; it simply assumed that hospitals were maintaining a certain level of infection control.
Inadequate infection control in hospitals and other health care facilities had a devastating effect on many health care workers during SARS. SARS was largely a hospital-spread infection. According to the Interim Report, 77 per cent of the probable SARS cases in Ontario were either health care workers, people who sought care at health care facilities, or visitors. Health care workers reported they were uncertain how to protect themselves against SARS. In addition, they reported a lack of equipment (such as N95 masks) available to them in hospital for proper protection against SARS and inadequate facilities in hospitals (such as negative pressure rooms) to assist in managing SARS. These problems, which may have contributed to the rapid spread of SARS through hospitals, will likely be examined in detail in the Final Report.
According to the Interim Report, as well as failure to play a role in hospital infection control during the SARS outbreak, the PHB also failed to effectively maintain links with nurses, emergency medical services workers, doctors, other health care workers, and their unions and professional organizations. The results of this failure to communicate had serious and harmful results, in particular because health care workers and their organizations did not receive critical information about SARS which they needed to protect themselves on a timely basis. At the outset of the SARS outbreak, on March 14, 2003, officials realized that there was an infectious disease at Scarborough Hospital. The PHB prepared a letter for distribution to all physicians in the province to advise them to be on the alert. It also sent a follow-up letter to physicians on March 18, 2003. The March 18 letter provided case definitions for suspect and probable SARS cases and outlined infection control measures for SARS, including the use of masks with an occlusive seal and high filtration (i.e. N95), the use of gloves and gowns, the use of eye protection when spraying or aerosolization of secretions was anticipated, and placing patients in negative pressure rooms.
Although the PHB had no means to distribute the initial March 14 letter, it was eventually able to reach most of the province's doctors with the assistance of the Ontario Medical Association. However, the March 14 and March 18 letters, and the critical information they contained, were not provided to other health care workers and their organizations. As stated by Justice Campbell,
The use of the Ontario Medical Association highlighted a disturbing systemic weakness, however. Other equally important front-line responders, such as nurses, ambulance services, paramedics and nurses – and their unions and professional organizations – were not included in this early notification.
In response to the question why information pertaining to the protection of health care workers and infection control practices would be sent only to physicians, Justice Campbell concluded:
There is only one appropriate answer to this disquieting question: All health care workers should have been immediately notified.
We know that in this early stage of SARS, without the benefit of the guidelines in the letters from the PHB, many health care workers were not taking any special steps to protect themselves from their patients and a significant number of health care workers contracted SARS in mid-March, 2003. Justice Campbell emphasized the following:
When the early warnings of an infectious disease became known, there was a need to notify health care workers, particularly nurses, emergency responders and front line physicians (both hospital and family physicians) immediately. Time was of the essence, as one missed case could spread and infect many others.
The Interim Report makes a number of recommendations about the problems directly affecting health care workers, including the following:
[The PHB] requires strong links with hospitals and other health care facilities and should establish, where necessary, an authoritative hospital presence in relation to nosocomial [i.e. hospital] infection. Respective accountability and roles and responsibilities of public health care institutions in respect of infectious outbreaks should be clarified.
Public health requires strong links with nurses, doctors and other health care workers and their unions and professional organizations.
Justice Campbell's Final Report will also no doubt provide important recommendations about health care worker protection and occupational health and safety in hospitals. In view of the very serious impact the lack of protection and the spread of SARS had on them, health care workers and their organizations will be interested in following up on the government's commitment to implementing these and the other recommendations of the SARS Report. In Justice Campbell's words:
The Ontario government has a clear choice. If it has the necessary political will, it can make the financial investment and the long-term commitment to reform that is required to bring our public health protection against infectious disease up to a reasonable standard. If it lacks the necessary will, it can tinker with the system, make a token investment, and then wait for death, sickness, suffering and economic disaster that will come with the next outbreak of disease. The strength of the government's political will can be measured in the months ahead by its actions and its long-term commitments.