SARS: The chain of errors
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Star investigation reveals litany of mistakes by officials
Lack of infection control, misdiagnosis helped to kill 44
KEVIN DONOVAN AND TANYA TALAGA (TS)
SARS was able to kill and sicken so many people in Toronto because of a
litany of mistakes made by hospital and public health officials, a Star
investigation shows.
The errors include: misdiagnosis; failure to enforce infection precautions;
routinely sending ill people back into the community; the use of an archaic
tracking system; lack of leadership; and refusal by the province to share
key information with its own scientific advisory team.
The Star's research is based on interviews with more than 100 people
involved in the outbreak, including relatives of 20 of the 44 people who
died of SARS, nurses, doctors and researchers on the front lines, and senior
officials at all levels of government. The Star also used freedom of
information legislation to obtain government documents.
Families of the dead told a similar story. Loved ones got sick, usually
because they were in SARS-affected hospitals where precautions (masks,
gloves, gowns) were not properly used. They developed fever, coughing,
chills, aches and returned to hospital. There, doctors sometimes sent them
back into the community, saying they did not have the disease, or sent them
to other hospitals without a proper warning. Other relatives, plus
health-care workers, became infected.
"The hospitals and public health could have saved us all by keeping
isolation precautions in effect," Vadim Bychutsky says.
His mother, uncle and grandmother were all killed by the second wave of SARS
that originated at North York General in April and swept through the
hospital in May. Hospital and public health officials had failed to identify
two new SARS clusters on separate floors at North York.
North York General's chief medical officer, Dr. Keith Rose, says his
hospital staff worked heroically to battle SARS.
"Nobody knowingly missed any patients," Rose says. "Our physicians used
their best judgment," adds Bonnie Adamson, hospital president.
During the original outbreak, Scarborough Grace hospital misdiagnosed James
Dougherty, 77, and sent him to York Central Hospital for urgent dialysis
treatment. Doctors did not realize he had SARS.
Dougherty lay in the intensive care unit of York Central for 13 days without
any SARS precautions, until March 27, when he was isolated from other
patients. This, despite the fact that he had been in Grace emergency on
March 7 with the first SARS patient to enter the hospital. Dougherty died on
March 29.
At least 15 people were infected at York Central as a result of exposure to
Dougherty. His wife, visibly ill with SARS, was transferred out of York
Central to a nursing home with another patient. His wife survived, but the
other patient died.
At the epicentre of Toronto's outbreak, Scarborough Grace hospital, the
disease was misdiagnosed and overlooked.
Originally, in early March, the respiratory ailments of five members of one
family were dismissed as tuberculosis, despite a hunch by a Chinese-speaking
Grace nurse that it was an emerging virus she had read about emanating from
southeast China and Hong Kong.
Among those infected at Grace was Joe Grande. His widow, Rosa, is angry with
a system that refused to believe her husband had SARS until it was too late.
"Something has happened to my family that I would not wish on my worst
enemy," she says.
Joe and Rosa Grande were infected as part of the original Grace outbreak.
They visited a sick friend there but were not told to protect themselves.
Later, when Grace was closed, a public health official suggested they go to
Markham Stouffville Hospital to be checked. They were turned away and told
they did not have SARS, although Joe was feverish and coughing so hard he
could barely stand.
Public health promised to send them a kit with masks and thermometers, but
it never arrived. Eventually, almost too sick to move, they called
ambulances to take them to emergency at Scarborough General.
A spokesperson for the Markham hospital said the disease was difficult to
diagnose because there was no accurate test. Senior Grace doctors and
officials were unavailable for comment.
As the outbreak developed, Toronto Public Health was overwhelmed with the
task of tracking people at risk. Many fell through the cracks of a system
that used an archaic paper-based tracking method that was not up to the
task.
Toronto's chief medical officer of health, Sheela Basrur, who blames chronic
underfunding, describes how difficult it was to keep track of the hundreds
of exposed patients and thousands in quarantine: "Someone takes the file.
Where is the file? Okay, well you look that way and I will look this way.
It's the dumbest thing in the world. I can't believe this is the state of
affairs," Basrur says.
"It's amazing to me that we have been able to manage the way we have, given
that degree of inadequate support on these central functions with basic
technology," Basrur says.
Public health struggled along with triplicate paper files and attempts on
the fly to create its own computer tracking system.
The Star's research shows that some people at risk, who should have been
warned they had been exposed, were not called. Others were called too often.
Two families reported to the Star they were called after SARS had killed
their loved ones. In both cases, Toronto Public Health called several times
to check the person's temperature (after that person had died).
At North York General, the site of the second outbreak, sick patients were
again misdiagnosed and some were sent home. The blame for the misdiagnosis
falls on the shoulders of both hospital doctors and top researchers called
in from other hospitals.
Nurses and doctors with less seniority repeatedly raised warning flags when
patients showed up in April and May with what, by that time, were known to
be classic SARS symptoms. But lead doctors at North York appeared to believe
what the province and top medical experts were telling them: SARS was over
and done with.
Although senior North York officials say the hospital did everything right,
they have begun making sweeping changes to the way the hospital does
business. More doctors and nurses, some with specific infectious disease
expertise, are being hired, and the hospital is working on protocols so any
concerns of nurses and other staff get to the right place. "This was a
wake-up call," says North York's Rose.
The problems at North York can be traced to two clusters of patients with
SARS that were discounted until it was too late. One was a group of three
patients on the psychiatric ward, the other was a growing number of patients
on the orthopedic ward. In both cases, patients had respiratory problems,
fevers and coughing. Some died before SARS was discovered.
Meanwhile, the psychiatric ward patients were checked out by a parade of
experts, doctors and nurses from Toronto Public Health, top microbiologists
and North York's own expert, Dr. Barbara Mederski.
Due to an ongoing judicial inquiry into the outbreak, Mederski has been told
by her hospital not to speak to the press.
At North York, a junior doctor sounded numerous alerts, and nurses were also
vocal, particularly when five family members showed up with near-identical
SARS symptoms. Despite all this, nobody blew the whistle and told the public
until May 23, when it was far too late.
Toronto Public Health's Dr. Bonnie Henry says that while they were alerted
to the psychiatric patients, they were not told about patients connected to
the orthopedic ward (where the outbreak is believed to have started) until
May 23.
`Something has happened to my family that I would not wish on my worst
enemy.'
Rosa Grande, widow of Joe Grande
"Everybody is at fault for the second outbreak, all of us got caught," says
Mount Sinai's Dr. Donald Low, a microbiologist who helped investigate many
suspected SARS cases.
Low personally blames himself for ruling out the psychiatric ward cases,
although Toronto Public Health's Basrur says she takes the ultimate blame.
The cases, Low says, did not provide a link to a known SARS case and so did
not fit the definition, despite the fact the people were very sick. The
cases turned out to be SARS, and one woman became so ill she had to be
intubated. The North York outbreak spread and claimed at least 13 lives and
sickened 118. (The first outbreak sickened 257 and killed 31.)
Within the provincial government, a lack of leadership caused conflict and
confusion throughout the public health system. In effect, nobody was in
charge during the SARS crisis. Provincial health officials even refused to
share crucial data on victims with the province's own SARS scientific
advisory committee.
"We desperately needed a general in this war," says Low, who was involved in
investigating many SARS cases but had no authority. Low's comment is
seconded by fellow microbiologists, Dr. Andrew Simor of Sunnybrook and Dr.
Allison McGeer of Mount Sinai, and by Basrur.
In the SARS outbreak, there were many lieutenants: Colin D'Cunha, provincial
medical officer of health; Dr. James Young, public security commissioner;
officials at Health Canada, the provincial health ministry and others. Low,
the approachable, highly respected disease expert from Mount Sinai, emerged
as another lieutenant.
Yet nobody was in charge. "If you ask who was leading this, you wouldn't get
an answer. There wasn't a leader and there should have been," Simor says. He
and others are using this example to press the federal government to set up
a Canadian centre for disease control, similar to the vaunted Centers for
Disease Control in Atlanta.
Young says he believes he and D'Cunha provided a great deal of leadership,
although improvements could be made to better define who does what in an
outbreak such as this.
"I think there was leadership and everybody pulled together and acted as a
team," Young says. "We did our best. Lots of people knew I was leading my
part and they came to me all day with questions."
D'Cunha was on vacation and unavailable for comment. Acting chief medical
officer of health Dr. Karim Kurji said he believes one leader is not
necessary. Instead, Kurji lauded everybody involved for "pulling together"
to combat the disease. He said several leaders emerged with responsibility
for specific areas, and that worked well.
The Star found occasions when leaders were reluctant to take action. For
example, Scarborough Grace hospital management were determined to remain
open despite pressure to close. Finally, on March 23 (the outbreak began
March 7 and was clearly identified by March 15), the hospital was closed
following consultations between hospital management and provincial health
officials. Keeping the hospital open resulted in more infection for families
of patients and for health-care workers.
Trying to determine who had SARS caused a myriad of problems, since there
was no test.
Hospitals and public health also did not have a clear idea of the risks.
For example, many of those who were infected, some of whom died, were
visitors to emergency wards or other parts of an affected hospital.
What seems so obvious to an observer - that sick people hacking away in a
cramped ER would infect others - did not register with hospitals until it
was too late.
"It never crossed anybody's mind that visitors would get sick," says Mount
Sinai's McGeer, who was infected but recovered.
McGeer has tough words for infection control at hospitals, an "underfunded"
public health system and for the design of hospitals themselves.
Hospital emergency rooms are poorly designed for infection control, she
says.
"People aren't in private rooms. They are in `bays.' Chances are, your face
isn't (more than) four feet away from someone else's," McGeer says.
"Patients are being admitted and lying in corridors."
The four-bed hospital rooms seen on some wards may make economic sense, but
not public health sense, she says.
Open-air intensive care units are also problematic, she adds. Open-concept
units allow medical staff to get to a patient more quickly in an emergency,
but McGeer says they make it difficult to control infectious diseases. More
expensive glass walls are good for infection control and allow patients to
be seen.
During the SARS crisis, hospitals quickly found there were far fewer
negative-pressure isolation rooms than patients requiring isolation.
Patients were either kept in less than perfect settings or sent home sick.
Hospitals like Sunnybrook purchased air devices that could turn a normal
room into a negative-pressure room.
As to the sharing of data, doctors and researchers say the provincial health
ministry refused to share key data with the provincially appointed SARS
scientific advisory council, which was charged with the job of investigating
and stopping the outbreak.
Members of the committee, including Simor, say the province did not work
"collaboratively" with them. The researchers needed key information on
specific patients, symptoms, where they got sick and how they got sick, but
found it difficult to obtain.
"We were clamouring for the information and they were not giving it to us.
The province basically said `It's our data,'" Simor says.
Public security commissioner Young says he was aware of the problem and
stepped in at one point to pressure the health ministry to get the
information to the council.
The Star's investigation also encountered examples of hospitals, doctors,
nurses and public health officials going beyond the call of duty.
Nurses such as Tecla Lin volunteered to care for fellow nurses in a special
SARS unit at West Park Hospital. Lin was infected and died.
Doctors and nurses at various hospitals worked tirelessly in a quarantine
situation that forced them to wear cumbersome gloves, masks, eye shields and
gowns around the clock.
And at Toronto Public Health, people like Toronto's associate medical
officer of health Henry went out of their way to help family members who
were in danger of falling through the cracks.
In the case of one sick family that was being overlooked at Scarborough
Grace (the father had just died of SARS) Henry and Mount Sinai's McGeer saw
that the mother, who was the sickest, was admitted to Sinai, and the
daughter closely monitored and then admitted herself. Mother and daughter
were reunited at Sinai shortly before the mother died.
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