香港政府華員會　暨　護士分會、登記護士分會、香港護士總工會主辦

廣州、香港防護 SARS經驗交流會日期： 2003 年 5 月 3 日

題目：互相關懷，互相支持，互相監察防止醫護人員及病人受感染

講者：新界東醫院聯網風險管理及質素保證總監雷兆輝醫生

NTEC SARS PREVENTION PROGRAM

w.e.f. Tuesday 8 April 2003

Main task To prevent secondary infection of SARS

amongst health care workers and patients

Mutual care, support and monitoring互相關懷，互相支持，互相監察

Protect yourself, your colleagues and your family Strictly follow all recommended infection control measures all the time.

Don’t give yourself a life threatening present (SARS).

Dr. SF Lui, SD (RM&QA), NTEC NTE0309a030412

311

HKSAR - SARS

E ? East wind,East Side

E-Block of Amoi Garden, AHNH, Ease of Spread

Mr. C’s family tree (n = at least 189, 49 case unclassified yet)

Layer 1 Layer 2(n=128) (n=61)

> Index case’ relatives 5 2 friends

HEALTH CARE WORKERS 73 13 FM> 8 A&E staff (during 2 visits by index case)

> 6 Doctors attended index case (out of 7)

> 5 Doctors visiting ward 8A> 9 Examiners of Med 3 students (out of 11)

> 8 Med 3 students taking clinical exam (out of 20)

> 9 Med 5 students visited ward 8A> 15 Ward 8A nursing staff (out of 17)

> 6 Ward 8A HCA / WA> 3 Physiotherapists visited ward 8A> 2 EMSD visited ward 8A> 2 Other staff visited ward 8A

PATIENTS / VISITORS of ward 8A 50 4 FM, 2 GP> 25 patients (15 discharged, 10 not discharged) > 25 visitors

> 40 HCW

Case study (1)

M30, SLE, on haemodialysis at PWH. Work in ShenZhen 15/3/03 claimed OK on arrival at HD centre

Looked unwell, temp 38C. Admitted to having fever for 1 days CXR: RLZ changes. WCC 6.0, lymphocytes 0.7

Dx: Atypical pneumonia. Admitted to AP ward NPA: Influenza A

Clinical improvement. Discharged on 19/3 Stay with brother on 19/3 before going back to ShenZhen Return to PWH on 22/3, fever, SOB, respiratory distress

CXR: diffuse changes. Admitted ITUDx: SARS

2 Diagnosis: ? Influenza A + SARS [note: lymphocyte count remained low]

Secondary spread > brother (fever on 23/3)> ? 321 cases at Amoi Garden> 2 renal nurses at renal unit

Case study (2)

F80, COAD, admitted from OAH with #NOF Day 1 post-op: afebrile, SOB, desaturation

Day 2: CXR bilateral pulmonary infiltrate Dx: Aspiration pneumonia

Isolated in side roomDay 8: Died, ARDS, DIC, ARF

PM: Atypical pneumonia

Likely admitted with AP/SARS ? Atypical presentation: afebrile in elderly [Note: day 3, WCC 14.1, Lymphocyte count 0.4 (3%)]

>> no outbreak (? in side room)

Case study (3) E1 of AHNH

2 cases of chest infection admitted into Medical ward Subsequent suspected SARS, transferred to PMH1 patient in side room, 1 patient in open cubicle

Protection for nurse - standard + maskNursing suspected AP patients without adequate

precaution and infection control measures

Secondary spread> 1 ward nurse (fever 25/3)> 3 ward nurse + 1 SS (fever 31/3)> 1 HCA + 1 doctor + 1SS (fever 7/4) HCW = 8

> 2 ward patient + 3 suspected> 4 ex-ward patients at TPH> 1 ex-ward patient at SH> 1 discharged + 1 suspected Patient = 8 +4S

M80, admitted to surgical ward E3 with PR bleeding Day 4: fever, chest infection

Dx: Strep. Pneumonia, UTI (E coli and Kleb) Transferred to Medical ward (E6), Day 6: Died

Likely typical pneumonia + AP/SARS [lymphocyte count 0.4 only]

Case study (4) E3 and E6 of AHNH

Secondary spreadOn ward E3> 1 HO, 1 Nurse, 1 HCA (fever 29/3, 30/3)> 1 A&E MO who saw HCA (fever 4/4) HCW = 4> 2 patient and 9 ex-patients Patient = 11

On ward E6> 1 MO, 10 Nurses, 1 HCA, 1 WC HCW = 13> 8 in-patients + 5 suspected> 9 ex-patients + 2 suspected Patient = 14> 3 Visitors Visitor = 3> secondary spread at OAH Layer 2 = 4

AHNH Staff Patient Ex-patient Visitor Layer 2 TOTAL

E1 8 (1 d, 4 n, 1 HCA, 2 ISS) 2 + 3S 6 +1S 　 1 SH(PTA) 17 + 4S

F1 1 (1 ho) 1 + 1S 　 　 　 2 + 1S

F5 1 (1 nurse) 4 2 2 　 9

E6 13 (1 d, 10N, 1 HCA, 1 WS) 8 + 5S 9 +2S 3 4 TPH pt 37 + 7S

F6 5 (5 HCA) 6 + 2S 5 +1S 　 3 + 4S (OAH)

17 + 7S

D6R 1 (1 Renal N) 　 　 　 　 1

　 　 　 　 　 　 　

E3 4 (1 dr, 2 N, 1 HCA) 2 9 　 　 15

D3 1 (1 HO) 　 　 　 　 1

　 　 　 　 　 　 　

A&E 1 (1 dr) 　 　 　 　 1

ICU 1 (1 HCA) 　 　 　 　 1

General 3 (1 Dr, 1 NO, 1 SS) 　 　 　 　 3

Adm 1 　 　 　 　 1

TOTAL 40 23 +11S 31 + 4S 5 8 + 4S 107 +19S

Structural problem

1. PWH is not an infection disease hospital. The isolation and supporting facility are not appropriate nor adequate.

Unexpected / rapid accumulation of a large number of patients

2. Unexpectedness of the outbreak. No preparation for the outbreak.3. The tremendous caseload (70 HCW over a few days only)4. Necessary to draft in temporary nursing staff from other ward / dept5. Viral load on the ward was likely to be very high.

OUTBREAK OF SECONDARY INFECTION OF SARSAMONGST HEALTH CARE WORKERS AT PWH

– REVIEW AND RECOMMENDATION

Staff issues

6. Most of the staff did not attended structured briefing on management of SARS case before commencement of duty (too

busy)

7. Problem with using the N95 mask – correct size, too stuffy, not tolerate continuous use, rubbing of nose,

etc.

8. Compliance all the infection prevention measure - hand washing is not routinely performed - wrong order in self-decontamination on leaving the infection ward- performing high risk procedure without full protection

9. Long exposure time of the nursing staff to the infected patients

10. Social contact with “infected” colleague with early (mild) symptoms such as tea break, dinning together, sharing room

tea break was held in the pantry within the infected ward area

11. Short posting of staff into infected area -HCW drafted into an infection ward for 1 day

Patient issues

12. Patient not wearing mask.

13. Possible contamination by patient (saliva, food, etc) during feeding, medication round, etc.

ACTION PLAN:

1. To establish an “Infection risk and safety” concept and culture across NTEC

- commenced Saturday 29th March 2002 across NTEC

2. Re-classification of level of “risk” of the wards and to ensure appropriate barrier protective apparel

for all staffs, patients and visiting relatives (i) Ultra-high risk wards

(ii) High risk wards

(iii) Moderate risk wards

3. Structured briefing and training on caring for patients with SARS

- compulsory for staff going to work in the infection wards.

4. Staff protection(i) Appropriate barrier protective apparel

(ii) Ensure the mask (N95) fit well for ultra high risk staff(iii) Proper barrier protective process [入門七事 , 出門七事 ]

(iv) Enforce hand washing / disinfection

5. Staff compliance(i) Safety controller (SC) to be on duty on each shift

(ii) SC to undergo proper instruction course (iii) Remind all the staff of the IC measure before each shift.

6. Patient compliance (i) Ensure all patients wear mask all the time (ii) prohibit patient touching the case note, x-ray etc

7. Use of Nebuliser Prohibited

8. Management issues / contingency plan

(i) Establish rapid surveillance system (a) surveillance team to closely monitor any outbreak (b) rapid analysis of the reason for the outbreak

(ii) Establish rapid response plan for outbreak of infection Be prepared for sudden major outbreak

(i) designated stand-by ward (preferably with isolation facility)(ii) identify trained standby staff (doctor, nurse, AH, HCA) (iii) protective apparels to be made available immediately.(iv) defined action plan (v) establish control centre

By Dr. SF Lui / Dr. Donald Lyon for Infection Control Unit of PWH and NTEC Committees for Risk Management and Quality Assurance6 April 2003

HOSPITAL IC ENFORCEMENT TEAM

HAHO IC ENFORCEMENT TEAM

DEPARTMENT IC ENFORCEMENT TEAM

WORK UNIT IC ENFORCEMENT TEAM

NTEC SARS PREVENTION TEAMIC officer IC unit staff RM staff SARS Data manager

HOSPITAL SARS PREVENTION TEAMIC officer IC unit staff RM staff SARS Data manager

DEPARTMENT SARS PREVENTION TEAMD - ICO

WARD / UNIT / OFFICE SARS PREVENTION TEAMU - ICO

Infection Control Officer (SARS ICO)

Infection control Unit (ICN)

Risk Management team

SARS Data manager (SARS DM)

NTEC Dr. SF LuiSD (RM&QA), NTEC

Dr. Donald Lyon Cons, Microbiology, PWH

Ms. Elsa TsangGM(N), AHNH

Dr. Louis ChanDept of O&G, PWH

PWH Dr. Peter ChoiCCS, PWH

Dr. Kitty FungMs Regina ChanMs Deborah Ho

Ms Becky Ho NO(PRO), PWH

Prof Peter TongDept of M&T, PWH

SH Dr. Kelvin OrCon, Med, SH

Ms Lorna Ho (p/t, ICN)

Ms Betty Wong SNO(PRO), PWH

Dr. Kelvin OrCon, Med, SH

SCH Dr. WC IpHCE, SCH

Ms Lu Chu Yeh(p/t, ICN, surg WM)

Ms Betty Wong SNO(PRO), PWH

Dr. WC IpHCE, SCH

BH Dr. Peter Choi Ms Polly Wong(p/t, ICN)

Ms Imelda Leung NO(PRO)

Dr. Peter Choi

AHNH Dr. H Y SoCOS, AIO, AHNH

Ms Amy Sit, AHNH Path NS(IC) Ms. Jane Leung

Ms Ellen Wong SNO(RM&PR), AHNH

Dr. Alex YuCon, Med, AHNH

TPH Prof Timothy KwokDep COS, Med, TPHMs. Helena Li GM(N), TPH

Ms. Jane Leung Ms Imelda Leung NO(PRO)

Dr. Emily KunCon, Med, TPH

NDH Dr. KC ChanCCS, NDH

Ms. Leung Fung Yee (p/t ICN, DOM ICU, NDH)Ms. Rosana Hung

Ms Terry Wu NO(RM&PR), NDH

Dr. KK WongCon, Med, NDH

Co-chairperson : Dr. SF Lui, Dr. Donald Lyon

Role of Unit ICOTo coordinate the IC programs at ward / unit / office level

(1) To conduct environmental risk scanning (for cross-infection)

(2) To verify the risk level (stratification) with the DICOif necessary, to add additional specific IC guideline for the unit

(3) To ensure the appropriate IC program - ensure the IC program is implemented on the department / ward level

- appoint shift ICO- ensure all staff have attended briefing on prevention of SARS

- ensure there is briefing on IC control for every shift

(4) to report suspected case to DICO

(5) To conduct regular random audit

(6) To monitor the health status of the staff on the ward / unit / office - ensure staff with febrile illness or symptoms of SARS

are refrained from work and advised to seek medical treatment

(7) To monitor the health status of the patientin particular, signs and symptoms of febrile illness

0

1

2

3

4

5

6

7

8

11 13 15 17 19 21 23 25 27 29 31 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30

Extra IC measure (27/3)

Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Phase 6

CONFIRMED CASE OF SARS OF HCWs AT PWH

N = 73 N = 40 N = 0 N = 16 N = 0 N = 4

open A&E (30/3)Close A&E (19/3)

Nebuliser (6-14/3)

Readmit Patient (6/4)

Barrier-Man, Extraction Fan(17/4)

PROBLEMS / ISSUES (1):

(1) ENVIRONMENTAL - ward layout, airflow, bedpan washer, etc

(2) PATIENT- Atypical presentation (especially elderly patient)

- Multiple diagnosis / infection> Need high level of awareness / suspicion

Unsuspected AP admitted or developed on the ward

> reorganize the ward / cohort patients with fever Triage / isolation system

(a)confirmed AP / SARS ward(b) suspected SARS ward

(c) infection triage / fever ward(d) Other ward

Problems / issues (2)

(3) CARING OF PATIENT Elderly patient, need nursing care, close contact ++, Handling of excreta, contact with saliva, vomitus

High risk procedures> Strict IC prevention measures

(4) CROSS INFECTION patient-staff, staff-staff, staff-patient, patient-patient

(staff continue to work with symptoms)> Strict IC measures on the ward

> take immediate sick leave when develop symptom (fever)

(5) Staff issues- Adequate training / preparation

- Adequate & appropriate protection (PPE)

口罩眼鏡頭帽擋飛

沫

外袍護手鞋套防病

毒

返回程序除裝備

護理前後要洗手

保護措施必遵行

戰勝病毒人人責

守紀律

依程序

防病毒

停擴散

互相關懷，互相支持，互相監

察

Action plan:

1. Establish NTEC SARS prevention team

2. Establish NTEC SARS infection control and prevention program

== > implementation at department / ward / unit / office level== > monitoring and auditing at department / ward / unit / office level

(The IC program must be established and implemented on every ward / unit / office within NTEC)

3. Appointment of Hospital Infection Control Officer==> Appointment of Department Infection Control Officer

==> Appointment of Unit Infection Control Officer(With on-duty Infection Control Officer for each shift)

Role of Hospital ICO

To coordinate the IC programs at hospital level

(1) To ensure each department has appointed a department ICO to implement the IC programs

(2) To ensure the IC programs are implemented across the hospital

(3) To conduct regular random audit

(4) To ensure the IC control protocols are being followed within the hospital(a) identification and reporting of suspected SARS case

(b) Policy for general ward after the identification of a patient or staff suspected / confirmed as a case of SARS.

Role of Department ICOTo coordinate the IC programs at department level

(1)To ensure each ward / unit / office has appointed a Unit ICO (UICO)

(2)To ensure all UICOs have attended briefing session on NTE SARS Prevention program

(3) To ensure the IC programs are implemented on the ward level- to agree with the UICO on the appropriate risk level for the unit

- to agree with the UCIO on additional / specific guidelines for the unit

(4) To ensure the IC control protocols are being followed within the hospital(a) identification and reporting of suspected SARS case

(b) Policy for general ward after the identification suspected case of SARS

(5) Establish channel of communication - between H-ICO, D-ICO and U-ICO

- With Hospital SARS Data manager

(6) To conduct regular random audit

Role of Infection control unit / staff

1. To provide relevant teaching material / information for the ICO

2. To provide briefing / training session on IC controls

3. To assist with the enforcement / monitoring of the IC measures being implemented

Role of Risk Manager Team 1. To promote the Infection risk and safety

culture

2. To assist with the enforcement / monitoring of the IC measures being implemented

3. To assist with the auditing of the IC measures on the ward.

Role of SARS DM (Hospital level) 1. To gather information of suspected or confirmed

case of SARS of the HCW and in-patient (from all ward, A&E and CND office)

2. To inform NTEC’s ICO / SARS Data manager of any new suspected or confirmed case.

3. To investigate the circumstances related to the case (epidemiology chasing)

4. To establish the contact list of discharged patient and visitors of existing patient on the ward is being compiled ASAP.