Training the
Trainors on the Management and Infection Control of SARS
DOH Research
Institute for Tropical Medicine
September
22-26, 2003 and October 6-10, 2003
Administrative Issues in a
Private Hospital (Manila Doctors Hospital)
Chair, MDH
Task Force SARS
Assistant
Medical Director
Manila Doctors
Hospital
September 25,
2003
October 9,
2003
Thank you for the
honor and privilege to be one of the panelists in the discussion of hospital
administrative issues on SARS
Thank you for giving
me the opportunity to share with you our MDH experience on SARS
Before I give you my
experiences on the challenges on a hospital SARS preparedness and control
program, let me just give you in exactly 12 sentences a summary of our MDH Task
Force SARS.
1. It was created April 2, 2003 and officially terminated on
August 10, 2003, totaling 4 months of operation.
2. NO SARS patient admitted in MDH.
2.1 8 patients with possible SARS detected at the ER and
referred to DOH referral centers.
2.2 2 patients with possible SARS detected inside hospital, one isolated
in Floor 11 and one referred to RITM.
Both later turned out to be NOT SARS.
3. A level 3 preparedness was achieved by May 16, 2003, about 6
weeks after the organizational meeting of the task force. Level 3 preparedness means completely
prepared with policies, strategies, and procedures; physical facilities, and
training with at least a drill.
4. Construction of a triage-isolation-holding room in the ER
which can be used for other cases of infectious diseases.
5. An expense of about PhP 200,000 in the preparedness program.
6. NO downturn in hospital business development and stability
associated with SARS scare and panic.
7. A transition phase for one month prior to phase-out of the
Task Force in the form of admitting patients with pneumonia only to single
private rooms for isolation and monitoring.
8. Lessons learned:
8.1 SARS panic and stigma are more destructive and dangerous
than the SARS disease itself. They must
be avoided at all cost and stopped immediately.
8.2 Doctors are difficult to manage in terms of cooperation and
collaboration in a hospital epidemic control program. Stern measures must be instituted to make the doctors respect and
follow the chain of command.
8.3 The humanitarian spirit of health professionals become
fragile in the face of an epidemic. Non-confrontational strategies and
persuasion should be done.
8.4 Multisectoral cooperation and a unity of command are
essential in a hospital epidemic preparedness and control program.
For more information,
visit http://xsarsmdh.tripod.com
The three challenges
in a private hospital SARS preparedness and control program:
The first challenge
that cropped out was to decide whether to admit patients with possible and
suspected SARS or not. It was a “damn if
you do and damn if you don’t” situation.
The SARS problem was being complicated by a stigma and a difficulty in
making a definite diagnosis.
To turn away patients
with possible and suspected SARS who turned out NOT to be SARS after all would
create a “damn you” reaction (I told you I don’t have SARS!). To turn away regular clients of MDH with
uncertain SARS diagnosis and who refused to go to DOH SARS referral centers
would also create a “damn you” reaction (I have been your regular client and
you are turning me away. What’s the
matter with you? I don’t like to go to San Lazaro or RITM!).
To accept a patient
with possible and suspected SARS to the hospital would likewise create a “damn
you” reaction not only from the staff but also from the other patients of the
hospital (You should never have admitted such a patient! You are putting our lives in danger!). Furthermore, it would create a panic and
stigma that would result in a wide-scale hospital withdrawal and avoidance
which would then lead to a disastrous downturn in hospital operation.
Weighing the risks of
the two options, going for the lesser evil, we decided on a policy NOT to admit
any SARS patient as much as possible.
To minimize the negative reactions associated with this policy, we tried
to inform the public of our policy in a polite and apologetic manner, either on
a face-to-face basis or through signboards in the entrances and corridors of
the hospital. We also tried to
facilitate using MDH ambulance the conduction of patients with possible SARS to
DOH referral centers. Furthermore, we
tried to get the DOH to make a public announcement that all patients should be
referred to the DOH SARS referral centers to avoid the ire of the public. DOH never made such a direct
announcement. However, thanks to the
media, by late May or June, the people were conditioned to think that all SARS
patients should be brought to the DOH referral centers.
The second challenge
that cropped up early in the stage of the SARS preparedness and control program
was the hesitancy, if not refusal of the health professionals in the hospital
to handle patients with possible SARS.
Reasons presented were “we are just trainees, not employees of the
hospital”, “we need hazard pay”, “ we are not competent in handling SARS”, “we
have the right to refuse”, etc.
We successfully
hurdled this second challenge through the following measures:
The
third challenge that cropped out was how to control the panic and stigma of
SARS when a patient with a possible SARS was admitted for observation. As preventive strategies, we put up a memo
for the all staff to desist from rumor mongering and we declared a policy of
transparency with Dr. Melecia Velmonte and Dr. Cecile Montalban as the only two
persons authorized to declare the
presence of SARS in MDH.
Sometime,
in June, 2003, a cancer patient was admitted by a medical oncologist to
MDH. This patient just arrived from
Singapore where he underwent chemotherapy.
Upon return to the Philippines, the patient developed respiratory
infection. He was referred to a
pulmonologist who raised the alarm of possible SARS. No amount of convincing would make the patient transfer to a DOH
SARS referral center. Thus, the patient
was transferred to Floor 11 for isolation and observation. Within 24 hours, verbal and text rumors were
spreading like wild fire and media were all over the hospital trying to
publicize the presence of a SARS patient in MDH. Sensing SARS panic and
stigma were in the offing, I immediately called for an emergency meeting of the
Task Force. I asked for the opinion and
decision of Dr. Velmonte whether the patient really had SARS. She said probably NOT. I insisted on a firm and definite answer
that was badly needed to control the panic and stigma of SARS going on. At the end of the meeting, we made a public
declaration that the patient had NO SARS.
Such declaration aborted the disaster that was about to occur as a
result of rumor mongering, panic and stigmatization.
Early
July, 2003, an Indian child was admitted for a severe pneumonia. Again, a pulmonologist raised the alarm of
possible SARS. Although very unlikely
for the patient to have SARS, precaution was undertaken just the same and the
patient was right away transferred to a DOH SARS referral center. This move to transfer patient out aborted
again the rumor mongering, panic, and stigmatization that started to occur few
hours after the admission of the patient.
If the transfer was not done right away, the rumor mongering, panic and
stigmatization could have wreaked havoc to the hospital.
With
these two experiences of admitted patients with possible SARS, even if they did
not actually have SARS, I realized that it is better not to admit any patient
with possible SARS at all cost. It is
too dangerous. To admit a patient with
possible SARS is to invite a big fire in the hospital. In these two cases, we were fortunate we
were able to put out the fire soon enough.
Much as I don’t like the inconveniences being suffered as a result of
stigmatization by patients with just a possibility of SARS and who most likely
will not have SARS, as chair of the MDH Task Force SARS, I have the mission to
protect the hospital, the welfare of its staff and its other
patient-clients. To the patients who
were conducted and transferred to San Lazaro and RITM, who turned out not to
have SARS, my sincerest apology.
The
SARS stigmatization is a very destructive force that cannot be abolished
overnight. However, we are still trying
our best to remove it. Last July 11,
2003, as part of our transition move to phase out MDH Task Force SARS, we
issued a memo that contained two policies:
1) To avoid the repercussions of SARS stigma, with incidence of
SARS already subsiding, we advised physicians to refrain from making a
diagnosis of SARS unless absolutely certain.
We advised the use of the usual terms “pneumonia” or “influenza”.
2) To continue our vigilance against SARS, we advised all
patients with pneumonia be admitted to single private rooms for at least 48
hours for isolation and monitoring.
Those are the 3 challenges that I have identified as chair of the MDH Task Force SARS.
Before I end, allow you to show you an action plan of preparedness that we used.
Transparencies.
Thank you for your
attention. I hope I have given you a meaningful
sharing of experience and insight into our MDH Task Force SARS.