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)

 

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg

 

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:

 

  1. We called up all the infectious disease specialists and pulmonologists and asked them if they were willing to handle SARS patient in case one would be unavoidably admitted.  If even our consultants are not willing, then all the more we would strictly enforce the NO SARS admission policy. The call yielded 5 positive responders.  We were happy to have 5 physician-specialists who could serve as role models and who could help in the SARS control program, in case a SARS is unavoidably admitted.
  2. We did not reshuffle the staff for purpose of creating a special anti-SARS preparedness and control team.  To do so would definitely encounter a lot of resistance.  The regular pre-SARS set-up and staffing were maintained.  Staff of units that would be involved in the management of SARS patients in case there would be were asked to be prepared for the eventuality and to be trained to handle such patients.  Such units were the emergency room, floor 11 where the isolation room was located, radiology, laboratory, linen and laundry, housekeeping, ambulance, and medical residents.
  3. We appealed to the humanitarian spirit and code of the health professionals assigned in areas where contact with SARS patients might occur.  We persuaded.  We did not use force. At the same time, we provided protective devices and other safety measures.  We created a special triage-isolation-holding room at the ER where contact with possible SARS patients were kept at the minimum, such as interviewing through an intercom and through a see-through glass divider.
  4. The results of these strategies -  there was no absence without leave or refusal to handle possible SARS patients on the part of the ER staff, floor 11 nursing staff, security guards, linen and laundry staff, ambulance driver, and medical staff.

 

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.