Four Major Events in Our History and the Lessons Learned Coleen - - PowerPoint PPT Presentation

Four Major Events in Our History and the Lessons Learned

Coleen Reiswig, Isobel McDonald, Ted Pincock, Carolyn Bouchard Joanne Archer

Outline:

1) Common Themes 2) The Event and lessons learned:

• Spanish Influenza 1918
• SARS
• Walkerton, Ontario
• Vegreville, Alberta

3) Common Themes 4) Group discussion

Common Themes – Culture (“culture eats strategy for lunch”)

• Culture of presentism
• Culture of autonomy/isolation
• Resistance to new ideas/processes
• Culture of frugality
• Staff feeling “picked on” – victim syndrome
• Learned helplessness
• Basement mentality
• Victimization of the “bearer of bad news”

Common Themes - Communication

• Delay in reporting due to other events

happening

• Inconsistent messages to public
• No structure for timely information sharing
• Misinformation deliberately provided
• Verbal directives not followed by written
• Reports not responded to by executive

Common Themes - Accountability

• Individual groups making own plans and processes in

isolation of the larger population

• No regulations
• No enforcement of the guidelines that are in place
• Disconnect and discourse between organizations who

are in leadership positions

• Absence of requirement or protocols for information

sharing and timely reporting

• Legislation and agreements that give all parties “final

authority”

The 1918 “Spanish “ influenza

• Wrongly attributed to Spain
• Actual source still a mystery

1918 Influenza

• Started in spring of 1918 and spread across the

globe in 3 waves

• 55,000 died in Canada; one in three contracted the

illness

• Younger people worse reaction – possibly due to

immune reconstitution inflammatory syndrome

• Spanish flu killed 50 to 100 million worldwide from

1918 – 1919

The Waves

• First wave early in the spring of 1918 in military

training camps throughout the US.

• In Canada 1st wave started In Montreal and Toronto
• Sept. 1918 (same time as 2nd wave in USA)
• Returning troops brought the virus back into the US

for the second wave of the epidemic in Sept. 1918

• November, 1918 the end of the war enabled a

resurgence.

What a Disaster!

• Just as the war had effected the course of influenza,

influenza affected the war; troops on both sides

• Military patients coming home from the war with

battle wounds and influenza

• Majority of qualified Drs. and Nurses were serving in

the war

• Others succumbed to influenza
• Hospitals completely overwhelmed
• Some health care providers refused to work because of fear
• f illness
• Morgue and death services (grave diggers) could not keep up

Lessons Learned

• In Canada no federal public health department or

provincial health departments so unable to have coordinated national response

• Communities had to conceive and realize own plans

during health crisis.

• Public was not receiving transparent and consistent

advice and information

Lessons Learned

• Cities that implemented multiple non pharmaceutical

interventions (avoiding crowds, wearing masks, shutting schools and cancelling public events) early in the outbreak fared better than cities who did it late or not at all

• Did not have plan prior to crisis, therefore did not have

‘buy-in’ from all ‘stakeholders’ – public health and government officials, business leaders and community members

Walkerton, Ontario

Walkerton Water Crisis – May 2000 Timeline of Events

• From May 8-12 heavy rainfalls caused flooding in

Walkerton

• May 12 heaviest rainfall day – by evening flooding

was observed at Well 5 and at 10:45pm well stopped pumping water.

• May 13 -15th fictitious entries made about chlorine

levels for Well 5

• May 15 several water samples taken and sent to lab

(normal protocol)

Timeline of Events

• First sign of wide spread illness occurred May 18th,

large number of children absent from school with bloody diarrhea.

• May 19 health unit contacted PUC and asked about
• water. Were not told of adverse sample results
• On May 21 hospital receive 270 calls and 1st of many

children airlifted to Toronto – Public Health took own water samples – MHO issued a boil water advisory

Timeline of Events

• 7 people died and over 2300 became ill. 27

developed Hemolytic Uremic Syndrome (HUS) from E-coli 0157:H7

• Many having lasting kidney damage

Lessons Learned

• Contaminants confirmed E-Coli 0157:H7 and

Campylobacter jejuni entered Well 5 on or shortly after May 12, 2000 – this was the key source, if not the only source

Lessons Learned

• Walkerton Commission led by Chief Justice Dennis

O’Connor released in Jan 2002. – Estimated cost a min of $64-155 million

• For more than 20 years Walkerton’s PUC operators

engaged in a host of improper practices, including failing to use adequate doses of chlorine, failing to monitor chlorine residuals daily, making false entries in daily

• perating reports and misstating the locations where

micro samples were taken.

Lessons Learned

• Ontario’s government was also blamed for not

regulating water quality and not enforcing the guidelines that were in place but no government politician was charged or found guilty of wrongdoing.

• Inquiry report included recommendations for

improving source water protection as part of a multi- barrier approach, training and certification of

• perators, quality management for water suppliers

and competent enforcement.

SARS

SARS – 2002/2003

• Droplet spread viral illness, emerged from

China in November 2002

• Health Canada aware in February 2003,
• World wide 8437 people infected, 900 deaths

Transmission

• Chinese doctor travelled to Hong Kong to attend a

wedding on Feb. 21, 2002

• While staying at the Metropole Hotel he began to

develop symptoms. In less than 24 hours, the illness spread to approximately a dozen other hotel guests, including a 78-year old woman from Canada who was in Hong Kong on holiday.

• She returned to Toronto on Feb. 23 and died in hospital
• n March 5 (unrecognised SARS)
• Her family member fell ill and was admitted to a

community hospital that led to a huge nosocomial

• utbreak

Transmission

• The Toronto SARS outbreak occurred in two waves—

March to April and April to July 2003 – 438 probable cases and 44 deaths – Of these 100 HCW’s infected and 3 deaths – 25,000 Toronto residents were placed in quarantine Approximately 85% of all Canadian SARS cases occurred in Ontario. Toronto received intense media coverage

What a Disaster!

• Media converged on the city and fuelled speculation that

SARS was spreading through the community

• World Health Organization (WHO) to issue a travel

advisory, April 23-30

• Devastating economic and social impact on Toronto.
• Tourism sustained a $350 million loss
• Retail sales declined by $380 million

Lessons Learned

• Lack of surge capacity in clinical and public health

systems – “Does Canada have enough skilled personnel in various public health fields and if not, how can the nation close these gaps?”

• Timely access to laboratory testing and results
• Inadequacies in institutional outbreak management

protocols, infection control and infectious disease surveillance

Lessons Learned

• Absence of protocols for data or information sharing

among levels of government – Uncertainties about data ownership – Inadequate capacity for epidemiologic investigations of the outbreak – Lack of coordinated communications processes across institutions and jurisdictions for outbreak management and emergency response

• Weak links between public health and the personal

health services system, including primary care, institutions and home care

Vegreville - 2007

Closure of Hospital and Community Wide Anxiety

• St. Josephs General Hospital
• Faith Based Hospital
• Was a “Voluntary” facility with an agreement with

East Central Health Region

• Regional Health Authorities Act granted final

authority to both organisations

Timeline of Events

• September, 2003: outbreak of MRSA suspected and

some strategies put into place – Increased cleaning of tubs, sinks and toilets delayed until 2006 – Permanent change to surface disinfectant (IPC recommendation) never done

• Incidence dropped but never to what was considered

to be a “safety threshold”

• Nov. 2003: discovered that reprocessing of

endoscopes did not follow standards at SJGH

Timeline of events:

• Over the next 2 years IPC submitted a number of

reports to executive, requesting direction (MRSA)

• Independent audits of CSR in Aug 2006 along with

education of staff began

• Jan 22, 2007 CSR audits completed and results

revealed several serious deficiencies

• January 29, 2007: meeting of MHO, IPC, SJGH

admin., nursing and lab (MRSA)

Timeline of Events

• Feb. 15, 2007 chart audits done to assess

compliance of nursing staff to IC practices (MRSA)

• March 15, 2007 no change in practice in CSR

Timeline of Events

• March 16, 2007 MHO and IPC Coordinator

inspect CSR at SJGH

• March 16, 2007 at 6:00pm MHO enacted the
• rder to:

– halt all inpatient admissions, and – close the sterile processing department

Root Cause Analysis Report

Governance and Administration;

• Legislation and agreements governing SJGH and ECH

and poor working relationships resulted in;

– unclear accountabilities and responsibilities and – patient safety hazards

• Unclear legislation and agreements between the

government and both, Voluntary facilities such as SJGH and regional health authorities like ECH, gave both bodies “final authority” for facility operations

HQCA Report - Findings

Poor working relationships between SJGH and ECH;

• Failed to ensure best practices for IPC and

Sterilization were implemented in SJGH, despite knowledge that practices did not meet standards

• Historically ECH held the belief that they needed to

be “invited in” to SJGH to make any service changes

• While SJGH considered directives from ECH to be

“optional”

HQCA Recommendation

Define relationships within service agreements between ECH and SJGH to;

• Ensure that authority, accountability, and

responsibility of regional managers and senior management is clear

• Ensure that this clarity is also defined for and

extends to quality and safety in all facilities across the region

Common Themes

Common Themes - Communication

• Communication at all levels:

– 1918 influenza – SARS – Walkerton – Vegreville

Common Themes - Accountability

• 1918 Influenza: no federal or provincial leadership
• Walkerton: no regulation or enforcement
• SARS: no protocals for information sharing
• Vegreville: no “final authority”, autonomy/isolation

Common Themes - Culture

• Culture (culture eats strategy for lunch):

– Culture of autonomy/isolation – Resistance to new ideas/processes – Culture of frugality – Staff feeling “picked on” – victim syndrome – Culture of presentism – Shooting the messenger