Laura Hawryluck

SARS control and psychological effects of quarantine, Toronto, Canada.

Explores effects of quarantine on those quarantined for SARS, Toronto, Canadarespiratory syndrome (SARS) was successfully contained globally by instituting widespread quarantine measures. Although these measures were successful in terminating the outbreak in all areas of the world, the adverse effects of quarantine have not previously been determined in a systematic manner. In this hypothesis-generating study supported by a convenience sample drawn in close temporal proximity to the period of quarantine, we examined the psychological effects of quarantine on persons in Toronto, Canada. The 129 quarantined persons who responded to a Web-based survey exhibited a high prevalence of psychological distress. Symptoms of posttraumatic stress disorder (PTSD) and depression were observed in 28.9% and 31.2% of respondents, respectively. Longer durations of quarantine were associated with an increased prevalence of PTSD symptoms. Acquaintance with or direct exposure to someone with a diagnosis of SARS was also associated with PTSD and depressive symptoms.

Conflicts in the ICU: perspectives of administrators and clinicians

PurposeThe purpose of this study is to understand conflicts in the ICU setting as experienced by clinicians and administrators and explore methods currently used to resolve such conflicts when there may be discordance between clinicians and families, caregivers or administration.MethodsQualitative case study methodology using semi-structured interviews was used. The sample included community and academic health science centres in 16 hospitals from across the province of Ontario, Canada. A total of 42 participants including hospital administrators and ICU clinicians were interviewed. Participants were sampled purposively to ensure representation.ResultsThe most common source of conflict in the ICU is a result of disagreement about the goals of treatment. Such conflicts arise between the ICU and referring teams (inter-team), among members of the ICU team (intra-team), and between the ICU team and patients’ family/substitute decision-maker (SDM). Inter- and intra-team conflicts often contribute to conflicts between the ICU team and families. Various themes were identified as contributing factors that may influence conflict resolution practices as well as the various consequences and challenges of conflict situations. Limitations of current conflict resolution policies were revealed as well as suggested strategies to improve practice.ConclusionsThere is considerable variability in dealing with conflicts in the ICU. Greater attention is needed at a systems level to support a culture aimed at prevention and resolution of conflicts to avoid increased sources of anxiety, stress and burnout.

Clinical review: SARS – lessons in disaster management

Disaster management plans have traditionally been required to manage major traumatic events that create a large number of victims. Infectious diseases, whether they be natural (e.g. SARS [severe acute respiratory syndrome] and influenza) or the result of bioterrorism, have the potential to create a large influx of critically ill into our already strained hospital systems. With proper planning, hospitals, health care workers and our health care systems can be better prepared to deal with such an eventuality. This review explores the Toronto critical care experience of coping in the SARS outbreak disaster. Our health care system and, in particular, our critical care system were unprepared for this event, and as a result the impact that SARS had was worse than it could have been. Nonetheless, we were able to organize a response rapidly during the outbreak. By describing our successes and failures, we hope to help others to learn and avoid the problems we encountered as they develop their own disaster management plans in anticipation of similar future situations.

An interactive educational workshop to improve end of life communication skills

Introduction: An understanding of legal, ethical, and cultural concerns and an ability to communicate when faced with clinical dilemmas are integral to the end of life decision‐making process. Yet teaching practicing clinicians these important skills in addressing conflict situations is not strongly emphasized. Methods: A one‐day interactive continuing education workshop was designed to improve interactions among multiprofessional intensive care unit (ICU) clinicians, their colleagues, and families in a range of end of life situations using standardized families and colleagues (SF/SCs). Workshop participants completed preworkshop and postworkshop evaluations. Data were analyzed using the McNemar test for paired categorical data to evaluate changes in comfort, knowledge, and skill. Results: The majority of evaluation respondents were nursing professionals, while only one physician (of two in attendance) responded. Statistically significant improvement was seen in all comfort levels, except when approaching cultural differences. Expectations were exceeded according to 76.2% of responses, while 82.4% rated SF/SCs “excellent” for improving communication skills and comfort levels with ethical and legal dilemmas. Peer discussions were highly valued in meeting educational objectives (95.2% good or excellent), and 95.2% rated achievement of personal learning objectives good or excellent. Qualitative data supported a high overall perception of success and achievement of educational objectives. Discussion: An interactive workshop can be a valuable educational intervention for building capacity and confidence in end of life communication skills and ethical and legal knowledge for health care providers; further physician involvement is required to extrapolate results to this population.

Impact on health care workers employed in high-risk areas during the Toronto SARS outbreak

Abstract Background A number of publications focusing on health care workers (HCWs) during a severe acute respiratory syndrome (SARS) outbreak have suggested that HCWs experienced psychological distress, particularly increased levels of posttraumatic stress symptomatology (PTSS). Factors contributing to increased distress in HCWs working in high-risk areas treating patients with SARS have not been fully elucidated. The goal of this study was to quantify the psychological effects of working in a high-risk unit during the SARS outbreak. Methods HCWs in a Toronto hospital who worked in high-risk areas completed a questionnaire regarding their attitude toward the SARS crisis along with the Impact of Event Scale—Revised, which screens for PTSS. The comparison group consisted of clinical units that had no contact with patients infected with SARS. Results Factors that were identified to cause distress in the 248 respondent HCWs were the following: (a) perception of risk to themselves, (b) impact of the SARS crisis on their work life, (c) depressive affect, and (d) working in a high-risk unit. In addition, HCWs who cared for only one SARS patient in comparison to those caring for multiple SARS patients experienced more PTSS. Conclusions As expected, HCWs who were working in high-risk units experienced greater distress. Contrary to expectations, HCWs who experienced greater contact with SARS patients while working in the high-risk units were less distressed. This suggests that HCW experience in treating patients infected with SARS may be a mediating factor that could be amenable to intervention in future outbreaks.

Ethics review: Position papers and policies – are they really helpful to front-line ICU teams?

During the past few years the ethics sections of critical care societies have proposed a number of policies describing the goals of intensive care unit (ICU) care and providing broad guidance on the diagnoses and physiological criteria that would mandate using the specialized skill and technologies of an ICU environment. Discussions on what constitutes appropriate use of such scarce resources, incorporating cultural and religious beliefs and exploring how they interact with these medical criteria, remain vague. To date, these policies do not provide any definitive guidance in the difficult decision making faced by clinicians. Some argue that they were never meant to do so and yet they have served to guide the development of local hospital policies. Many have explored how critical care services are allocated without achieving consensus on the best way to achieve fair and equitable access to life-sustaining interventions. A consensus is needed though, one that is reflective of both individual and societal values and goals. Otherwise, increasing pressure to provide treatments with marginal benefits at best will threaten the ability of others to access treatments that may offer them very real benefits.

Multi-Professional Recommendations for Access and Utilization of Critical Care Services: Towards Consistency in Practice and Ethical Decision-Making Processes

Multiprofessional guidelines for fair access to and use of adult critical care services are desperately needed to define a consistent transparent standard of care: when such therapies have the potential to benefit and help a patient as they journey with illness and when they cannot.