Prepared Witness Testimony

The House Committee on Energy and Commerce

SARS: Assessment, Outlook, and Lessons Learned

Subcommittee on Oversight and Investigations
May 7, 2003
2:00 PM
2123 Rayburn House Office Building 

Ms. Karin Kerby R.N
Loudoun Hospital Center
44045 Riverside Parkway
Leesburg, VA, 20176

Good afternoon Mr. Chairman, members of the committee. My name is Karin Kerby and I am a registered nurse and Team Leader for the Emergency Department at Loudoun Hospital Center in Leesburg, Virginia. I would like to thank the Committee for the invitation to testify today specifically on the issue of clinical staff safety as it relates to infectious disease triage and treatment.

On the morning of February 17, 2003, the nations' capital had experienced a 2-foot snowfall the previous day. As I made it in to my job, little did I know that awaiting me was the first suspected case of SARS in the U.S. At that point, there was, to our knowledge, no such disease. This was weeks before an emerging pattern was recognized and addressed by the W.H.O. and C.D.C.

A patient had just arrived by ambulance into our ED. Her symptoms were easy to recognize: acute shortness of breath, fever and cough. Her oxygen level was such that she required supplemental oxygen therapy and chest X-ray revealed pneumonia. This particular patient was quickly moved from her stretcher into a room with oxygen. This was our negative airflow room which, when activated, creates an environment where infectious airborne elements are vented away from the rest of the Emergency Department.

Approximately 2 hours after arrival I received a phone call from her nephew which helped guide the course of events. He related to me that the patient had just returned from the Guangdong Province in China. He had just received information from family in China that there was an "atypical pneumonia" in their area from which people were dying. This information correlated with what I had read in The Washington Post. I alerted the ED physician and isolation procedures were reinforced and contacts with the Health Department and Infection Control were made.

The protocol that we developed after 9/11 guides us in reporting suspected bio-terrorism and infectious cases. While the physician contacted the infectious disease specialist, I immediately called the Loudoun County Health Department's epidemiologist, Benita Boyer, to consult. She confirmed that there was a reported outbreak of an unidentified pneumonia in China, and agreed that the patient should be kept in isolation at this point.

The CDC, in conjunction with our Health Department and our hospital, launched an epidemiological investigation, contacting every person who had come in contact with this patient; even isolating the Emergency room physician for 3 days because of mild Upper respiratory symptoms. Remember, SARS did not become a known entity until weeks later.

This event shows how, on any given day in any Emergency department or physicians' office, a new, emerging threat to our society's health can present and infiltrate. An enormous amount of work and planning has taken place since 9/11 as we have struggled to research and develop protocols to respond to the threat of smallpox, and in our community the reality of Anthrax, West Nile Virus and malaria. Countless hours and thousands of dollars of unbudgeted funds have had to be poured into training, surveillance, decontamination equipment and education of our staff.

However, no matter how prepared and equipped one is, there will always be that moment of vulnerability before we can respond when an unknown virus or bacteria may infect a triage nurse; it is a risk we in emergency medicine choose to take.

This event could have had a very different outcome. For example, had she been without proper isolation precautions and infection control measures, not only would our staff but community been negatively affected.

Suffice it to say that since 9/11, if not before, the concerns related to infection control have migrated out of Epidemiological Departments to general public awareness via county health department's and local hospital ER's. If there is an additional action that has come about not just related to SARS, but infection threats in general, it has been this migration to the forefront of triage and public venues for education.

From my perspective as a staff nurse on the front line in an Emergency department, I submit the following observations:

1. Hospitals should assume all patients suspected of having SARS risk factors are highly infectious until proven otherwise, since the various modes of transmission of SARS remain unclear. To protect vulnerable patients, staff, visitors and the surrounding community, hospitals should activate all transmission precautions; including airborne, droplet, contact and contaminated materials control measures. Caregivers should not ignore basics of Personal Protection Equipment, which includes gowns, gloves, N-95 masks, goggles as well as particular attention to hygiene.

2. No amount of training or preparedness can substitute for a well-informed public aware of an infectious disease and how to limit its spread. The difference between a person presenting to the ED stating, "I might have been exposed"...and a person or physician calling ahead to forewarn of their arrival cannot be emphasized enough. Being able to isolate individuals BEFORE they enter a health care facility is absolutely imperative to stemming the spread among healthcare workers. The only way this can be accomplished is via public education. Case in point: this past week, in a conversation between a Southeast Asian couple and their ESL instructor I overheard the following: The couple asked about "something called SARS". They were just last week hearing about this! Why? There is a large contingent of citizens in this country who do not speak English, who do not own computers, who work 2 or 3 jobs and never read a newspaper or watch TV. I submit that public education needs to immediately go forward in multiple languages using a variety of media to inform everyone of this disease.

3. Hospitals in the US are not generally equipped to handle large outbreaks of this disease. Most hospitals have limited numbers of isolation beds, many of which are already taken by Tuberculosis patients. The expense involved in creating more negative- airflow rooms to accommodate more patients is almost cost-prohibitive and few hospitals have the budgeted amounts to spend on this as-yet emerging threat.

4. As we have seen in Honk Kong, Toronto and China, the impact on healthcare has been devastating, from infected healthcare workers to the overwork of those left to serve creating unsafe isolation environments due to fatigue. Continued development of surge capacity plans for response to outbreaks, quarantine and the economic impacts must continue to be addressed between local hospitals, county and state health departments as well as federal health authorities.

Thank you. I will be happy to address any questions you may have.

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