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Factors Associated With Critical-Care Healthcare Workers' Adherence to Recommended Barrier Precautions During the Toronto Severe Acute Respiratory Syndrome Outbreak

Published online by Cambridge University Press:  02 January 2015

A. Shigayeva
Department of Microbiology, Mount Sinai Hospital, Toronto, Ontario
K. Green
Department of Microbiology, Mount Sinai Hospital, Toronto, Ontario
J. M. Raboud
University Health Network, Toronto, Ontario
B. Henry
British Columbia Centre for Disease Control, Vancouver, British Columbia
A. E. Simor
Sunnybrook Health Sciences Centre, Toronto, Ontario
M. Vearncombe
Sunnybrook Health Sciences Centre, Toronto, Ontario
D. Zoutman
Queen's University, Kingston, Ontario
M. Loeb
McMaster University, Hamilton, Ontario
A. McGeer*
Department of Microbiology, Mount Sinai Hospital, Toronto, Ontario
Room 210, Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario, CanadaM5G 1X5 (



To assess factors associated with adherence to recommended barrier precautions among healthcare workers (HCWs) providing care to critically ill patients with severe acute respiratory syndrome (SARS).


Fifteen acute care hospitals in Ontario, Canada


Retrospective cohort study.


All patients with SARS who required intubation during the Toronto SARS outbreak in 2003.


HCWS who provided care to or entered the room of a SARS patient during the period from 24 hours before intubation until 4 hours after intubation.


Standardized interviews were conducted with eligible HCWs to assess their interactions with the SARS patient, their use of barrier precautions, their practices for removing personal protective equipment, and the infection control training they received.


Of 879 eligible HCWs, 795 (90%) participated. In multivariate analysis, the following predictors of consistent adherence to recommended barrier precautions were identified: recognition of the patient as a SARS case (odds ratio [OR], 2.5 [95% confidence interval {CI}, 1.5-4.5); recent infection control training (OR for interactive training, 2.7 [95% CI, 1.7-4.4]; OR for passive training, 1.7 [95% CI, 1.0-3.0]), and working in a SARS unit (OR, 4.0 [95% CI, 1.8-8.9]) or intensive care unit (OR, 4.3 [95% CI, 2.0-9.0]). Two factors were associated with significantly lower rates of consistent adherence: the provision of care for patients with higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores (OR for score APACHE II of 20 or greater, 0.4 [95% CI, 0.28-0.68]) and work on shifts that required more frequent room entry (OR for 6 or more entries per shift, 0.5 [95% CI, 0.32-0.86]).


There were significant deficits in knowledge about self-protection that were partially corrected by education programs during the SARS outbreak. HCWs' adherence to self-protection guidelines was most closely associated with whether they provided care to patients who had received a definite diagnosis of SARS.

Original Articles
Copyright © The Society for Healthcare Epidemiology of America 2007

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1.Low, JG, Wilder-Smith, A. Infectious respiratory illnesses and their impact on healthcare workers: a review. Ann Acad Med Singapore 2005;34:105110.Google ScholarPubMed
2.Salgado, CD, Farr, BM, Hall, KK, Hayden, FG. Influenza in the acute hospital setting. Lancet Infect Dis 2002;2:145155.CrossRefGoogle Scholar
3.Szucs, TD, Ruef, C, Muller, D, Sokolovic, E, Beeler, I, Ostermayer, W. The economic impact of influenza in a university hospital setting. Infect Control Hosp Epidemiol 2001;22:472474.CrossRefGoogle Scholar
4.Menzies, D, Fanning, A, Yuan, L, Fitzgerald, M. Tuberculosis among healthcare workers. New Engl J Med 1995;332:9298.CrossRefGoogle Scholar
5.Varia, M, Wilson, S, Sarwal, S, et al. Investigation of a nosocomial outbreak of severe acute respiratory syndrome (SARS) in Toronto, Canada. CMAJ 2003;169:285292.Google Scholar
6.Lee, N, Hui, D, Wu, A, et al. A major outbreak of severe acute respiratory syndrome in Hong Kong. New Engl J Med 2003;348:19861994.CrossRefGoogle Scholar
7.Lau, JT, Fung, KS, Wong, TW, et al. SARS transmission among hospital workers in Hong Kong. Emerg Infect Dis 2004;10:280286.CrossRefGoogle ScholarPubMed
8.Loeb, M, McGeer, A, Henry, B, et al. SARS among critical care nurses, Toronto. Emerg Infect Dis 2004;10:251255.CrossRefGoogle ScholarPubMed
9.Seto, WH, Tsang, D, Yung, RW, et al. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet 2003;361:15191520.CrossRefGoogle Scholar
10.Teleman, MD, Boudville, IC, Heng, BH, Zhu, D, Leo, YS. Factors associated with transmission of severe acute respiratory syndrome among healthcare workers in Singapore. Epidemiol Infect 2004;132:797803.CrossRefGoogle Scholar
11.Steingart, KR, Thomas, AR, Dykewicz, CA, Redd, SC. Transmission of measles virus in healthcare settings during a communitywide outbreak. Infect Control Hosp Epidemiol 1999;20:115119.CrossRefGoogle ScholarPubMed
12.Goldmann, DA. Nosocomial viral infections: recent developments and new strategies. Eur J Clin Microbiol Infect Dis 1989;8:7581.CrossRefGoogle ScholarPubMed
13.Pittet, D, Mourouga, P, Perneger, TV. Compliance with handwashing in a teaching hospital. Infection Control Program. Ann Intern Med 1999;130:126130.CrossRefGoogle Scholar
14.Pittet, D. Improving adherence to hand hygiene practice: a multidisci-plinary approach. Emerg Infect Dis 2001;7:234240.CrossRefGoogle Scholar
15.Afif, W, Huor, P, Brassard, P, Loo, VG. Compliance with methicillin-resistant Staphylococcus aureus precautions in a teaching hospital. Am J Infect Control 2002;30:430433.CrossRefGoogle Scholar
16.Gershon, RR, Vlahov, D, Felknor, SA, et al. Compliance with universal precautions among healthcare workers at three regional hospitals. Am J Infect Control 1995;23:225236.CrossRefGoogle ScholarPubMed
17.Tokars, JI, McKinley, GF, Otten, J, et al. Use and efficacy of tuberculosis infection control practices at hospitals with previous outbreaks of multidrug-resistant tuberculosis. Infect Control Hosp Epidemiol 2001;22: 449455.CrossRefGoogle ScholarPubMed
18.Public Health Agency of Canada. National case definitions for the SARS outbreak period. Available at: Accessed September 12, 2007.Google Scholar
19.Aquino, M, Raboud, JM, McGeer, A, et al. Accuracy of healthcare worker recall and medical record review for identifying infectious exposures to hospitalized patients. Infect Control Hosp Epidemiol 2006;27:722728.CrossRefGoogle ScholarPubMed
20.Ontario Ministry of Health and Long-Term Care. Ontario best practice manual: preventing febrile respiratory illness. Available at: Accessed January 24, 2007.Google Scholar
21.Knaus, WE, Draper, AE, Wagner, DP, Zimmerman, JE. APACHE II: a severity of disease classification system. Crit Care Med 1985;13:818829.CrossRefGoogle ScholarPubMed
22.Svoboda, T, Henry, B, Shulman, L, et al. Public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in Toronto. N Engl J Med 2004;350:23522361.CrossRefGoogle ScholarPubMed
23.Poutanen, SM, Low, DE, Henry, B, et al; National Microbiology Laboratory, Canada; Canadian Severe Acute Respiratory Syndrome Study Team. Identification of severe acute respiratory syndrome in Canada. New Engl J Med 2003;348:19952005.CrossRefGoogle Scholar
24.Scales, DC, Green, K, Chan, AK, et al. Illness in intensive care staff after brief exposure to severe acute respiratory syndrome. Emerg Infect Dis 2003;9:12051210.CrossRefGoogle ScholarPubMed
25.Heymann, DL. The international response to the outbreak of SARS in 2003. Philos Tran R Soc Lond B Biol Sci 2004;359:11271129.CrossRefGoogle ScholarPubMed
26.Ho, PL, Tang, XP, Seto, WH. SARS: hospital infection control and admission strategies. Respirology 2003;8(suppl):S41S45.CrossRefGoogle ScholarPubMed
27.Low, DE, McGeer, A. SARS—one year later. N Engl J Med 2003;349:23812382.CrossRefGoogle ScholarPubMed
28.Kellerman, SE, Saiman, L, San Gabriel, P, Besser, R, Jarvis, WR. Observational study of the use of infection control interventions for Mycobacterium tuberculosis in pediatric facilities. Pediatr Infect Dis 72001;20:566570.CrossRefGoogle Scholar
29.Cutter, J, Jordan, S. Uptake of guidelines to avoid and report exposure to blood and body fluids. J Adv Nurs 2004;46:441452.CrossRefGoogle ScholarPubMed
30.Muller, MP, Richardson, SE, McGeer, A, et al.;Canadian SARS Research Network. Early diagnosis of SARS: lessons from the Toronto SARS outbreak. Eur J Clin Microbiol Infect Dis 2006;25:230237.CrossRefGoogle ScholarPubMed
31.Davies, HTO, Harrison, S. Trends in doctor-manager relationships. BMJ 2003;326:646649.CrossRefGoogle ScholarPubMed
32.Sax, H, Perneger, T, Hugonnet, W, Herrault, P, Chraiti, MN, Pittet, D. Knowledge of standard and isolation precautions in a large teaching hospital. Infect Control Hosp Epidemiol 2005;26:298304.CrossRefGoogle Scholar
33.Moore, D, Gamage, B, Bryce, E, Copes, R, Yassi, A. Protecting healthcare workers from SARS and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines. Am J Infect Control 2005;33:8896.CrossRefGoogle ScholarPubMed
34.DiGiacomo, JC, Hoff, WS, Rotondo, MF, et al. Barrier precautions in trauma resuscitation: real-time analysis utilizing videotape review Am J Emerg Med 1997;15:3439.CrossRefGoogle ScholarPubMed
35.Nickell, L, Crighton, EJ, Tracy, CS, et al. Psychosocial effect of SARS on hospital staff: survey of a large tertiary institution. CMAJ 2004;170: 793798.CrossRefGoogle Scholar
36.Dejoy, DM, Searcy, CA, Murphy, LR, Gershon, RR. Behavioral-diagnostic analysis of compliance with universal precautions among nurses. J Occup Health Psychol 2000;5:127141.CrossRefGoogle ScholarPubMed
37.Lam, BC, Lee, J, Lau, YL. Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection. Pediatrics 2004;114:e565e571.CrossRefGoogle Scholar
38.Garner, JS. Guideline for isolation precautions in hospitals. The Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1996;17:5380.CrossRefGoogle ScholarPubMed
39.Health Canada, Laboratory Centre for Disease Control, Division of Nosocomial and Occupational Infections. Routine practices and additional precautions for preventing the transmission of infection in health care. Can Comm Dis Rep 1999;25(s4):1155.Google ScholarPubMed
40.Dimoulas, P, Green, KA, Shigayeva, A, Aquino, M, McGeer, A, Scales, DC. Patient contact recall after SARS exposure. Emerg Infect Dis 2005;11:625628.CrossRefGoogle ScholarPubMed