ISSUE: The emergence of Severe Acute Respiratory Syndrome (SARS) in 2003 challenged the world of infection control. During the SARS epidemic, Toronto was included as a travel location in the SARS definition. The lack of preparedness at our facility became evident in June 2003, when a patient was admitted with a fever, infiltrates, and recent travel to Toronto. This admission revealed many failure modes in our system for identifying and containing SARS. Twenty-one healthcare workers (HCWs) had unprotected exposure to the suspected case. As a result, the HCWs were screened prior to reporting to work for the 10 days following their exposure. Improper handling of lab specimens delayed testing. The case eventually was ruled out as a SARS case.

PROJECT: A multidisciplinary team was formed to conduct a root-cause analysis (RCA) of the potential SARS exposure. Several process failures were identified, from admission through specimen handling. The team recognized that the frequency of admitting a SARS patient was low; however, the potential health threat was high. Rather than conduct additional educational sessions, a SARS Toolkit was developed for the hospital units. The kit contained step-by-step instructions, visuals, and a notification list. The kit's built-in forcing functions were designed to move the process along, but not to rely on HCWs memory. The new process was tested in a mock SARS admission drill. Only administration and the RCA team knew about the drill. The drill was completed in 3 hours.

RESULTS: The kit was activated immediately and key departments, including infection control, were notified. Personal protective equipment was obtained and the patient was placed in the proper isolation. Laboratory specimens were processed and handled appropriately. HCW exposure did not occur. The kit assisted in preventing exposures while allowing for patient care. A debriefing followed the drill and included all HCWs involved, administration, and the RCA team. The mock patient was able to provide additional information regarding objects with potential fomite contamination that were brought out of the room.

LESSONS LEARNED: Preparedness for events that may or may not occur challenged us to create a process that would succeed. Overall, the kit proved its worth with well-defined instructions for communication. At any time, it could easily be updated. It was identified that some signage needed clarification, and changes were made to the kit. The kit has since been adopted by our system hospitals.