This is the first instalment in a three-part series on Ontario’s response to the 2003 SARS outbreak. Watch for Part 2 on Thursday.
In 2003, the severe acute respiratory syndrome-related coronavirus came to Canada. SARS caused a major crisis, mainly in Toronto and its suburbs, for the health-care system and public-health officials. Hundreds fell ill, and 44 died, before the epidemic was brought under control. Now that cases of a novel coronavirus have been confirmed in Toronto and Vancouver, officials have begun referring to “the lessons of 2003” and how they have prepared us for this challenge. What are those lessons? In a new series, TVO.org interviews three people who were involved in dealing with the SARS crisis to ask them what insights they’d offer their counterparts today. In this instalment, I talk to Vicki McKenna, the president of the Ontario Nurses' Association, who was a staff nurse and nurses’-union leader during the 2003 epidemic.
Matt Gurney: Can you start by telling me what you were up to during the SARS epidemic in 2003?
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Vicki McKenna: I was a staff nurse at Victoria Hospital, in the London Health Sciences Centre, in London. I was also the president of the local nurses’-union association. As a front-line nurse, working in the hospital units, we were on high alert. We didn’t have an active SARS case in our facility, but we were working to prepare for it.
Gurney: What did that mean for you guys in practice?
McKenna: We had emergency plans. We had all these codes — code reds, code silvers. But we didn’t really have, at that time, a real, solid, ongoing preparedness plan for something like SARS. We just didn’t have it. The situation was fluid every day. Everyone needed advice. We had experts, but they all had different opinions. There was no lead in the province. We had daily or even two- or three-times daily senior meetings, with communications coming down the organization about the latest information. It changed every time. We learned quickly that communication was key. And not just the information we received. We had to then communicate that information to people who had come in and were worried. We wanted to be transparent and take the fears of the public seriously. The anxiety level in the public was very high. And when you arrive at a hospital and you’re being screened, that made people even more anxious. And there were also the patients in the hospital already and their friends and family. Everyone needed assurance that they were being protected. We nurses learned very quickly that we couldn’t just wait for information. We needed to go look for it, because people expected it from us — I was the go-to person for the patients I had and also the nurses in my union. They were afraid. It wasn’t just about work. We could have brought this back home to our families.
Gurney: Even though you guys didn’t end up with any SARS cases in London, I have to imagine that anyone showing up with any respiratory issue whatsoever would have been treated as one immediately. What did that mean for you guys on the front lines? What did a day look like during the SARS operations?
McKenna: We had to learn as we went, because our understanding of SARS evolved. But, very soon, we were doing active screening at points of entry. In fact, we shut down points of entry. We were in a huge facility with many ways in and out for families and patients. We shut the doors. We had to control how people were coming in, making sure everyone was screened. This was upsetting to a lot of people — patients and families. Sometimes people parked and realized they had to walk all the way around this huge facility to get to a screened entrance. With people coming in at only one or two points of entry, the screening took time. The screening questions were detailed, and if anyone gave us an answer that raised any questions, we then had to screen in even more detail. The questions changed every day as we learned more. We had to tell some people we needed to investigate further before we could let them in, even for a planned appointment. Now imagine doing this with emergency patients — they were there to get treatment. They needed help. But we had to screen them. So we cleared some people, and they were allowed in. Others were sent for secondary investigation because they’d raised a concern. And some of them needed laboratory tests. People were very anxious that they’d been exposed.
Gurney: You’ve said “screening” a bunch of times. I just want to clarify what exactly you mean. You mean questions, right? They had to answer a list of questions about their travel history, any symptoms they were experiencing, stuff like that.
McKenna: Yes, that’s right. Exactly. Detailed questions, and as I said, they changed all the time.
Gurney: Let me throw a hypothetical at you. You’re a nurse at Victoria Hospital in 2003, and two patients arrive at once. One is coughing up a lung. The other is breathing normally but has an obviously and spectacularly broken arm and is in a lot of pain — and very cranky about getting questioned. What happens to them both?
McKenna: Both would be screened in the same fashion. The same screening questions, whatever the questions were that day. Then we’d triage them for whatever their presenting symptoms were. So the poor individual with the broken arm would be sent off for X-raying and then the rest. But the person with the respiratory problem would be checked extensively and very quickly. They’d be fast-tracked. But both would still have the complete screening, and the respiratory patient would be treated as a potential SARS case and isolated for treatment. The fracture would be sent somewhere else and not triaged as high. We didn’t delay anyone with respiratory issues — that’s always a very high concern: anyone in respiratory distress is rushed in. But, in 2003, it was even more so. Treatment and isolation, immediately.
Gurney: Everyone got the same screening at the door.
McKenna: Yes. We would have patients arrive in obvious and imminent life-threatening condition that we had to admit and treat immediately, but, even then, we took maximum precautions to protect us and them. We were running into capacity issues in our emergency room very quickly.
Gurney: Let’s talk about that. In 2003, you were having “capacity” issues — what kind of capacity? Personnel? Equipment? Supplies? Information? Some combination of all of those? What did you start to run out of?
McKenna: All of the above. A combination. But, in 2003, and this is what I’m telling government and nurses today, we’re in a very different situation. In 2003, we did not have the kind of physical-capacity issues that we have today in our hospitals. That’s very worrisome. When something happens like this, or even a terrible motor-vehicle accident — planes, trains, automobiles, whatever — I’m very worried. We have major overcapacity issues today. We have to find space, somehow, somewhere. We’re trying to find physical capacity in closed hospitals, for Pete’s sake, and that’s just to meet current capacity challenges. What’s the plan should we need more than that?
Gurney: In 2003, Toronto opened a mothballed isolation ward for SARS. In 2020, Toronto has already reactivated mothballed hospitals just to sustain daily operations.
McKenna: I was just saying that this morning on a conference call. What’s the plan? In 2003, we reopened West Park to add capacity for isolation. But, today, patients are in every nook and cranny. Every hospital in Ontario is full. But we’re being told we need to hold negative-pressure isolation rooms open, in reserve, in case we need to put a patient in right away. There’s no capacity for that. In 2003, we had some and were able to open a ward solely for SARS patients.
But, in 2003, we had other challenges. We didn’t have enough masks and other protective supplies. There just weren’t the quantities we needed. Gloves and masks, all the personal protective equipment, were not available. Hospitals then always stocked some but not in the quantities we ended up needing. There was a huge push for equipment and supplies in 2003. This time, the government is telling us that we have sufficient supplies. We know from a briefing last night that a few hospitals are facing some challenges, running low on protective supplies, and the government has told us that they have stockpiles of supplies and a rapid-response system in place to resupply hospitals that run low and systems to obtain more.
Gurney: Let me jump in here just to try to make sure I have this. Is this a good summary: In 2003, we had problems with consumables — not enough supplies. But we had enough real estate — we had physical capacity to expand. But, in 2020, that’s been flipped around. We’ve stockpiled supplies, but we don’t have the square footage to expand capacity?
McKenna: That’s a good summary, yeah. Some organizations have some consumables concerns, and the government is saying they have reserves and are talking with suppliers. So that’s better.
Gurney: So that’s real estate and supplies. How about personnel?
McKenna: That’s a similar problem. In 2003, our staffing situation was better. We had more capacity. Our hospital occupancy rates were lower in 2003. Nurses could, if needed, move into other units to support staff there. We didn’t have nearly the challenges with unfilled nursing positions. In 2020, we have a big problem there. We have a high number of registered-nursing positions unfilled. The system’s human-resources planning — or lack thereof — has us in a situation where we have unfilled positions and are also laying people off. For budgeting purposes, a lot of nurses are only working part-time at a hospital, but they’re working at several different facilities. If we end up in a pandemic, you can’t have that. We can’t have that. After SARS, we realized we needed full-time nurses working for specific institutions. If one hospital becomes a centre of infection in a pandemic, you can’t have personnel who’ve been exposed finishing a shift there and driving to another hospital to start another shift. But we have nurses with two, three, four jobs at different facilities. In a pandemic, they can’t do that, so some of our institutions would lose some of their nurses.
Gurney: Right. Especially if, in a pandemic, we tried to convert some hospitals to “fever wards” and route all non-pandemic cases through the remaining hospitals. You can’t casually shuffle staff back and forth between the fever ward and the hospital setting broken bones and delivering babies.
McKenna: That was a big lesson from 2003. But hospitals say they’re underfunded, and they’ve moved to part-time staffing for nurses to stay afloat. Well, here we are in 2020 faced with a major potential problem, and we might see the same staffing-mobility challenge again.
Gurney: So we’ve learned some lessons from 2003, but we didn’t implement them for 2020.
McKenna: Exactly. It’s one step forward, one step back. We do have much better data sets. We have much better analytics. We have much better communication across the country and globally. We’re getting information faster. In 2003, there were a lot of isolated departments not communicating with others. We’re better at that now. We’ve improved. But! On the clinical side, yeah, one step forward, one step back. Many of our nurses have lived-experience with SARS. They remember this. It’s very real to them. There’s real concern. And we’ve been telling them, speak up. Speak out. Make sure you have the equipment you need and the supplies — we didn’t have enough in 2003, but this time, we’re told we do. In 2003, nurses who asked were told they were foolish, that it wasn’t needed. But nurses knew better. Nurses were telling the government that we needed to stay on guard, that we couldn’t stop our precautions. But we weren’t listened to, and we had a second wave of SARS in Toronto. Analytics are good. Monitor the data. But listen to the front lines. The doctors and nurses see and hear. They know.
Gurney: Okay, let me bring this right to a very basic question — what do you want us to get right this time that we didn’t get right in 2003?
McKenna: I want precautionary principles. We have to err on the side of caution. If health-care workers need supplies, when the science is not clear — and we don’t know a lot about this virus yet — we need to get them the supplies. We can’t have the government worrying about how much masks cost. Right now, it’s good. The government isn’t worrying about that. They’re getting us what we need. But until we know more about this virus, we need to make sure we have the right equipment, the right isolation capacity, the right screening. Once the science catches up, we can decide what isn’t needed. But, for now, we need to err on the side of caution. That’s the most important thing. We can’t fight small battles if someone thinks we’re being excessive in our demands. We need to keep patients safe, and the health-care workers, and the communities.
Gurney: Okay, same question, but now aimed right at your staff — your nurses, doctors, technicians. Everyone. What do you want the front-line personnel to know in 2020 that we learned in 2003?
McKenna: Find your voice. Speak up. Err on the side of caution, ask questions, keep up with communications, and make sure you understand the latest. Trust your gut. Protect yourself, the patients, and communities. This particular virus has an unknown incubation period. We’re not clear on the symptoms yet. This doesn’t present with a fever. SARS did. We don’t know enough yet. Let’s not pretend we do. Speak up, always. Be heard.
Gurney: Right. And, if nothing else, this is all one hell of an unplanned training exercise.
McKenna: Hah. Yes! People are planning. Families, professionals, institutions. That’s good. That should always be happening. And we’ve seen a few small gaps already, mainly with some communications across many different health-care providers. So we can fix those and learn. Planning can’t be an event — it has to be a constant process. We’re doing our part.
This interview has been condensed and edited for length and clarity.