Factors associated with critical-care healthcare workers' adherence to recommended barrier precautions during the Toronto severe acute respiratory syndrome outbreak

OBJECTIVE. 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). SETTING. Fifteen acute care hospitals in Ontario, Canada DESIGN. Retrospective cohort study. PATIENTS. All patients with SARS who required intubation during the Toronto SARS outbreak in 2003. PARTICIPANTS. 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. METHODS. 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. RESULTS. 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]). CONCLUSIONS. 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.