Case Study: A 67-year-old woman was admitted to the hospital on May 24, 2003. The patient's mother had recently been admitted to the same hospital and died from pneumonia. Progressive respiratory failure later developed in the patient, and, on May 28, 2003, she suffered respiratory arrest. Medical staff attempted cardiopulmonary resuscitation. Three Intensive Care Unit (ICU) nurses (referred to here as Nurses 1 to 3) participated in the resuscitation, along with other personnel. The nurses were wearing PPE, including two gowns, two sets of gloves, goggles, and a full-face shield (except Nurses 1 and 2), shoe covers, hair cover, and NIOSH-approved N95 disposable respirators that were not fit-tested. Later, Nurse 1 complained of headache and nausea, and Nurse 2 reported difficulty breathing. Of the three nurses, Nurse 2 met the World Health Organization criteria for probable SARS.
Key Takeaway: This case study describes the apparent transmission of SARS from a patient to healthcare workers during an attempted resuscitation. The nurses were wearing N95 disposable respirators that were designed to protect them against the airborne transmission of respiratory aerosols, including SARS. However, in this case, the N95 disposable respirators used by the nurses were not fit-tested to ensure an adequate seal. The situation may have been prevented had the nurses been wearing properly-fitted respirators. Additionally, a respirator with a more powerful air-purification system, including a disposable full hood with a face shield that covered the healthcare worker's upper body, could have provided a higher level of protection against airborne infections.
