A recent bulletin from the Ontario Hospital Association (OHA) to hospital chairs and chief executive officers criticizes the Pan-Canadian Public Health Network’s Task Group’s (TGAP) conclusion that the widespread use of antiviral medications for staff prophylaxis during an influenza pandemic outbreak is not justifiable. In particular, OHA expressed concerns that the TGAP’s recommendations:

“1. Do not support the provision of antivirals to hospital staff for prophylaxis during an outbreak of pandemic influenza, resulting in a lower standard of practice than is currently provided during outbreaks.

2. Proposed outbreak control measures during the pandemic will result in patients and health care workers in “closed” facilities being treated differently than those in acute care hospitals, even though the risk may be the same.

3. Do not reflect the realities of the health system where in the absence of clear MOHLTC direction regarding the use of antiviral prophylaxis, most Ontario hospitals developed and implemented their own policies, with many supporting the use of antivirals for prophylaxis and having stockpiles in place.”

The OHA understands that the Government of Ontario will use the national TGAP policy recommendations as a guide for pandemic preparedness and response in Ontario.

The OHA’s views are consistent with the Pandemic Influenza Planning Guidelines (v.1, May 19, 2006) of the Toronto Academic Health Sciences Network (TAHSN), which recommend stockpiling antivirals for both prevention and treatment of staff.

With two clearly conflicting recommendations on the table, many hospitals are understandably confused about the appropriateness of a hospital stockpiling antivirals for prophylaxis and treatment of staff.

The decision is an extremely complex one and must consider the hospital board’s statutory and regulatory obligations (under both the Occupational Health and Safety Act and the Public Hospitals Act) to protect its staff and to ensure that the hospital has plans in place to deal with:

“(i) emergency situations that could place a greater than normal demand on the services provided by the hospital or disrupt the normal hospital routine, and

(ii) the failure to provide services by persons who ordinarily provide services in the hospital.” (Section 2(3)(e), Regulation 965, Public Hospitals Act.)

It is clear from the legislation and regulations that the decision to stockpile antivirals for staff protection is a board decision.

Given the significant risks associated with the decision, we believe that it is extremely important that the board exercise and be able to demonstrate that it has exercised appropriate business judgment in making its decision. In reaching its decision, the board should fully consider the alternatives and the following important factors:

1. The standard of care the board should exercise is a standard modified by Mr. Justice Archie Campbell’s precautionary principles, which are outlined in his SARS Commission report (December 2006) entitled “Spring of Fear”:

“The Commission therefore recommends:

  • That the precautionary principle, which states that action to reduce risk need not await scientific certainty, be expressly adopted as a guiding principle throughout Ontario’s health, public health and worker safety systems.
  • That the health concerns of health workers be taken seriously, and that in the spirit of the precautionary principle, health workers be made to feel safe, even if this means continuing with levels of heightened precautions that experts believe are no longer necessary.”

2. SARS-related litigation has clearly identified that the federal, provincial and municipal governments do not, in the ordinary course, owe a duty to the hospital’s staff and patients. The hospital’s board clearly does.

3. In light of TAHSN’s decision to stockpile for staff prevention and treatment, how will your hospital’s business continuity plans be impacted if the board chooses not to stockpile.