treated initially in the ICU and 8 were treated in isolation rooms on other units. (The number of patients is greater than 19, because of patient transfers between units.) The hospital’s response The timeline of the responsive measures instituted by Mount Sinai Hospital is outlined in and the screening questions asked of staff at the hospital entrance are listed in Appendix 1. Maunder et al 1246 JAMC • 13 MAI 2003; 168 (10) Fig. 1: Dates of admission of 19 patients with suspected or probable severe acute respiratory syndrome at Mount Sinai Hospital, Toronto. 0 1 2 3 4 March 13 March 15 March 17 March 19 March 21 March 23 March 25 March 27 March 29 March 31 April 2 April 4 April 6 April 8 April 10 2003 No. of cases Health care workers Others The hospital established a command centre, headed by the Vice-President of Nursing and the Chief Information Officer, who led a team composed of key senior administrators and the Chair of the Medical Advisory Committee. The composition of the team was fluid as experts and department heads (e.g., microbiologists, Chief of Medicine, human resources and occupational health personnel) were included as required for a changing list of operational tasks. Administrators received frequent public health directives from the Ontario Ministry of Health and Long-Term Care and participated in daily conference calls with other hospitals in the same network to discuss implementation of the directives, which were increasingly inflexible (e.g., no transfers of critically ill patients between hospitals without prior approval from the province). The hospital’s CEO, the Vice-President of Nursing and the Chief Information Officer sent a daily joint email message to all staff updating SARS information, outlining procedural changes, and providing information about the numbers of patients with SARS, the number of staff in quarantine and the number of staff admitted to hospital for treatment. The email message was used to express praise and gratitude to all staff for their contributions. The hospital’s Intranet was also used extensively, for example, to provide instructions on the proper use of face masks. Administrators faced the emotional challenge of balancing their responsibilities to ensure optimal care for patients with SARS while ensuring the safety and well-being of health care workers. These efforts were complicated by incomplete knowledge about the actual risks, especially about modes of transmission of the infectious agent(s). On occasion, staff were observed to be not fully complying with infection control procedures. Under the circumstances it could not be determined whether this was due to inadequate communication (especially because of frequently changing guidelines), technical difficulty, or because of psychological responses such as denying risk or simple rebelliousness. Leaders responded with clear, authoritative instructions to inform staff of new directives and maximize compliance. There was minimal resistance to this approach. Substantial logistical problems were posed by, for example, the need to screen over 1800 people entering the building daily, or to procure the daily allotment of 5000 masks and 3000–4000 gowns. Staff were redeployed to overtaxed areas to meet these needs. Management staff volunteered to coordinate and supervise screening functions without direct instruction from the command team. Psychological effects of the SARS outbreak Patients with SARS Hospital inpatients with suspected and probable SARS presented a range of symptom severity from acute respiratory distress syndrome to relatively mild symptoms such as fever, headache and myalgia. Generally, more psychosocial support was required by patients with mild-to-moderate symptoms, and these patients were in the majority. Shortly after admission, recent contacts who would require quarantine were identified, resulting in feelings of guilt, anger and fear for the welfare of friends and family. Identifying contacts also raised fear that the patient would be resented. Patients worried that their contacts would be stigmatized and would lose income due to quarantine. Patients with SARS often had to spend several hours alone between brief contacts