Are you ready for the return of SARS?
Plan for PPE, screening, resources
If severe acute respiratory syndrome (SARS) returns this fall, is your hospital prepared? A lull in SARS activity is giving hospitals vital time to plan for a possible reemergence of the disease, which public health authorities say could occur this fall or winter. "Even if there’s no detected SARS in the community, the country, or the region — at the national level, we have to have systems in place to be monitoring for its [occurrence]," says Linda Chiarello, RN, MS, epidemiologist with the Division of Healthcare Quality and Promotion at the Centers for Disease Control and Prevention (CDC).
"Once it begins to appear in the United States, facilities need to be at a point where they’re implementing a SARS prevention plan. The time for planning is now," she adds.
U.S. hospitals avoided outbreaks, and it now seems that the total number of SARS cases was significantly lower than previously estimated. Only eight SARS cases have been confirmed by serologic testing; serum specimens are not available for another 28 probable and 175 suspected cases of SARS. CDC has ruled out 169 suspected and 38 probable cases that had negative antibody tests.1
That positive news was tempered by an awareness of what could have been and what could happen in the future.
"Hopefully, SARS will not be an annual disease we see similar to influenza, but I think we all need to be prepared for that," says Cindy Fine, RN, MSN, CIC, director of infection control and employee health at San Ramon (CA) Regional Medical Center, which treated several suspected SARS cases that were ruled out later. Fine also volunteered to go to Canada to help with infection control at Scarborough (Ontario) Grace General Hospital this summer, as the hospital struggled to recover from the outbreak.
"We had an early warning [from Asia and Canada]. In the United States, we were very lucky not to be affected the way other countries were," she says. "That’s all it was — luck. All we needed was one superspreader to be admitted to one of our hospitals, and we would have had the same situation Canada had."
According to public health and employee health experts, here are some areas that hospitals should address as they prepare for the possibility of a new SARS outbreak:
• Distinguishing SARS from other respiratory illness.
Fine has requested rapid influenza tests as a diagnostic tool. She also will make a strong push for influenza vaccination of health care workers.
"I can see with the flu season emerging, everyone who walks in with symptoms is going to be suspected of having SARS. We want to be able to distinguish SARS from influenza as rapidly as we can," she says.
It would be unnecessary and overwhelming to treat every patient with respiratory symptoms as if he or she has SARS, Fine explains.
However, some basic precautions can be put in place, says Chiarello. For example, patients with respiratory symptoms can be segregated from other patients to prevent transmission, she says.
• Maintaining adequate personal protective equipment (PPE).
Fine and others are stocking their shelves with gowns, masks, and goggles. But if a SARS outbreak occurred, the demand for PPE would quickly overwhelm supplies. How would you get more if you needed them? Would other area hospitals work with you to share resources? You may want to fit test employees with multiple brands of N95 respirators in case the brands you normally provide are not available, notes Chiarello.
"This is something that needs to be carefully considered in planning activities," she says.
Hospitals are fit testing additional staff and considering policies on annual fit testing.
"When the SARS scare first started, we realized that the department managers did not have lists of who in their department was fit tested and who wasn’t," says Fine. "That was something we supplied to our departments. We had to ensure that we had on all shifts an individual who was fit tested."
Proper training is essential
In addition to fit testing, employees need to be trained in how to use PPE and how to properly remove the equipment without inadvertently causing contamination.
Employees also need to understand the proper use of PPE, so the limited resources are not wasted, Chiarello notes. For example, employees who have no patient contact do not need to wear masks. Routine double-gloving is not necessary, she says. The CDC is continuing to study the transmission of SARS and the effectiveness of PPE and will make recommendations related to its appropriate use.
"Double gowns are not needed, double masks and double gloves are not needed to protect against SARS," says Chiarello, who traveled to Vietnam as part of the CDC’s SARS investigative team. "Fear drives a lot of PPE."
Medical clearance and policies on the duration of wearing PPE also would become important in an outbreak. Some Toronto health care workers had difficulty with the masks because they were wearing them for 12-hour shifts — much longer than the episodic use associated with caring for tuberculosis patients, notes Gabor Lantos, MD, PEng, MBA, president of Occupational Health Management Services in Toronto.
"Anybody who is properly garbed for this cannot work a 12-hour shift and maintain respiratory protection and containment," he says. "You’ve got to go to washrooms. You’ve got to eat; you’ve got to talk. That hard core group of people who are literally on the front line may have to rotate in on a four-hour basis."
• Verifying isolation capacity.
Are your negative-pressure rooms really under negative pressure? You need to test the rooms and evaluate your ventilation system before SARS reemerges, says Lantos.
Everything is not always as it seems. For example, one hospital in Toronto discovered that air from the emergency department was venting into an operating room, he says. "You need proper isolation. Just because somebody calls something isolation doesn’t mean it’s isolation."
What is your actual capacity for isolating patients? What would you do if your needs exceeded that capacity? Would another area hospital take some of your SARS or other patients? "Human, consumable and durable resources will be important components of that planning process," says Chiarello.
• Establishing policies on screening or restricting visitors or employees.
During the last SARS outbreak, CDC advised health care workers with unprotected high-risk exposures, such as during an intubation, to go on furlough for 10 days to make sure no symptoms developed. Employees with exposures that were not high risk were advised to monitor their temperature and be alert for symptoms.
If a SARS outbreak occurred in a U.S. hospital, health care workers might face some of the efforts implemented in Toronto. At some Toronto hospitals, employees answered a questionnaire and had their temperatures taken before every shift. Every visitor to the hospitals also had to be screened.
Fine says she will think through the policies that would be implemented if a SARS outbreak occurred. How would the screening take place? Who would conduct it? Who would be screened?
Another policy question to consider: What if a health care worker works at another facility with a SARS outbreak and also works at your hospital?
"Unless we were under emergency restrictions that were put in by public health, we would not limit physicians from working at another hospital," Fine says. "But we would check them just as we would check our staff."
• Reviewing environmental cleaning.
The quality of your environmental cleaning may be critical to preventing the spread of SARS. "I had a very strong sense, based on observation, that there was a very important environmental component to this disease," says Chiarello.
"There was a lot of opportunity for environmental contamination. In our recommendations, there’s a very strong emphasis on environmental cleaning," she adds.
You may want to have designated personnel clean the rooms of SARS patients — employees who are thorough and have been trained in how to properly clean surfaces. Those employees may need a financial incentive to work in the higher-risk environment.
"You don’t want people who are just going to run in and run out and be afraid to clean in those rooms," Chiarello says. "You want people who will go in and thoroughly clean frequently touched surfaces. Look at environmental services in general and assess the quality of those services. I look at SARS as an opportunity to improve the basic infrastructure and quality of infection control in our health care system."
• Focusing on early detection and good communication.
Bioterrorism provided a framework for communication with local and state health departments and with colleagues at other hospitals. Use that planning infrastructure to prepare for SARS, Chiarello advises.
The preparation for SARS also mirrors the steps needed to respond to another threat: pandemic influenza. "Some of the more aggressive control measures that are [implemented] for SARS may be similar to those for controlling the entry of [pandemic] influenza," she says. "You develop an infrastructure of containment that I don’t think people have given a lot of thought to in recent years."
A multidisciplinary "hazmat" or emergency response team can address some of the questions that arise in SARS preparedness, Lantos says. For example, the team could determine priorities for PPE use and methods of screening for symptoms. The team could evaluate the respiratory protection program and availability of resources. The policies can apply for other biologic hazards, Lantos notes.
"I think it’s necessary to go beyond SARS so people don’t think it’s some unique entity," he points out.
1. Centers for Disease Control and Prevention. Update: Severe acute respiratory syndrome —- worldwide and United States, 2003. MMWR 2003; 52:664-665.