Critical Care Plus: Special Report: Hospitals Nationwide Preparing for SARS

CDC and WHO Advisories Change Rapidly 

By Julie Crawshaw

More than 2000 cases of severe acute respiratory disease (SARS) with more than 70 deaths were reported to the World Health Organization (WHO) by April 2, 2003. Though cases have occurred in 18 countries in Asia, Europe, and North America, more than eighty-five percent have been in China and Hong Kong, Nonetheless, U.S. hospitals are preparing to handle more SARS cases here.

The WHO and the Centers for Disease Control (CDC) have both issued case definitions for SARS. WHO identifies suspected SARS cases as presenting after Feb.1, 2003 with a fever of 100.5ºF or more, cough, shortness of breath or difficulty breathing and close contact with someone already diagnosed with SARS and/or history of travel to places where SARS has been reported, both within 10 days of symptom onset.

WHO defines as probable cases those suspected cases with chest radiograph findings of pneumonia or acute respiratory distress syndrome (ARDS) or with an unexplained respiratory illness that ended in death and an autopsy that showed ARDS pathology but no identifiable cause.

The CDC defines only suspected cases and includes radiographic findings along with respiratory symptoms. Both organizations define close contact as having cared for, lived with, or had direct contact with mucus or other body fluids of a suspected case of SARS.

Proximity to Canada

Because of its proximity to Canada, where 58 SARS cases with six deaths have occurred, Carol Chenoweth, MD, medical director of infection control at the University of Michigan School of Public Health in Ann Arbor says her hospital is taking all possible readiness precautions and includes Toronto on the infectious travel list. "We’re not being overrun with cases as elsewhere, but we’ve had to come up with plans and recommendations for implementing the guidelines issued on an almost daily basis by the CDC," Chenoweth says.

Chenoweth’s department has written screening plans for managing the emergency room, a plan for an ambulatory care clinic, and an employee exposure plan. She and her colleagues are working with other hospitals and universities in the region to develop a coordination plan against increased SARS cases that includes considering a telephone triage system and possibly an evaluation site and designated ward as well.

Chenoweth’s emergency room uses a protocol in which the triage nurse queries every patient about recent travel destinations, and presence of a fever or cough. Patients who respond positively are immediately given a mask and put into an isolation room. From that point on every staff member who has contact wears an N95 mask, eye protection, gown and gloves.

"We’re trying to avoid the kinds of exposures other institutions have experienced," Chenoweth says, adding that all surfaces in the isolation room are thoroughly cleaned after each potential SARS patient presents. "We’re also asking area physicians not to refer every patient with any SARS symptoms to the ER because some patients may be able to be managed at home. If they’re very ill they’re instructed to put on a mask before coming to the hospital."

Chenoweth observes that, unfortunately, there are a number of things that still need to be sorted out with this disease. "The CDC and WHO have been working on the assumption that people aren’t very contagious before they experience fever themselves," Chenoweth says, "I’m not convinced that’s true, because some people may have sub-clinical infections. But if we’re screening for the highest risk people then we should at least be able to isolate them."

10-Day Incubation Period Recommended

Though current data indicate that the usual incubation period for SARS is two to seven days before onset of first symptoms, a 10-day incubation-monitoring period is recommended because several reports have indicated a longer time before symptoms occur, says Robert L. Beaton, MD. Beaton is medical director for the department of emergency medicine at Moses Cone Health System, a 1,400-bed health system located in Greensboro, N.C. His facility is located near North Carolina’s Furniture Market, which puts on major tradeshows for the furniture industry that attract many business people from Asia.

Though the market was running its spring show when the SARS crisis began, as of mid-April Beaton’s hospital has seen several suspected but no confirmed SARS cases. The show featured numerous factory tours attended by many visitors from Southeast Asia.

"One factory worker had been exposed to travelers from Southeast Asia," Beaton says. "We called the CDC and decided that unless he had had direct contact with someone who was ill they wouldn’t classify that as a SARS case."

Beaton noted that SARS is currently believed to be a mutated form of coronavirus, which can last two or three hours on surfaces before it degrades. Though some SARS cases may have occurred because the patient touched something previously touched by a SARS infected person, Beaton observes that the virus had to be transmitted to respiratory system. "Casual transmission is a frightening thought," Beaton says. "If the war weren’t going on, I think SARS would have been the lead news story 24/7."

Beaton says there’s no doubt that SARS has the potential to become a pandemic. But thus far the mortality rate is running somewhere 3-5% and most patients who have died had co-morbid problems. "If you infected 100 people with SARS, nine out of every 10 would just get body aches, cough, shortness of breath and a fever, then recover," Beaton says. "Most people with SARS aren’t going to die from it, but it’s very scary to think you could catch a cold and die."

Despite the low death rate, Beaton finds the possibility of having to add 5% more patients to already over-crowded intensive care facilities even scarier. "SRS has got my attention," Beaton says. "It’s changed the way I practice-now when I pick up the chart for a patient with a fever and cough, I put on a gown and gloves immediately."

Hand Washing Still Best Preventive

Jerry McDermott, president of Technical Concepts in Northbrook, IL, the largest manufacturer of touch-free bathroom products, says his office has experienced a dramatic increase in requests for product information. The company manufactures hands-free soap dispensers, water faucets, and toilets. The CDC, McDermott notes, has reaffirmed that the best way to stop the spread is to wash your hands. Automatic soap and faucet systems encourage people to wash their hands and recent studies have shown that only 62% of people wash their hands after using the rest room.

Both the WHO and the CDC say that the most important element of infection control in the community is frequent and thorough hand washing. Other household members should use gloves if they have contact with a SARS patient’s bodily fluids. Either the patient or those with whom he or she is in contact should also wear a mask. Family members and others in contact with SARS patients may leave their home as long as they themselves are asymptomatic.

Quick Staff Updates are Critical

Marie Kassai, RN, MPH, CIC is manager of infection control at the General Hospital Center at Passaic, NJ, and sits on a statewide infection control task force that now conducts weekly conference calls with the state’s department of health. She says that biggest management issue with SARS is seeing that all staff members receive prompt updates for the frequently changing guidelines and recommendations from the WHO and CDC.

"The most critical piece of handling SARS is getting and keeping the current information to every staff member," Kassai says. "We’ve begun by with the most comprehensive infection control guidelines. As we learn more about the disease, some of these may not be necessary."

Kassai says she has had no problems with staff resistance to treating SARS patients thus far. She emphasizes that healthcare workers should be excluded from work if they develop fever and/or respiratory symptoms within 10 days of exposure to a patient with SARS. They should remain out of work for a full 10 days after fever and respiratory symptoms have resolved.

General Hospital currently uses both contact and airborne isolation. The facility does not alert ER patients that they may be exposed to SARS but has posted signs to inform visitors that they are not to visit the patients and should notify hospital personnel right away if they have been in contact with anyone who has a respiratory illness.

Leave the Liability to the Agencies, Attorney Advises

Edward Kornreich, an attorney with the Proskauer & Rose firm in New York, encourages hospitals to stay in close touch with their local health departments and have their own legal counsel involved. "Health departments should be responsible for managing control procedures-they should be the ones restricting patients’ civil liberties," Kornreich says. "You don’t want the liability for that. Hospitals should be active in protecting public health but should make sure the actual limitations on freedom come from the public health authority."

Generally speaking, Kornreich says that state public health authorities and the CDC have very broad authority to quarantine or isolate people who have or are suspected of having contagious diseases. The CDC’s power requires a presidential proclamation that a disease is believed to be contagious and dangerous, which was issued for SARS in early April.

State law is generally at the discretion of the authorities. Even so, Kornreich says legal challenges may arise from people exposed to SARS who have no symptoms themselves and are non-compliant to isolation.

The mechanism for detaining people varies from state to state, Kornreich says, but in the face of a perceived emergency all state public health authorities have the power to take action without going to court. "Right now in virtually every state there is a statute that empowers health authorities," he says. "The concern is that many of these are antiquated, dating from the late nineteenth and early twentieth centuries."

Kornreich adds that during the 1960s and early 70s our understanding of personal liberty and individual rights vis a vis the government changed pretty dramatically, but most existing statutes do not provide for due process. Health authorities can still put a person in the hospital without a court order but proposed model legislation provides for confinement but mandates obtaining a court order within five days.

Kornreich says that if the number of SARS cases greatly increases, a legal question of whether or not hospitals can turn prospective SARS patients away may arise. "Under federal law it would be very difficult to turn away anyone eligible for Medicare," Kornreich says. "It may be that as counties react they develop central facilities that are better able to provide isolation services to these patients."

One fact Kornreich sees as critical is that SARS spread rapidly among healthcare workers in Asia. He adds that the possibility of staff resistance to caring for SARS patients is a concern because hospitals have a legal obligation to provide a safe work environment for staff.

Kornreich also says that handling SARS patients in ICUs could prove legally challenging because OSHA requirements mandate handling patients in a safe environment. If SARS patients in the ICU are not isolated then non-SARS ICU patients could be endangered, he says.

(For more information contact Carol Chenoweth at (734) 764-0000, Robert L. Beaton, MD at (336) 339-4290, Jerry McDermott at (847) 837-4100 ext. 154, Marie Kassai at (973) 365-4597, and Edward Kornreich at (212) 969-3395.)