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Take-home points: Dealing with SARS in a hospital

Tips and strategies to deal with suspect cases

Infection control professionals trying to hone their approach to severe acute respiratory syndrome (SARS) in the hospital may wish to review the following "take-home" points by Patti Grant, RN, BSN, MS, CIC, director of infection control for RHD & Trinity Medical Centers in Dallas. An editorial board member of Hospital Infection Control, Grant reviewed Centers for Disease Control and Prevention (CDC) guidelines at a recent audio conference on SARS.

The conference was sponsored by Thomson American Health Consultants, the Atlanta-based publisher of HIC. (To order a CD of the May 6, 2003, audioconference, see note at the end of this article.)

SARS case definition

Check the CDC web site daily (www.cdc.gov/ncidod/sars/casedefinition.htm).

"The definition has changed at least three times based on evolving epidemiological investigation findings," Grant said. "The U.S. case definition for SARS has been grouped into suspect and probable [cases]. The case definitions are building blocks of discovery, all grounded in international travel history and/or association with [SARS cases]."

Isolation vs. quarantine

Include all education levels.

"This is very important. One of the first things that happened when we started getting rule-out SARS cases was the rumor was flying around the hospital that they were going to lockdown the hospital and quarantine everybody and not let them go home. So it is very important that you get the information out. Share that isolation is generally for sick people and that restricts their movement and separates them from other people with communicable disease. Quarantine on the other hand is for well people who are believed to have been exposed to a communicable disease and requested to restrict their interactions with others during the incubation period."

Triage: Entry into your health care facility

Current SARS case definition based on travel and close contact history is key.
Triage before routine check-in procedures.

"It is helpful to have signs posted in your emergency department asking people to report to the desk if they have fever, cough, or shortness of breath and if they have traveled or been in close contact with people in travel alert areas."

Place surgical mask on all suspected SARS patients.
Place them under negative air pressure or HEPA-filtration with contact precautions quickly after entry.

"If an airborne isolation room with negative pressure is not available, a portable HEPA filter is the next best [option]. If that is not available, you are relegated to a private room as the next best defense."

Specifics of SARS isolation for health care facilities

Hand hygiene, as always, is paramount.
Follow 1994 CDC TB guidelines for aerosol-generating procedures.
Use airborne and contact isolation with an N-95 respirator.
Unlike TB, N-95 must be discarded after each use.

"All health care workers entering the room must wear a new N-95 particulate respirator. Unlike TB, SARS is believed to have a very strong contact component with contamination of the environment with large droplet nuclei when the patient sneezes or coughs.

If you must reuse respirators because of supply difficulties

Wear loose-fitting surgical face mask or shield over the N-95.
When done, remove/discard outside N-95 barrier.
Perform hand hygiene.
When reapplying the used N-95, wear gloves then remove gloves once N-95 is properly fitted.
Perform hand hygiene before engaging in patient care with a new pair of disposable gloves.

Contact isolation and SARS visitor management

Contact isolation includes gloves and eye protection/gown use for all patient/environment contact.

"[This] is even if obvious contamination and/or splashing with blood or body fluids is not anticipated."

Visitors (family and co-workers) may be incubating SARS. Implement a screening process so they do not enter the health care facility if they become suspect SARS patients themselves.
Educate visitors about importance of not coming to the hospital or other public places if they have fever or respiratory illness.

[Ask] them to call the hospital so you can get their history and demographic information, and you can call the local health department for them and give them the phone number. This was extremely important in our SARS rule-out cases. A lot of time was spent with the visitors of close contacts of the patients so they knew what to look for and who to contact if they became ill."

Management of unprotected health care worker exposure to SARS

Actively monitor for signs and symptoms of SARS for 10 days post-exposure event.
Report any suspect SARS cases.
Do not exclude from work if workers are without signs and symptoms of SARS.

"Currently, there is no recommendation to automatically furlough an employee for the 10-day incubation period, if they had unprotected exposure to a SARS patient, as long as the employee is without signs and symptoms of SARS. Each employee involved must report to employee health or infection control each day of the 10-day quarantine for a temperature check and to answers questions about SARS signs and symptoms. This can be done over the phone if the employees have the day off, as long as they have a thermometer to take and report their temperature."

If an employee develops fever or respiratory symptoms, exclude from work and also limit interactions outside of home (no public areas or transportation).
Review routine infection control precautions to use while on medical furlough (cover cough, hand hygiene, mask if must be around others, no public areas).
If signs and symptoms do not progress in 72 hours, workers may return to work.

"If they originally develop a fever or they have signs of SARS, but they don’t get any worse, they may report back to work, but only after they have consulted with employee health or infection control."

If workers progress to suspected SARS, they cannot return for 10 days after afebrile and must be asymptomatic and cleared by infection control/employee health.

[Editor’s note: To order a copy of the audioconference, SARS: What U.S. Hospitals Must Learn from the Canadian Outbreak, contact customer service at (800) 688-2421.]