CDC: Use surgical masks around respiratory patients

Precautions, planning will prevent SARS spread

Severe acute respiratory syndrome (SARS) forever may alter the way hospitals handle patients with respiratory illnesses. Patients with fever and cough should be segregated in waiting areas and asked to use "respiratory etiquette," and health care workers should wear surgical masks as an infection control precaution, the Centers for Disease Control and Prevention (CDC) has recommended in draft SARS preparedness guidance.

"We think it’s important not only for SARS preparedness, but also [to prevent] transmission of other viral respiratory illnesses," says John Jernigan, MD, MPH, chief of the intervention and evaluation section in CDC’s division of healthcare quality promotion.

For example, the droplet precautions would help stem the spread of pandemic influenza, which public health experts cite as a looming threat. The last influenza pandemic occurred in 1968.

Patients with respiratory illness also may be asked to wear surgical masks, or at least cough into a tissue and use hand hygiene. 

During the cold and flu season, the use of surgical masks could become commonplace in hospitals. Some hospitals may view the surgical masks as an awkward barrier between the patient and provider. But Jernigan notes that the precautions are used routinely for some other conditions. "I’ve cared for lots of patients in droplet precautions. I think it’s a workable solution," he says.

The CDC is recommending the use of surgical masks, as a part of droplet precautions, if no known cases of SARS have been identified. Respirators such as N95s still are recommended when caring for SARS patients or in an outbreak situation. Although SARS is transmitted primarily through close contact, CDC has not ruled out airborne spread of the disease.

The plan uses a tiered approach, offering different recommendations based on the presence or absence of SARS worldwide, in the community or in the facility. For example, if nosocomial cases of SARS occur in the hospital, the hospital would need a method to monitor health care workers daily for symptoms.

Planning for SARS can be incorporated into other preparedness plans for handling infectious diseases, including bioterrorism. But in its document, Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS), CDC urges hospitals to take steps now that would allow them to act swiftly if SARS re-emerges.

"SARS-CoV transmission in a health care setting presents occupational and psychological challenges that, in the 2003 outbreaks, required heroic efforts to overcome," according to the report. "Experience also indicates, however, that early detection and isolation of cases, strict adherence to infection control precautions, and aggressive contact tracing and monitoring can minimize the impact of a SARS outbreak."

Planning should occur across the country, and all hospitals should consider themselves at risk for encountering SARS, Jernigan adds. "We can’t predict who with SARS is going to walk into which facility. Every facility needs to be able to recognize a case of SARS and be able to manage a case of SARS."

The first step is to create a multidisciplinary planning team with a designated SARS coordinator. This team would be linked into communitywide planning with public health agencies, health care facilities, law enforcement agencies, and other organizations.

Employee health would be a part of the planning team along with other related areas, including infection control, environmental services, respiratory therapy, and the hospital disaster/emergency coordinator.

Here are some key areas covered by the guidance document:

1. Strengthen infection control training.

The SARS outbreak eventually was controlled by relying on basic infection control precautions. Yet in the absence of a crisis situation, studies have shown that adherence to basic practices, such as hand hygiene, is poor.

"I’m not sure we’ve successfully communicated the importance of infection control to health care workers," Jernigan says. "Something like SARS underscores the education. Perhaps education pointing to SARS as an example is something that might actually motivate change."

Hospitals should reinforce their ongoing infection control training with an emphasis on how the precautions can prevent transmission of SARS, pandemic influenza, and other illnesses.

The plan also recommends conducting a readiness drill, which would include a method for monitoring compliance with infection control practices and other preparedness issues.

2. Review the provisions of personal protective equipment (PPE).

Make sure that your staff are fit-tested for N95 respirators and have received adequate instruction on their use, the CDC says. Hospitals should review their available supplies of PPE and determine how they could get additional items in an emergency situation. For example, hospitals might want to conduct fit-testing using more than one brand of respirator, which would allow for flexibility if supplies were limited during an outbreak.

The CDC is planning to issue additional guidance on the use of PPE.

3. Create SARS response teams.

"Ideally, you want to have everybody prepared." But a focused team would be familiar with the hospital’s contingency plans for setting up a SARS unit and would be a resource to other employees, Jernigan adds.

Response teams could include medical, nursing, housekeeping, and ancillary staff who would provide initial care for suspected SARS patients. Hospitals might develop an emergency response team to provide resuscitation, intubation, and emergency care. Similarly, a respiratory procedures team would be trained to use the highest levels of PPE with highest levels of protection in the high-risk procedures.

In the past SARS outbreak, health care workers became more comfortable with the SARS-specific practices over time. Response teams would leverage experience and training. "It might be potentially advantageous to have a team who knows it might be called upon to deal with this if an outbreak occurs," Jernigan explains.

4. Consider special staffing needs.

A SARS outbreak could require hospitals to furlough health care workers who have had high-risk exposures. Some employees might be asked to be on work-home quarantine, in which they travel only between their home and work during a designated period. Employees using PPE will need "PPE breaks," when they are able to remove the equipment.

All of those scenarios would put a strain on staffing and could create staffing shortages.

The CDC is asking hospitals to consider the staffing issues as a part of their planning, including determining the minimum number of staff needed to care for a patient or group of patients on a given day. Hospitals might want to use nonhealth care workers or retired health care workers to help out with supplementary duties.

"It might require some level of community coordination," says Jernigan. "The most important thing we’re trying to say is anticipate that contingency now."

And while you’re considering the needs of patients and the hospital, keep in mind the potential needs of your employees. If they are on work-home restrictions, they may need support with basic issues such as child care and buying groceries. "Health care workers should have access to mental health professionals to help them cope with the emotional strain of managing a SARS outbreak," the CDC advises.

[Editor’s note: For a copy of Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS), go to:]

CDC: Six key elements of SARS preparedness

According to the Centers for Disease Control and Prevention, hospitals should take these steps to prepare for severe acute respiratory syndrome (SARS):

  1. Organize a planning committee to develop an institutional preparedness and response plan.
  2. Develop surveillance, screening, and evaluation strategies for various levels of SARS activity.
  3. Develop plans to implement effective infection control measures.
  4. Determine the current availability of infrastructure and resources to care for SARS patients and strategies for meeting increasing demands.
  5. Determine how the staffing needs for the care of SARS patients will be met.
  6. Determine strategies to communicate with staff, patients, and the health department and to educate staff and patients.

Could it be SARS? Check for these clinical clues

Severe acute respiratory syndrome (SARS) isn’t distinctive enough to diagnose only from clinical symptoms, according to the Centers for Disease Control and Prevention.

But there are features that are common to SARS cases:

  • Symptoms emerge within two to 10 days of exposure, with a median incubation of four to six days.
  • Fever, headache, and myalgia will often develop first, with respiratory symptoms coming two to seven days later.
  • Patients may have a nonproductive cough or shortness of breath but usually do not have a sore throat, runny nose, or other upper respiratory symptoms.
  • All laboratory-confirmed SARS patients had radiographic evidence of pneumonia. Most (70% to 90%) had lymphopenia.
  • The overall fatality rate was 10%, but could be more than 50% in people older than 60.
  • Spread of the virus does not seem to occur before symptoms emerge. Most transmission occurs late in the illness when patients are likely to be hospitalized. 

Universal Respiratory Etiquette Strategy

  • Provide surgical masks to all patients with symptoms of a respiratory illness. Provide instructions on the proper use and disposal of masks.
  • For patients who cannot wear a surgical mask, provide tissues and instructions on when to use them (i.e., when coughing, sneezing, or controlling nasal secretions), how and where to dispose of them, and the importance of hand hygiene after handling this material.
  • Provide hand hygiene materials in waiting room areas, and encourage patients with respiratory symptoms to perform hand hygiene.
  • Designate an area in waiting rooms where patients with respiratory symptoms can be segregated (ideally by at least 3 feet) from other patients who do not have respiratory symptoms.
  • Place patients with respiratory symptoms in a private room or cubicle as soon as possible for further evaluation.
  • Implement use of surgical or procedure masks by health care personnel during the evaluation of patients with respiratory symptoms.
  • Consider the installation of plexiglass barriers at the point of triage or registration to protect health care personnel from contact with respiratory droplets.
  • If no barriers are present, instruct registration and triage staff to remain at least 3 feet from unmasked patients and to consider wearing surgical masks during respiratory infection season.
  • Continue to use droplet precautions to manage patients with respiratory symptoms until it is determined that the cause of symptoms is not an infectious agent that requires precautions beyond standard precautions.

Source: Centers for Disease Control and Prevention, Atlanta.