SARS is greatest disaster threat at this moment’: Make changes now

New CDC guidelines give you updated strategies for the ED

Do you have an action plan for what to do when the next patient comes to your ED with respiratory symptoms consistent with severe acute respiratory syndrome (SARS)? ED nurses nationwide urgently are developing strategies to prepare for another outbreak.

"We recognize that SARS is our greatest disaster threat at this moment. Not only does it threaten our community, it threatens the infrastructure of our hospital," says Vicki Blucher, RN, BSN, clinical educator for the ED at St. Joseph Medical Center in Towson, MD. "The emergence of SARS has caused us to re-examine what we do in our everyday ED nursing practice. It has changed the way we interact with patients who walk into our ED."

The good news is that there are now clear guidelines to use in your clinical practice. The Atlanta-based Centers for Disease Control and Prevention (CDC) has just released a draft plan with strategies based on lessons learned from the 2003 global epidemic, which has sickened 8,098 and killed 774.

There is no indication that SARS has been eradicated, Julie Gerberding, director of the CDC, said at an Oct. 30 conference. "We never saw an infectious disease appear and disappear like that. We do need to be prepared."

At press time, there were no cases of SARS in the world, "but it is expected to make a return this year," says Rosemary Kucewitz, RN, BSN, ED director at Northwest Community Hospital in Arlington Heights, IL. "No one knows where it will turn up."

But even if SARS doesn’t re-emerge, CDC officials predict that your ED will be more crowded this winter, due to an influx of patients with flu symptoms worried about the possibility of SARS.

James Hughes, MD, director of the CDC’s National Center for Infectious Diseases, said, "Whether the virus comes back this winter or not, we will be dealing with SARS."

Officials worry that physicians with limited SARS experience could confuse early SARS symptoms with the flu, so the CDC plans to release a plan for physicians and hospitals to prevent outbreaks.

The fact that an eventual SARS diagnosis may not be made in the ED points to the need to stay vigilant to protect yourself and other patients, says Trudy Meehan, RN, CHE, former director of the ED at East Jefferson General Hospital in Metairie, LA, and principal of Gonzales, LA-based Meehan Consultants, a legal nurse consulting company. "As with many infectious diseases, by the time the final diagnosis is made or a trend determined, many infected patients will have received care in the ED," she adds.

Use these strategies, based on the CDC’s new recommendations:

• Revamp your ED’s policies for universal precautions.

"We realized we must change the way we look at universal precautions, which have been the norm in health care," says Blucher. "For this reason, our ED has developed what we call The New Normal.’ Here are the key changes that were made:

— Patients who are getting nebulizer treatments must do so in a closed room due to aerosolization of any germs.

Any patient undergoing respiratory procedures that include intubations, suctioning, and sputum induction, or noninvasive methods of ventilation such as continuous positive airway pressure (CPAP) and bidirectional positive airway pressure (biPAP) will have droplet precautions instituted, says Blucher.

Anyone who is in the room during the treatment must wear a mask, gown, gloves, and face shield, she explains. "We have also asked emergency medical services to stop nebulizer treatments prior to coming into the facility, and they have agreed to do so," she says.

— Anyone who presents to triage with a cough will be asked to wear a surgical mask. 

"This not only will help if SARS recurs, but also with the spread of influenza, colds, respiratory syncytial virus, and the like," says Blucher. "We also have an antibacterial hand sanitizer available in the waiting room with an informational display."

At Northwest Community Hospital, a large sign on an easel is posted by the ED entrance stating in English and Spanish, "If you have a cough and runny nose or a cough and fever, please take and put on a mask. (Alto! Para la seguridad de todos, Por favor pongase una mascara y use panuelos deschables si usted tiene: Tos, tos y fiebre, tos y catarro. Se agradece su cooperacion.)"

A box underneath the sign contains resealable plastic bags, each with a mask and a box of tissues. "These kits are able to be ordered from our storeroom, so they are easy to restock," says Kucewitz. "Triage nurses also have these supplies and would ask the patient to put on a mask if they have not already done so."

ED nurses need to "go back to the basics," with strict adherence to hand hygiene guidelines to decrease exposure by staff and patients, argues Meehan.

"Room cleanliness between patients becomes as important as direct patient care," she says, pointing to simple actions such as cleaning stretchers and countertops with disinfectant solutions between patients and emptying waste containers. "Of course, this diligence is also effective in diminishing the effects of our more familiar winter friends: influenza and the common cold," she says.

• Monitor ED staff with respiratory illness.

Staff who call in sick now are routinely asked if they have a respiratory illness, says Blucher. "If they say yes, then they will need to follow up with employee health so they can be monitored," for SARS, she adds.

• Create a web page to update ED nurses.

At Methodist Hospital in Indianapolis, ED staff created a web page to keep staff up to date on SARS exposure risks and geographical incidents, says Kathy Hendershot, RN, MSN, CS, director of clinical operations for the emergency medicine and trauma center. "This way, updated information is immediately available to every ED nurse," she adds.

Current information on geographical locations and airline terminals with suspected and confirmed SARS cases gives nurses accurate screening criteria directly from the CDC, Hendershot says. There also is a page listing day and evening contact telephone numbers in case staff members need to contact the laboratory, an infectious disease physician, or the local health department, says Hendershot.

In addition, a SARS resource binder is kept at the charge nurse’s desk for quick reference, says Hendershot. "It has the latest information as to suspected case presentations that we get from the CDC and state and local health departments, triage guidelines, isolation requirements, and all the telephone numbers that you would need," she says.

• Screen patients before they enter the main ED waiting room.

At Duke University Medical Center in Durham, NC, the triage liaison desk is the first station that patients come to as they enter the ED waiting room, says Theresa Cromling, RN, advanced clinical staff nurse in the ED.

The triage liaison, usually a nursing assistant, asks every patient to wash their hands with antiseptic hand foam before they go in to see the triage nurse. "Each patient is asked screening questions about fever, travel to high-risk areas, or close contact with any patient with SARS," says Cromling.

At triage, if the patients are suspected of having SARS, they are immediately given a mask and moved into a private room where a high-efficiency particulate air (HEPA) filter and an isolation cart containing personal protective equipment (PPE) is located, says Cromling. "Standing orders are started to include full respiratory isolation," she adds.

• Monitor patients diagnosed with pneumonia in your ED.

A screening tool was developed for admitted patients diagnosed with pneumonia by chest X-ray in the ED, says Blucher. The screening tool asks if the patient has traveled to certain areas within the last two weeks or has had contact with someone who has, if the patient is a health care worker, and if they have had contact with anyone diagnosed with pneumonia in the last two weeks.

"In addition, we are making certain we draw a complete blood count with differential on anyone who has pneumonia," she says. "Also, we are presently developing written discharge instructions for people with pneumonia informing them what to do if they get worse."

Sources and Resources

For more information on limiting exposure to SARS in the ED, contact:

  • Vicki Blucher, RN, BSN, Clinical Educator, Emergency Department, St. Joseph Medical Center, 7601 Osler Drive, Towson, MD 21204. Telephone: (410) 337-1524. Fax: (410) 337-1118. E-mail: vickiblucher@chi-east.org.
  • Theresa Cromling, RN, Advanced Clinical Staff Nurse, Emergency Department, Duke University Medical Center, Box 3869, Durham, NC 27705. Telephone: (919) 416-8202. Fax: (919) 286-9219. E-mail: croml001@mc.duke.edu.
  • Kathy Hendershot, RN, MSN, CS, Director of Clinical Operations, Emergency Medicine and Trauma Center, Methodist Hospital, I-65 at 21st Street, P.O. Box 1367, Indianapolis, IN 46206-1367. Telephone: (317) 962-8939. Fax: (317) 962-2306. E-mail: KHendershot@clarian.org.
  • Rosemary Kucewitz, RN, BSN, Director, Emergency Department, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-4010. Fax: (847) 618-4098. E-mail: RKucewicz@nch.org.
  • Trudy Meehan, RN, CHE, Principal, Meehan Consultants, Gonzales, LA. Telephone: (225) 622-5949. Fax: (866) 422-0262. E-mail: tmeehan@meehanconsultants.com.

The Centers for Disease Control and Prevention’s draft Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS), dated Oct. 21, 2003, can be downloaded at no charge at www.cdc.gov/ncidod/sars/sarsprepplan.htm. For recommendations specific to the ED, click on "Supplement C: Preparedness and Response In Healthcare Facilities" and scroll down to "Matrix 1: Recommendations for Inpatient Facilities and Emergency Departments."