Triage, waiting rooms, and respiratory etiquette

Initial examination could lead to exposure

The Centers for Disease Control and Prevention (CDC) is emphasizing that prevention must begin at the first point at which a person with suspect or probable severe acute respiratory syndrome (SARS) encounters the health care system. Key points from a recent CDC health care training broadcast include:

1. Examine triage, reception, and appointment procedures:

Train personnel to query patients about respiratory symptoms and to observe for such symptoms in patients and visitors. Instruct personnel in procedures to follow with patients who are symptomatic.

2. Waiting rooms:

As the infected patient (or an infected person accompanying the patient) waits for care, other people in the waiting area could be exposed. Steps for preventing exposures could include:

  • posting visual alerts instructing patients to immediately report symptoms of a respiratory infection and to use "respiratory etiquette"
  • providing separate sick and well patient waiting areas;
  • creating physical barriers between patients and triage/reception personnel to further reduce the risk of exposure.

3. Respiratory etiquette:

Because SARS primarily spreads via respiratory droplets, practicing respiratory etiquette is a simple intervention that confines infectious material at its source. To facilitate respiratory etiquette, outpatient facilities should consider:

  • instructing people with symptoms of a respiratory infection to cover their nose and mouth with a tissue when coughing or sneezing;
  • making hand hygiene products and tissues available in waiting areas;
  • providing designated containers for disposal of used tissues;
  • offering masks to symptomatic patients.

4. Protecting the health care worker:

When a patient with respiratory symptoms presents to an emergency department (ED) or outpatient office, there are numerous contact points at which opportunities arise for transmission, including triage and reception, waiting rooms, and examination by the health care provider

Examining a patient presents an opportunity for SARS transmission to health care personnel. In preparing for the possibility that a patient may be a suspect or probable case of SARS, it is important to plan in advance where the examination will be conducted and what personal protective equipment (PPE) the provider will wear.

Health care providers should wear a gown, gloves, respirator (or surgical mask if a respirator is not available), and if the patient is coughing, a face shield or goggles. Assess for the availability of this equipment in the work setting. An N95 or higher respirator that has been fit-tested to the health care worker is the preferred respiratory protection for SARS. If respirators are not available, a surgical mask should be worn. Establish a protocol and provide training on the use of PPE.

Identify an area that will be used for the initial examination of suspect or probable SARS patients. An airborne isolation room is ideal. If none is available, identify an appropriate room for this purpose, preferably one that is farthest from other patient examination areas and has the ability to have the room air directed away from the surrounding area.

5. Transport of patient:

Preventing SARS transmission in an ED or outpatient facility requires consideration of such routine procedures as patient transport and movement in the office or ED setting, including patient transport:

  • Determine how and by whom the patient will be transported for diagnostic procedures (e.g., chest X-ray, collection of laboratory specimens) or for hospital admission.
  • Create a communication plan for notifying areas that may receive the patient (e.g., admissions office, radiology, inpatient unit) and authorities that need to know about the possible SARS case (e.g., health department, infection control). Ensure phone numbers for these contacts are readily available.