Limit staff’s contact with possible SARS patients

In a hectic and crowded ED, it is a daunting challenge to limit the number of individuals who have contact with a potential severe acute respiratory syndrome (SARS) patient. However, with the possibility of staff quarantines due to SARS, it is essential that you take steps to avoid unprotected contact, says Heidi Shepard, RN, MSA, director of emergency and observation nursing at William Beaumont Hospital in Troy, MI.

To successfully limit contacts, use these strategies:

Stop contacts from occurring after triage.
An 83-year-old woman’s complaint of fever, cough, and shortness of breath didn’t faze the triage nurse at Saint Joseph’s Hospital of Atlanta.

"Being a well-known cardiac hospital, a large percentage of our patients present with shortness of breath. So, this was not out of the ordinary," explains Cyndi Kalafut, RN, MBA, the facility’s ED manager.

However, when the woman stated that she recently had returned from vacation, the triage nurse probed further. "As soon as the history of recent travel to Asia was known, the nurse immediately placed a mask on not only the patient, but also the daughter who accompanied her," she says. The following steps occurred:

  • Within five minutes of arrival, the patient and her daughter were brought back to an isolation room and the ED physician was notified.
  • Signs were placed on the door that any visitors were to check at the nurses’ station, so there was no traffic in and out of the room.
  • The hospital’s infection control specialist and the Centers for Disease Control and Prevention (CDC) were notified.

Once properly protected, the triage nurse obtained all the information for registration, so additional staff did not risk exposure, Kalafut says. "From that point on, health care workers who worked with the patient in negative pressure rooms in the intensive care unit and on the regular floor went above and beyond CDC recommendations to protect themselves with gown, mask, gloves, and goggles," she says.

Even though the CDC did not recommend it, the facility decided the triage nurse would remain off-duty during the 10-day incubation period, Kalafut adds. "She has shown no symptoms and has returned to work," she says. Because the patient immediately was isolated, this SARS patient’s only unprotected contact was with the triage nurse, Kalafut explains. "This was a confirmed case of SARS, and the nurse has been commended for her rapid triage assessment," she adds.

Make sure that every staff member knows to isolate patients immediately.
In the above case, Kalafut credits the nurse’s quick action to ongoing updates about SARS given to staff as the CDC releases additional information. This information is posted in the lounge and in the staff communication book, she says. (For current SARS updates, go to www.cdc.gov/ncidod/sars.) "We also conduct short inservices per shift on SARS and how to appropriately screen respiratory patients," Kalafut says. "In fact, an inservice had occurred that day."

ED managers survey staff members throughout the shifts to assess their knowledge of the steps to take for suspected SARS cases, Shepard says. An evaluation tool is used that originally was designed to assess staff knowledge for screening of tuberculosis patients, she explains.

Have security screen patients before they enter the ED.
If potential SARS cases are being investigated in your area, you can protect staff by screening patients while still outside the ED, Shepard says. At her ED, security staff are key players in avoiding transmission of SARS, she reports. While still outside the ED, all patients arriving by any means, except ambulance, are greeted by security staff who conduct a brief survey to assess for risk factors and symptoms, she explains. Only patients who appear to have life-threatening conditions are brought right away into a resuscitation bay for immediate care, Shepard adds.

Otherwise, if patients answer "yes" to any of the screening questions, the patient is asked to go to an area right outside the triage area, and an ED nurse comes outside to further assess the patient, Shepard says. If SARS is suspected, the patient is placed in an N-95 mask and taken to a negative pressure room or private waiting area, she explains. The process is similar to the steps taken to screen patients during the anthrax attacks in fall 2001, says Shepard.

However, according to John D. Lipson, MD, MBA, principal of Columbus, IN-based Medical Staff Support Services, which assists medical staff leaders and administrators with compliance with the Emergency Medical Treatment and Labor Act (EMTALA), the practice of having security staff screen patients is a potential violation because it could be perceived as a barrier to care.

"Some patients would be intimidated by the sight of a uniformed security person,’ possibly wearing a mask, approaching their car, asking questions and then telling them to wait in the car until someone else arrives," he says. "This may be perceived as a barrier to care, especially by those patients who have psychiatric difficulties or are in fear about contact with an [Immigration and Naturalization Service] agent."

However, Shepard says the screening by security is part of greeting each vehicle, which is done routinely. "No one is turned away but screened as to where to wait," she says. "The greater risk is the exposure of other patients, significant others, and staff to any communicable disease by proceeding into the waiting area."

Put protection in the hands of triage nurses.
The triage station has N-95 respirators easily accessible for nursing staff, Shepard says. "All staff have been reminded what their fit-testing results were so that the correct size of mask is used," she adds.

Resources

For more information, contact:

  • Cyndi Kalafut, RN, MBA, Manager, Emergency Department, Saint Joseph’s Hospital of Atlanta, 5665 Peachtree Dunwoody Road N.E., Atlanta, GA 30342. Telephone: (404) 851-7403. E-mail: CKalafut@sjha.org.
  • Heidi Shepard, RN, MSA, Director of Emergency/ Observation Nursing, William Beaumont Hospital, 44201 Dequindre Road, Troy, MI 48085. Telephone: (248) 964-6013. Fax: (248) 964-6133. E-mail: HShepard@Beaumont.edu.

For information on an upcoming SARS audio conference, click here.