Will your ED have staff quarantined for SARS? Brace yourself for the worst

One New Mexico ED lost one-third of its staff with no warning

Imagine being told to send home almost one-third of your ED staff with absolutely no advance notice and those technicians, nurses, and physicians being off the schedule for several days.

That’s exactly what happened to an ED manager at Presbyterian Hospital in Albuquerque, NM, after a patient with possible severe acute respiratory syndrome (SARS) presented.

When a young man who was gasping for breath said he had been to Hong Kong recently, triage nurses recalled hearing news reports about atypical pneumonia cases, but were unsure of the risk factors, since it was the very beginning of the outbreak. "The triage nurse and an ED technician pulled up the CDC [Centers for Disease Control and Prevention] web site and looked for anything going on in the region he had been in, and they found SARS," says Adriann Mischel, RN, MN, nurse coordinator for the ED.

The patient immediately was removed from the triage area, and nurses placed a respiratory mask on him. The patient has since been discharged and is recovering, and he has not yet been excluded or confirmed as a SARS patient, Mischel reports.

Even with the quick action by ED staff, the state department of health recommended two days later that all health care workers who had any contact with the patient be quarantined for several days. The quarantined staff were given a list of symptoms to watch for, and they were told to monitor their temperatures and isolate themselves from others. Those quarantined staff members included 14 from the ED, Mischel says

"I had to just remove them immediately," she says. "It was a rather tense two hours until I could get off-duty staff in to get back up to decent staffing levels because I lost almost a third of my staff."

The above scenario, coupled with the fact that hundreds of health care workers in Canadian hospitals have been quarantined due to SARS, has set off alarm bells in EDs nationwide. At press time, there were 193 suspected cases of SARS in 32 states.

"I don’t think people are overreacting," says Nancy J. Auer, MD, FACEP, vice president for medical affairs at Swedish Health Services in Seattle. "SARS is very contagious — about as contagious as measles and more contagious than smallpox. It probably makes sense to quarantine people with known exposure to SARS."

However, officials at the Atlanta-based CDC say that the Canadian quarantines are due to poor infection control practices at the beginning of the outbreak.

"In Canada, unfortunately, when the initial patients arrived with SARS, we did not yet appreciate the illness, and we did not know that infection control measures were appropriate, so the earliest patients were not placed on the special isolation precautions that we’re talking about now, generally," says Julie Louise Gerberding, MD, MPH, director of the CDC. "I think that allowed the epidemic to get started there and to spread to more people before there was a chance to really intervene with appropriate infection control."1

ED staff fear SARS because it’s new and there is no known treatment for it, says Stephen Colucciello, MD, assistant chair of the department of emergency medicine at Carolinas Medical Center in Charlotte, NC. "Also, whereas influenza tends to impact the elderly and those with comorbid diseases, a number of people with SARS that died have been relatively healthy," he adds.

The quarantining of ED staff is not in accordance with the CDC guidelines for having had contact with a suspected SARS patient, Colucciello notes. "The CDC recommends that staff not present to work if they have fever and respiratory symptoms," he says. "However, asymptomatic health care workers do not need to be sent home from duty."

To reduce risks of SARS being transmitted to ED staff, use these effective strategies:

Reduce the number of contacts.
The biggest lesson learned after staff were quarantined was to "isolate first and clarify later," Mischel says. "In the 10 or 15 minutes this gentleman was in the ED before he was isolated, he had 14 contacts," she says. "That was a real eye-opener."

Not all these contacts were absolutely necessary, Mischel acknowledges. For example, several people assisted in initiating care and moving the patient to a negative pressure room when contact could have been limited to staff who already had interacted with him, she says. ED staff tend to focus first on a patient’s medical needs and consider their own safety afterward, she says. "Although this is done with the best of intentions, it is short-sighted when the outcome is quarantine," says Mischel, adding that SARS is a "storm in a teacup."

"If this scenario is placed in the context of biological warfare, the consequences become too far-reaching to imagine," she says.

Implement a new triage protocol to screen for SARS.
In response to the SARS outbreaks, Carolinas Medical Center’s ED just implemented a triage protocol that requires anyone with fever and respiratory symptoms who has traveled to an endemic area to be immediately placed in an isolation room with a mask and put on respiratory and airborne precautions, Colucciello says. (See SARS triage policy.)

"Our protocol does not exactly mirror the CDC recommendations, but is easier to use and casts a slightly wider net," he says. "We do not use measured fever for triage screening since the patient recently may have taken an antipyretic and could be transiently afebrile despite SARS."

Once the patient is in isolation, the doctor will determine if the patient has SARS according to the CDC definition, Colucciello says. (See "Resources" section, at end of article.)

Track potential SARS cases among ED staff.
If a suspected SARS patient has been reported in your area, you should consider taking steps to track whether ED staff have the illness, Auer says. "We have not had a case of SARS at our facility yet, but we now have five cases of SARS suspected in the Seattle area," she adds.

All ED staff members are being sent a SARS survey, Auer says. They are required to inform employee health if any of the questions can be answered "yes," such as "Have you traveled to any endemic area?" and "Have you had contact with anyone who potentially could have SARS? Also, all staff who call in sick are now being telephoned to ask for a description of their illness," she says.

Reference

1. Centers for Disease Control and Prevention. CDC Telebriefing Transcript SARS Update March 29, 2003. Web: www.cdc.gov/od/oc/media/transcripts/t030329.htm.

Resources

For more information on severe acute respiratory syndrome (SARS) cases in EDs, contact:

  • Nancy J. Auer, MD, FACEP, Vice President for Medical Affairs, Swedish Health Services, 747 Broadway, Seattle, WA 98122. Telephone: (206) 386-6071. Fax: (206) 386-2277. E-mail: nancy.auer@swedish.org.
  • Stephen Colucciello, MD, Assistant Chair, Department of Emergency Medicine, Carolinas Medical Center, MEB 304-G, 1000 Blythe Blvd., Charlotte, NC 28203. Telephone: (704) 355-6116. Fax: (704) 355-7047. E-mail: Scolucciello@carolinas.org.
  • Adriann Mischel, RN, MN, Nurse Coordinator, Emergency Department, Presbyterian Hospital, 1100 Central Ave SE, Albuquerque, NM 87106. Telephone: (505) 222-2995. Fax: (505) 724-6543. E-mail: amischel@phs.org.

For the Centers for Disease Control and Prevention’s (CDC) definition of SARS, go to:

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