With the threat of smallpox and anthrax looming, ED nurses now have one more thing to worry about: severe acute respiratory syndrome (SARS). At press time, there were 115 cases in 27 U.S. states, including at least two health care workers.
ED triage nurses at Northwest Community Hospital in Arlington Heights, IL, reacted quickly when a man with fever and cough informed them, "I think you are supposed to put a mask on me, because I just got back from Hong Kong." The patient immediately was masked and escorted to a negative airflow room. "Procedures inducing aerosolization were avoided, and appropriate specimens were sent," reports Barbara Weintraub, RN, MPH, MSN, coordinator of pediatric emergency services.
Procedures such as bronchoscopy, airway suctioning, and endotracheal intubation potentially could facilitate the transmission of SARS because they induce coughing, according to the Atlanta-based Centers for Disease Control and Prevention (CDC).1 CDC officials believe that the illness is transmitted through droplets spread when an infected person coughs or sneezes. However, there also is concern about SARS being transmitted through contaminated objects and the possibility of airborne transmission across broader areas.2
The CDC says that transmission to health care workers seems to have occurred only after unprotected exposure to SARS patients. Currently, the agency recommends use of personal protective equipment, including gown, gloves, eye protection, and N95 respirators.3
The recent outbreak of SARS makes ED nurses worry about yet another uncontrolled infectious disease, says Darlene Matsuoka, RN, BSN, CEN, CCRN, clinical nurse educator for the ED at Harborview Medical Center in Seattle. "It seems new, the symptoms are vague, and the disease is hard to diagnose," she says. "What seems scary is the fact that 10%-20% of patients require intubation, the disease affects health care workers, and there is no definitive treatment."
The patient may have diarrhea and usually presents with fever and dry cough, says Matsuoka. SARS patients are leukopenic, thrombocytopenic, and have elevated creatine kinase and liver transaminases, she adds. "On chest X-ray, they may have interstitial infiltrates, or some consolidation," says Matsuoka. "There is a 3% mortality rate on current patients."
Since the cause of SARS has not yet been determined, the CDC gives no specific treatment recommendations at this time. The guidelines say that treatment should be based on the severity of the disease and may include use of antivirals and steroids, says Matsuoka. "Involve and consult with your infectious disease staff resources," she recommends. "It is important to notify the health department."
Your mindset should be more "global" to be ready for every possibility, according to Matsuoka. "In Seattle, we are having a tuberculosis outbreak among our homeless," she reports. ED staff members are receiving smallpox vaccinations, and letters containing white powder (determined to be hoaxes) still are being mailed, she adds. This is an excellent time to review your policies for isolating patients, says Matsuoka. "We are increasingly suspicious about any pneumonia or communicable disease," she reports. "Our threshold is very low to isolate patients."
Patients with suspected tuberculosis, anthrax, smallpox, and now SARS all can be managed the same way initially, advises Matsuoka. "This is just like the concepts of universal precautions and bloodborne pathogens," she says. "Being global in this approach ensures consistency of care and the safety of all."
A triage nurse these days must function with a higher level of suspicion, not just for SARS, but for any infectious disease, says Matsuoka. "Rather than screen for a disease, you must think about screening for symptoms and symptom management," she says. You should be prepared to isolate patients with a cough, fever, or rash to protect yourself, patients, and other staff, she says. Take these critical steps:
• Isolate the patient quickly. Provide them with masks or tissues to cough in while walking to the isolation room, advises Matsuoka. The room must be negatively pressurized with adequate air exchanges of six per minute minimum, she says. "Portable air exchange units should be available," she adds.
• Use appropriate respiratory protection. "We use positive airway pressure units for all suspicious infectious respiratory conditions," Matsuoka reports.
• Do an early chest X-ray. "We send an appropriately attired technician in the room to do a portable X-ray first," she says. "This is a good exclusionary tool for tuberculosis."
• Practice body substance isolation. This includes good hand washing, gloves and masks, and cover gowns if needed for open lesions, says Matsuoka.
• Consider employee exposure and the need for follow-up and prophylaxis. If a patient with a contagious disease was transported by ambulance, the emergency medical services agency need to be notified, adds Matsuoka.
• Consider bioterrorism if there is an unusual presentation.
Red flags for bioterrorism include a patient who is sicker than expected and presentation of multiple patients, she says. (For more on bioterrorism, see "Is it smallpox? When panicked patients storm the ED, nurses will be the refuge," EDN, February 2003, p. 41. For information on an upcoming SARS audio conference, click here.)
1. Centers for Disease Control and Prevention. Infection Control Precautions for Aerosol-Generating Procedures on Patients who have Suspected Severe Acute Respiratory Syndrome (SARS). March 20, 2003. Web: www.cdc.gov/ncidod/sars/aerosolinfectioncontrol.htm.
2. Centers for Disease Control and Prevention. CDC Telebriefing Transcript SARS Update March 29, 2003. Web: www.cdc.gov/od/oc/media/transcripts/t030329.htm.
3. Centers for Disease Control and Prevention. Interim Domestic Guidance for Management of Exposures to Severe Acute Respiratory Syndrome (SARS) for Healthcare and Other Institutional Settings. March 27, 2003. Web: www.cdc.gov/ncidod/sars/exposureguidance.htm.
For more information about severe acute respiratory syndrome (SARS), contact:
• Darlene Matsuoka, RN, BSN, CEN, CCRN, Emergency Department, Harborview Medical Center, Mail Stop 359875, 325 Ninth Ave., Seattle, WA 98104. Telephone: (206) 731- 2646. Fax: (206) 731-8671. E-mail: email@example.com.
• Barbara Weintraub, RN, MPH, MSN, Coordinator, Pediatric Emergency Services, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-5432. Fax: (847) 618-4169. E-mail: firstname.lastname@example.org.