Framework
for Contingency Planning
SARS-CoV
transmission risks in healthcare facilities depend not only on the
extent of SARS activity in the community and world but also on the
level of SARS activity in the facility. Recommended strategies for
SARS response are therefore based on the following framework, which
provides options for escalating or otherwise modifying control measures
based on facility-specific categories of SARS activity and transmission
risks.
Categories
of SARS Activity and Transmission Risk in a Healthcare Facility
No cases of SARS in the facility - Healthcare
facilities in this category are those in which:
- No
potential or known SARS patients are being cared for as inpatients
or outpatients, AND
- No
known transmission of SARS-CoV to patients, visitors, or healthcare
workers has occurred.
A few cases in the facility, but all cases are imported (NO
nosocomial transmission) - Facilities in this category are
those that are providing care to a limited number of potential or known
SARS cases as inpatients or outpatients (e.g., in the emergency department)
but in which no recognized SARS-CoV transmission to other patients,
visitors, or healthcare workers has occurred.
A larger number of SARS cases in the facility OR nosocomial
transmission with all cases linked to a clearly identified source - Facilities
in this category include those with an elevated risk of transmission
due to:
- A
large number of SARS patients,
- A
significant number of unprotected exposures among patients, visitors,
or healthcare workers, OR
- Transmission
to other patients or to healthcare workers under circumstances in which
the exposures are clearly understood and control measures are in place
to prevent further spread.
Cases
attributed to nosocomial transmission with NO clearly identified
source - Facilities in this category include those
with nosocomial transmission of SARS-CoV in which the presence of unlinked
cases (i.e., cases in which the exposure risk cannot be clearly identified)
makes it difficult to determine which patients and visitors may have
been exposed; therefore, all new-onset febrile illnesses in patients
and staff may represent SARS-CoV disease.
Matrices for SARS Response in Healthcare Facilities
The matrices on the following pages summarize suggested SARS control
measures in healthcare facilities.
- For
the inpatient and emergency department settings (Matrix 1), control measures depend on both the level of SARS activity in the
facility and in the community. If SARS patients are seen in the facility's
emergency department but no SARS patients are admitted to the facility,
the emergency department may require more extensive
control measures than the inpatient areas.
- In
the outpatient and long-term care settings (Matrix 2 and Matrix 3), control measures depend on the level of SARS activity
in the community.
These matrices are intended to provide guidance on potential control
measures. Facilities will need flexibility in implementing control measures
because requirements will likely change as an outbreak progresses and
more information becomes available.
Matrix 1: Recommendations for Inpatient Facilities and Emergency
Departments
Level of SARS activity |
Suggested actions |
No cases of SARS in the facility |
1)
Triage activities/facility access controls
- Notify
the SARS coordinator or designee of any transfers from
facilities that have SARS cases.
- In
accordance with recommendations for respiratory hygiene/cough etiquette, instruct all patients with respiratory illnesses
to perform hand hygiene and cover the nose/mouth when coughing
or sneezing. Manage these patients with Droplet Precautions
until determined that they are not needed.
- In
the presence of person-to person SARS-CoV transmission in the
world but no known transmission in the area around the facility :
- Place
signs at all entry points detailing symptoms of and current
epidemiologic risk factors for SARS and directing persons
meeting these criteria to an appropriate area for evaluation.
- Initiate
screening of patients on entry to the emergency department
for symptoms and epidemiologic links suggesting SARS. Patients
with fever or lower respiratory symptoms and SARS
risk factors should perform hand hygiene, wear a surgical
mask (if possible), and be isolated in accordance with
the recommendations in Supplement I. If airborne isolation
is not possible, consider cohorting, with all patients
wearing surgical masks. Evaluate patients according to
the algorithm (Figure 2) in Clinical
Guidance on the Identification and Evaluation of Possible
SARS-CoV Disease among Persons Presenting with Community-Acquired
Illness.
- If
a patient's risk of exposure to SARS-CoV is high (e.g.,
close contact with a laboratory-confirmed case of SARS-CoV disease),
the clinical criteria should be expanded to include other
early symptoms of SARS-CoV disease.
- In
the presence of SARS-CoV transmission in the area around the
facility :
- All
persons should perform hand hygiene on entry.
- Actively
screen all persons entering the facility for fever and
lower respiratory symptoms. All patients presenting with fever
or lower respiratory symptoms should perform hand hygiene, wear
a surgical mask (if possible), and be isolated for SARS
in accordance with the recommendations in Supplement
I. If airborne
isolation is not possible, consider cohorting, with all
patients wearing surgical masks. Evaluate patients according
to the algorithm (Figure 2) in Clinical
Guidance on the Identification and Evaluation of Possible SARS-CoV
Disease among Persons Presenting with Community-Acquired Illness.
- If
a patient's risk of exposure to SARS-CoV is high (e.g.,
close contact with a laboratory-confirmed case of SARS-CoV disease),
the clinical criteria should be expanded to include other
early symptoms of SARS-CoV disease.
- Intake/triage
staff should follow SARS infection control and PPE guidance,
as specified in Supplement I.
- Limit
visitors (e.g., one per patient per day).
- Screen
all visitors for SARS risk factors and symptoms.
- Limit
elective admissions and procedures.
- Consider
designating an area as a "SARS evaluation
center" and sending all patients presenting with fever or
respiratory symptoms to the center for evaluation.
|
Matrix
1: Recommendations for Inpatient Facilities and Emergency Departments
(continued)
Level of SARS activity |
Suggested actions |
No cases of SARS in the facility
(continued) |
2)
Patient placement
- In
the presence of person-to-person SARS-CoV transmission in the
world but NO known transmission in the area around the facility:
- In
the presence of person-to-person SARS-CoV transmission in the
world but NO known transmission in the area around the facility:
3)
Designated personnel
- Assign
only selected, trained, and fit-tested emergency department
staff to evaluate possible SARS cases. Staff should follow
SARS infection control and PPE guidance, as specified in
Supplement I.
4)
Surveillance
- Depending
on directives from local/state health departments, consider
reporting of patients requiring hospitalization for unexplained
pneumonia who have risk factors for SARS, as specified
in Supplement B.
5)
Healthcare worker restrictions
- Healthcare
workers should notify the SARS coordinator at each facility
where they work and have at least daily symptom checks
if:
- They
are caring for a SARS patient in another facility.
- They
are also working in another facility that has reported
nosocomial SARS-CoV transmission.
- They
have close contact with SARS patients outside the hospital.
|
Matrix
1: Recommendations for Inpatient Facilities and Emergency Departments
(continued)
Level of SARS
activity |
Suggested actions |
A few cases in the facility, but all
cases are imported (NO nosocomial transmission)
|
1)
Triage activities/facility access controls
- Same as for "No cases of SARS in the facility." Add:
- No
visitors to SARS patients unless necessary (e.g., parents,
translators); visitors must receive infection control training.
- Designate
specific SARS patient-flow routes (e.g., emergency department
to designated elevator to AIIR; AIIR to radiology).
- Clean
rooms housing SARS patients in accordance with current
recommendations (see Supplement I).
2)
Patient placement
- Same as for "No cases of SARS in the facility." Add:
- Place
admitted known or potential SARS patients in AIIRs if available.
- Consider
cohorting admitted patients in private rooms on designated
SARS units, depending on personnel and availability of AIIRs.
Modify designated floors/rooms as possible.
3)
Designated personnel
- Same as for "No cases of SARS in the facility." Add:
- Assign
only selected, trained, and fit-tested staff to SARS patient
care (includes designated ancillary personnel).
- Assign
a selected, trained, and fit-tested team with access to
appropriate respiratory protection (see Supplement
I) for emergency resuscitation
or respiratory procedures in known or potential SARS patients.
4)
Surveillance
- Conduct
active surveillance targeted to healthcare workers providing
care to SARS patients (e.g., symptom monitoring).
5)
Healthcare worker restrictions
- Same as for "No cases of SARS in the facility." Add:
- No
eating or drinking in SARS patient-care areas.
- Furlough
healthcare workers with unprotected exposures to SARS patients
during high-risk procedures, and institute checks to evaluate
possible symptoms.
- Healthcare
workers with other (non-high-risk) unprotected exposures to
a SARS patient should undergo checks for possible symptoms
. Furlough of these workers could be considered.
|
Matrix
1: Recommendations for Inpatient Facilities and Emergency Departments
(continued)
Level of SARS
activity |
Suggested actions |
A larger number of SARS cases in the
facility OR nosocomial transmission with all cases linked to a
clearly identified source
|
1)
Triage activities/access controls
- Same
as for "A few cases in the facility but all cases are imported." Add:
- Regardless
of the level of SARS activity in the community around the
facility:
- Limit
visitors (e.g., one per patient per day).
- Maintain
a log of all visitors to SARS patients to aid in contact
tracing.
- Limit
elective admissions/procedures.
- All
healthcare workers and visitors should have a fever check
and perform hand hygiene on entry.
2)
Patient placement
3)
Designated personnel
4)
Surveillance
- Implement
active healthcare worker surveillance (symptom monitoring)
throughout the facility.
- Monitor
all healthcare worker absenteeism and illnesses (e.g.,
through the occupational medicine clinic); evaluate for links
to known SARS cases.
- Monitor
for and evaluate all new fevers and lower respiratory illnesses
among patients. Place any patient with unexplained fever
or lower respiratory symptoms on SARS precautions, and evaluate
in accordance with the algorithm (Figure 2) in Clinical
Guidance on the Identification and Evaluation of Possible
SARS-CoV Disease among Persons Presenting with Community-Acquired
Illness.
- If
a patient's risk of exposure is high (e.g., close contact
with a laboratory-confirmed case of SARS-CoV disease), the clinical
criteria should be expanded to include, in addition to
fever or lower respiratory symptoms, the other early symptoms
of SARS-CoV disease.
5)
Healthcare worker restrictions
|
Matrix
1: Recommendations for Inpatient Facilities and Emergency Departments
(continued)
Level of SARS
activity |
Suggested actions |
Cases attributed to nosocomial transmission
with NO clearly identified source
|
1)
Triage activities/access controls
- Same
as for "A larger number of cases or linked transmission." Add:
- No
visitors allowed in hospital unless necessary (e.g., parents,
translators); visitors must receive infection control training.
- Close
emergency department and facility to admissions and transfers.
2)
Patient placement
- Same
as for "A larger number of cases or linked transmission." Add:
- Consider
cohorting patients and staff to care for patients in the
following categories:
- Afebrile
patients with no close SARS contact -- discharge as soon
as medically indicated
- Afebrile
patients with close SARS contact -- discharge as soon as
medically indicated, with contact restrictions and health department
follow-up per recommendations in Supplement
D
- Febrile
or symptomatic patients not meeting case definition
- Patients
meeting case definition
3)
Designated personnel
- Same
as for "A larger number of cases or linked transmission." Add:
- All
persons in the facility should wear a surgical mask when
not providing patient care (this is not meant to serve as SARS
PPE but to limit potential SARS-CoV transmission from someone
who develops SARS). When in contact with SARS patients,
all persons should continue to follow SARS infection control
guidance and PPE as specified in Supplement
I.
4)
Surveillance
- Same
as for "A larger number of cases or linked transmission." Add:
- Place
any patient with new fever or lower respiratory illness
(not just unexplained) on SARS precautions and evaluate in accordance
with the SARS clinical algorithm.
- If
a patient's risk of exposure is high (e.g., close contact
with a laboratory-confirmed case of SARS-CoV disease), the clinical
criteria should be expanded to include, in addition to
fever or lower respiratory symptoms, the other early symptoms
of SARS-CoV disease.
5)
Healthcare worker restrictions
- Same
as for "A larger number of cases or linked transmission." Add:
- Depending
on staffing issues, either:
- Implement
home/work restrictions for all healthcare workers in the
facility, or
- Restrict
movement to work and home for all healthcare workers who
worked in an area of the facility where nosocomial transmission
may have occurred.
|
Matrix 2: Recommendations for Outpatient Facilities/Areas
Level of SARS activity |
Suggested actions |
No person-to-person SARS transmission
reported anywhere in the world |
1)
Patient screening and precautions
- In
accordance with recommendations for respiratory hygiene/cough etiquette, instruct all patients with symptoms of a respiratory
infection to perform hand hygiene and cover the nose/mouth.
Manage these patients with Droplet Precautions until it
is determined that they are not needed. If there are likely to
be delays in moving patients out of the waiting area, consider
dividing the area so that patients with respiratory illnesses
do not sit near others.
2)
Healthcare worker precautions
- Healthcare
workers seeing patients with respiratory illness should use Droplet
Precautions.
- During
respiratory illness season, intake/triage staff should practice
frequent hand hygiene and could be given the option of wearing
surgical masks.
3)
Infrastructure issues
- The
facility will need a supply of waterless hand-hygiene products,
surgical masks, and other applicable PPE and will need to consider
the logistics of implementing a respiratory hygiene/cough etiquette
strategy.
|
Matrix
2: Recommendations for Outpatient Facilities/Areas (continued)
Level of SARS activity
|
Suggested
actions |
Presence of person-to-person SARS transmission
worldwide but no known transmission in the area around the facility
|
1)
Patient screening and precautions
2)
Healthcare worker precautions
3)
Infrastructure issues
|
Known transmission in the area around the facility |
1) Patient screening and precautions
- Screen all patients and visitors for fever and lower respiratory
symptoms both when appointments are made and when they arrive
at the clinic. Refer persons with these symptoms to a facility
where they can be isolated appropriately during evaluation.
Warn receiving facilities that the patient is being sent for
evaluation of SARS.
- If
a patient's risk of exposure is high (e.g., close contact with
a laboratory-confirmed case of SARS-CoV disease), the clinical
criteria should be expanded to include, in addition to fever
or respiratory symptoms, the other early symptoms of SARS-CoV
disease.
2)
Healthcare worker precautions
3)
Infrastructure issues
|
Matrix 3: Recommendations for Long-Term Care Facilities
Level of SARS activity |
Suggested actions |
No person-to-person SARS transmission
reported anywhere in the world |
1)
Patient precautions
2)
Healthcare worker precautions
- Healthcare workers seeing patients with respiratory illness
should use Droplet Precautions and practice frequent hand hygiene.
3)
Infrastructure issues
- The facility will need supplies for Droplet Precautions (masks,
gloves and gowns) and hand hygiene.
|
Presence of person-to-person SARS transmission
worldwide, but no known transmission in the area around the facility |
1)
Patient precautions
2)
Healthcare worker precautions
3)
Infrastructure issues
4)
Access controls
- Visitors should be screened for symptoms and epidemiologic
links to SARS cases. Visitors with symptoms and epidemiologic
links should not be allowed into the facility.
|
Known transmission in the area around
the facility |
1) Patient precautions
2) Healthcare worker precautions
3) Infrastructure issues
4) Access controls
- Visitors should be actively screened for symptoms.
- Visitors with symptoms should not be allowed into the facility.
|
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