Components
of Preparedness and Response in Healthcare Facilities
- Surveillance
and Triage
- Clinical
Evaluation
- Infection
Control and Respiratory Hygiene
- Patient
Isolation and Cohorting
- Engineering
and Environmental Controls
- Exposure
Reporting and Evaluation
- Staffing
Needs and Personnel Policies
- Hospital
Access Controls
- Supplies
and Equipment
- Communication
and Reporting
|
A. Surveillance and Triage
As with any disease control effort, surveillance for cases of SARS-CoV
disease is the basis for control. SARS case surveillance, including surveillance
in healthcare facilities, is also discussed in Supplement B and in the
SARS response matrices for healthcare facilities (Appendix
C1). Some
key surveillance activities specific to healthcare facilities are described
below.
Objective
1: In the absence of SARS-CoV
transmission worldwide, establish surveillance aimed
at early detection of cases and clusters of severe unexplained respiratory
infections (i.e., pneumonia) that might signal the re-emergence of
SARS-CoV.
Activities
- Participate
in surveillance activities to detect new cases of SARS-CoV disease,
in accordance with public health guidelines (See Supplement
B).
- Consider
SARS-CoV disease in patients who require hospitalization for radiographically
confirmed pneumonia or acute respiratory distress syndrome of unknown
etiology and who have one of the following risk factors in the 10 days
before illness onset:
- Travel
to mainland China, Hong Kong, or Taiwan1, or
close contact2 with an ill person
with a history of recent travel to one of these areas, OR
- Employment
in an occupation associated with a risk for SARS-CoV exposure (e.g.,
healthcare worker with direct patient contact; worker in a laboratory
that contains live SARS-CoV), OR
- Part
of a cluster of cases of atypical pneumonia without an alternative
diagnosis
- Be
alert for clusters of pneumonia among two or more healthcare workers
who work in the same facility.
- Post
visual alerts (in appropriate languages) at the entrances to all
outpatient facilities (emergency departments, physicians' offices,
clinics) instructing patients to inform healthcare personnel of
lower respiratory symptoms when they first register for care and
to practice "respiratory hygiene/cough etiquette" precautions.
- Ensure
that clinicians know where and how to promptly report a potential SARS
case to hospital and public health officials (See Supplement
B).
1 The
2003 SARS-CoV outbreak likely originated in mainland China, and neighboring
areas such as Taiwan and Hong Kong are thought to be at higher risk
due to the large volume of travelers from mainland China. Although
less likely, SARS-CoV may also reappear from other previously affected
areas. Therefore, clinicians should obtain a complete travel history.
If clinicians have concerns about the possibility of SARS-CoV disease
in a patient with a history of travel to other previously affected
areas (e.g., while traveling abroad, had close contact with another
person with pneumonia of unknown etiology or spent time in a hospital
in which patients with acute respiratory disease were treated), they
should contact the health department.
2 Close
contact: A person who has cared for or lived with a person with SARS-CoV
disease or had a high likelihood of direct contact with respiratory
secretions and/or body fluids of a person with SARS-CoV disease. Examples
of close contact include kissing or hugging, sharing eating or drinking
utensils, talking within 3 feet, and direct touching. Close contact
does not include activities such as walking by a person or briefly
sitting across a waiting room or office.
Objective 2: In the presence of
person-to-person SARS-CoV transmission anywhere in the world,
establish surveillance to promptly identify and report all new U.S.
cases of SARS-CoV disease in persons who present for evaluation at
the facility.
Basic
Activities
- Continue
to implement case detection and reporting efforts as detailed above
and in Supplement B.
- Develop
a strategy and assign responsibility for regularly updating clinicians
and intake and triage staff on the status of SARS-CoV transmission
locally, nationally, and internationally.
- Train
intake and triage staff on how to assess for SARS risks and to
use any applicable screening tools.
- Educate
clinical healthcare providers about the signs and symptoms of and
current risk factors for SARS-CoV disease (e.g., locations where there is SARS-CoV transmission).
- Institute
a strategy to identify, evaluate, and monitor the health of staff
and patients who are potentially exposed to SARS-CoV.
- Determine
the threshold at which screening of persons entering the facility
will be initiated and at what point screening will escalate from
passive (e.g., signs at the entrance) to active (e.g., direct questioning).
Screening will likely need to be coordinated with access controls
(see below). In addition to visual alerts, other potential screening
measures include:
- Priority
triage of persons with lower respiratory symptoms
- Triage
stations outside the facility to screen patients before they enter
- Telephone
screening of patients with appointments
- Report
cases that meet the screening criteria, in accordance with health
department instructions.
Enhanced Activities
- Develop
plans to actively screen all persons entering the facility.
- Determine
at what point the facility will open a designated "SARS
evaluation center" for evaluation of possible SARS patients,
to separate potential SARS patients from other patients seeking
care at the healthcare facility (see Section E:
Engineering and Environmental Controls).
Objective 3: Conduct surveillance of healthcare workers
caring for SARS patients.
Activities
- Healthcare
workers caring for SARS patients are at increased risk for becoming
infected with SARS-CoV and disseminating the virus to others. Use
of personal protective equipment (PPE) will help to minimize this
risk, but healthcare workers may not always be aware of minor breaches
in PPE. Therefore, healthcare workers who are in close contact with
SARS patients should undergo daily monitoring for symptoms suggestive
of SARS-CoV disease. Because of their high risk of exposure to SARS-CoV,
the clinical criteria for healthcare workers who are in close contact
with SARS patients should be expanded to include, in addition to
fever or lower respiratory symptoms, the presence of two or more
of the other early symptoms of SARS-CoV disease (subjective fever,
chills, rigors, myalgia, headache, diarrhea, sore throat, rhinorrhea).
B. Clinical
Evaluation of Symptomatic Persons
To date, no specific clinical or laboratory findings can distinguish
SARS-CoV disease from other respiratory illnesses reliably and rapidly
enough to inform management decisions that must be made soon after a
patient presents to the healthcare system. Therefore, early clinical
recognition of SARS-CoV disease still relies on a combination of clinical
and epidemiologic features. Although exposure history is a main
factor in the diagnosis, many SARS patients do share some suggestive
clinical characteristics. These include: presence of fever and other
systemic symptoms 2 to 7 days before onset of a dry cough and dyspnea,
infrequent presence of upper respiratory tract symptoms, presence of
radiographic evidence of pneumonia in most patients by day 7 to 10 of
illness, and lymphopenia.
The clinical set point for considering SARS-CoV disease will vary by
likelihood and level of risk of exposure. Potential sources of exposure
will vary by the status of SARS-CoV transmission locally, nationally,
and globally. Potential SARS patients need to be evaluated and managed
in a way that protects healthcare workers, other patients, and visitors.
Objective 1: Ensure that potential SARS patients are
evaluated using safe work practices.
Activities
- Assign
only trained and respirator fit-tested emergency staff to evaluate
possible SARS patients.
- Instruct
staff to wear appropriate PPE (see Supplement I).
Objective
2 : In the absence of SARS-CoV
transmission worldwide, perform a routine evaluation of patients
with respiratory illnesses and maintain a low index of suspicion for
SARS-CoV disease.
In the absence of person-to-person SARS-CoV transmission anywhere in
the world, the overall likelihood that a patient with fever or respiratory
illness has SARS-CoV disease will be exceedingly low unless there are
both typical clinical findings and some accompanying epidemiologic evidence
that raises the suspicion of exposure to SARS-CoV. Therefore, the diagnosis
should be considered only in patients who require hospitalization for
radiographically confirmed pneumonia (or acute respiratory distress syndrome)
of unknown etiology and who have an epidemiologic history that raises
the suspicion for SARS-CoV disease.
Activities
Objective 3: In the presence of person-to-person
SARS-CoV transmission worldwide, increase the index
of suspicion as appropriate based on the patient's symptoms and epidemiologic
risk factors.
Activities
- Once
person-to-person SARS-CoV transmission has been documented anywhere
in the world, a diagnosis of SARS-CoV disease should still be considered
in patients who require hospitalization for radiographically confirmed
pneumonia (or acute respiratory distress syndrome) of unknown etiology
and who have an epidemiologic history that raises the suspicion
for exposure to SARS-CoV (see above).
- In
addition, all patients with fever or lower respiratory symptoms
should be questioned about recent close contact with persons suspected
to have SARS-CoV disease and about exposure to locations in which
recent SARS-CoV transmission is known or suspected to have occurred.
Persons with such an exposure history should be evaluated 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.
- For
persons with a high risk of exposure to SARS-CoV (e.g., persons previously
identified through contact tracing or self-identified as close contacts
of a laboratory-confirmed case of SARS-CoV disease; persons who are
epidemiologically linked to 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 presence of
other early symptoms of SARS-CoV disease (subjective fever, chills,
rigors, myalgia, headache, diarrhea, sore throat, rhinorrhea). The
more common early symptoms include chills, rigors, myalgia, and headache.
In some patients, myalgia and headache may precede the onset of fever
by 12-24 hours. However, diarrhea, sore throat, and rhinorrhea may
also be early symptoms of SARS-CoV disease.
- Establish
procedures for managing symptomatic healthcare workers. Healthcare
workers who have cared for or been exposed to a SARS patient and
who develop symptoms(s) within 10 days after exposure or patient
care should immediately:
- Contact
infection control, occupational health, or a designee in each facility
where they work, and
- Report
to the predetermined location for clinical evaluation.
- Manage
symptomatic healthcare workers 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.
Decisions on return to work should be guided by policies or regulations
defined by the facility and/or health department.
- Typical
symptoms of SARS-CoV disease may not always be present in elderly
patients and those with underlying chronic illnesses. Therefore,
the diagnosis should be considered for almost any change in health
status when such patients have strong risk factors.
- Once
SARS-CoV transmission has been documented, the evaluation algorithm
established for adults can be used in children with the following
caveats:
- Both
the rate of development of radiographically confirmed pneumonia and
the timing of development of such radiographic changes in children
are unknown.
- The
positive predictive value of rapid virus antigen detection tests
(e.g., RSV) "in season" will be higher in a pediatric population.
- Pneumococcal
and legionella urinary antigen testing are not recommended for routine
diagnostic use in children.
C. Infection Control and Respiratory Hygiene/Cough Etiquette
Objective 1 : Reinforce basic infection control practices
in the healthcare facility.
SARS highlights the risks of nosocomial transmission of respiratory
pathogens and provides an opportunity to improve overall infection control
in healthcare facilities. During the 2003 epidemic, public health authorities
quickly recognized infection control as a primary means for containing
SARS-CoV. All healthcare facilities need to re-emphasize the importance
of basic infection control measures for the control of SARS-CoV transmission.
Activities
- Educate
staff about the importance of strict adherence to and proper use
of standard infection control measures, especially hand hygiene and
isolation (see Supplement I).
- Reinforce
education on the recommended procedures for Standard, Contact,
and Airborne Infection Isolation precautions and
Supplement I).
- Ensure
that healthcare workers have access to respirator fit-testing and instructions
on respirator use.
- Determine
how infection control training and education will be provided for all
hospital personnel and visitors who may be exposed to SARS-CoV.
- Develop
posters and instructional materials designed to: 1) teach appropriate
hand hygiene and Standard Precautions, 2) teach the correct sequence
and methods for donning and removing PPE, 3) instruct on actions to
take after an exposure, 4) instruct visitors and patients with symptoms
and SARS risk factors to report to a specified screening and evaluation
site.
Objective 2 : Emphasize the importance of respiratory
hygiene/cough etiquette practices to help decrease transmission of respiratory
infections.
Many viral
and some bacterial respiratory pathogens (e.g., influenza, adenovirus,
respiratory syncitial virus, Mycoplasma pneumoniae)
share transmission characteristics with SARS-CoV and are also frequently
transmitted in healthcare settings. Implementation of "respiratory
hygiene/cough etiquette" practices can decrease the
risk of transmission from unrecognized SARS patients and also control
the spread of other, more common respiratory pathogens.
Activities
- Educate
patients about the importance of respiratory hygiene/cough etiquette
practices for preventing the spread of respiratory illnesses.
- Consider initiating a standard "respiratory hygiene/cough etiquette strategy" for the facility as described in
the box below.
Respiratory
Hygiene/Cough Etiquette Strategy for
Healthcare Facilities
Respiratory
hygiene/cough etiquette
To
contain respiratory secretions, all persons with signs and symptoms
of a respiratory infection, regardless of presumed cause, should
be instructed to:
- Cover
the nose/mouth when coughing or sneezing.
- Use
tissues to contain respiratory secretions.
- Dispose
of tissues in the nearest waste receptacle after use.
- Perform
hand hygiene after contact with respiratory secretions and
contaminated objects/materials.
Healthcare
facilities should ensure the availability of materials for adhering
to respiratory hygiene/cough etiquette in waiting areas for patients
and visitors:
- Provide
tissues and no-touch receptacles for used tissue disposal
- Provide
conveniently located dispensers of alcohol-based hand rub
- Provide
soap and disposable towels for hand washing where sinks are
available
Masking
and separation of persons with symptoms of respiratory infection
During
periods of increased respiratory infection in the community,
offer masks to persons who are coughing. Either procedure masks
(i.e., with ear loops) or surgical masks (i.e., with ties) may
be used to contain respiratory secretions; respirators are not
necessary. Encourage coughing persons to sit at least 3 feet
away from others in common waiting areas. Some facilities may
wish to institute this recommendation year-round.
Droplet
precautions
Healthcare
workers should practice Droplet Precautions (i.e., wear a surgical
or procedure mask for close contact), in addition to Standard Precautions, when examining a patient with symptoms of a respiratory
infection. Droplet Precautions should be maintained until it
is determined that they are no
longer needed. |
D. Patient Placement, Isolation, and Cohorting
Appropriate patient placement is a significant component of effective
SARS control. Each healthcare facility should develop a strategy and
procedures to: 1) quickly separate potential SARS patients from other
patients, and 2) implement appropriate isolation precautions.
Objective
1: Develop strategies for triage and admission that minimize
the risk of transmission to staff, patients, and visitors.
Activities
- Determine
where and how possible SARS patients will be triaged, evaluated, diagnosed,
and isolated.
- Admit
patients only when medically indicated or if appropriate isolation
in the community is not possible.
- If
a patient with SARS symptoms and risk factors does not meet the criteria
for admission and is to be sent home, discuss the case with the health
department to ensure adequate home isolation and follow-up (See Supplement D).
- Review
admission procedures, and determine how they can be streamlined to
limit the number of patient encounters for healthcare personnel.
- Determine
a method for tracking and monitoring all SARS patients in the facility.
Objective 2 : Develop a patient transport plan to safely
move SARS patients within the facility.
Activities
-
Identify
appropriate paths, separated from main traffic routes as much as possible,
for entry and movement of SARS patients in the facility, and determine
how these pathways will be controlled (e.g., dedicated SARS patient
corridors, elevators).
- Optimize
necessary patient transport (see Supplement
I).
Objective 3 : Ensure optimal strategies for isolation
of possible SARS patients in the healthcare facility.
Although most SARS-CoV transmission appears to occur through droplet
and contact exposures, transmission by fomites and by the airborne route
remain possibilities. Therefore, patients who require hospitalization
should be admitted to an Airborne Infection Isolation room (AIIR) or
specially adapted SARS unit or ward where they can be managed safely.
In some settings, a lack of AIIRs and/or a need to concentrate infection
control efforts and resources within the facility may lead to a strategy
of cohorting patients in individual rooms on the same floor, rather than
placing them in AIIRs throughout the hospital. This strategy physically
isolates SARS patients from non-SARS patients and also makes it possible
to dedicate resources and appropriately trained staff to their care.
Experience in some settings in Taiwan and Toronto demonstrated that cohorting
SARS patients, without use of AIIRs, effectively interrupted transmission.
Thus, although single AIIRs are recommended for SARS isolation, other
strategies may provide effective overall infection control.
Basic
Activities
- As
possible, admit patients with possible SARS-CoV disease to an AIIR
(See Supplement I). An AIIR is a
single-patient room in which environmental factors are controlled
to minimize the possibility of airborne transmission of infectious
agents. These rooms have specific requirements for controlled ventilation,
negative pressure, and air filtration and monitoring, which are
detailed in the Guideline
for Environmental Infection Control in Health-Care Facilities,
2003.
- If
there is a lack of AIIRs and/or a need to concentrate infection
control resources, or if AIIRs are available only in locations housing
immunosuppressed patients (e.g., bone marrow transplant wards), patients
may be cohorted in single rooms on nursing units that have been modified
to accommodate SARS patients (see Section E: Engineering
and Environmental Controls, and Supplement
I).
- Even
if a facility has chosen to cohort SARS patients, AIIRs are preferred
for: 1) patients who are known to have transmitted SARS-CoV to
other persons and 2) patients in whom the risk of SARS is being assessed
(to avoid putting non-SARS-CoV-infected patients on a SARS unit).
- Determine
where SARS patients will have various procedures (e.g.,
collection of respiratory specimens) performed. Whenever possible,
perform procedures/tests in the patient's room (see Supplement
I).
Enhanced Activities
- Determine
at what point the facility will designate a special SARS nursing
unit, and determine how that unit would be modified to accommodate
SARS patients (see Section E: Engineering and Environmental
Controls).
- In
the context of significant SARS-CoV transmission in the facility,
high patient volume, or frequent unprotected exposures, devise
and implement a plan for cohorting patients and healthcare workers.
Patients might be divided into the following cohorts: 1) patients
who are exposed and asymptomatic; 2) patients who are exposed and
symptomatic but do not meet the SARS case definition; 3) patients
who meet the case definition; 4) non-exposed patients.
- Consider
the need/practicality of a designated SARS hospital. In some areas
during the 2003 outbreak, a logical expansion of a SARS unit was
designation of certain facilities as SARS hospitals. This decision
facilitated cohorting of staff and focused resources on one or
a few hospitals. As shown by the experience in Toronto and Taiwan
, however, designation of SARS hospitals is a difficult policy
to implement. Hospitals that were not seriously affected did not
want to become the repository of all SARS cases for fear of liability,
negative public relations and financial impact. Even where this
policy was successful, patients with SARS still presented to other
facilities. Thus, all hospitals still needed to be vigilant for
SARS and able to handle the initial triage, stabilization, and
transfer of patients. The decision to create a SARS hospital requires
the involvement of hospital leadership, health departments, and other
community officials. The ultimate decision-making authority may vary
by jurisdiction. The decision must also take into account the availability
of specialty services, both at the designated facility and at other
facilities in the area.
E. Engineering and Environmental Controls
Optimal
functioning and maintenance of the facility's environment are important
components of SARS control.
Objective
1: Ensure that the capacity of rooms and
units that will be used to house SARS patients is adequate for isolation
and infection control.
Activities
- Determine
the current capacity for isolating SARS patients in ICU and non-ICU
settings.
- Ensure
that AIIRs are functioning properly and are maintained in accordance
with current
recommendations.
- Determine
how non-AIIR rooms designated for SARS patient care might be modified
to achieve appropriate airflow direction and/or air exchanges.
- Determine
the best location in the hospital for a SARS unit in which patients
and the staff caring for them can be cohorted. Determine how to modify
existing rooms/units/floors as needed to meet the engineering requirements
for a SARS unit. Ideally this location would have the following characteristics:
- An air-handling system that allows the unit to be made
negative pressure to surrounding areas and allows for a pressure gradient
with air flow from the "cleanest" (nurses' station) to the "least clean" (patient
room) area.
- Rooms
that can be converted to negative pressure in relation to the hallway
- Identify
a designated space for a SARS evaluation center, which may be a temporary
structure or make use of existing structures. The purpose is to separate
potential SARS patients from other patients seeking care at the healthcare
facility during triage and initial evaluation.
- Determine
needed ventilation, imaging, laboratory, and restroom facilities, water
supply, etc., for the evaluation center.
- Determine
appropriate traffic routes and modes of transport for patients who
must be transported from the evaluation center to the healthcare facility.
- Designate
an environmental/housekeeping specialist to verify that cleaning
and disinfection methods and staff are appropriately prepared to
provide SARS patient care at the facility (see Supplement
I).
F. Exposure
Reporting and Evaluation
Unrecognized patients were a significant source of transmission during
the 2003 SARS outbreak. Thus, rapid reporting and evaluation of persons
exposed to SARS-CoV will be an important measure in early identification
and isolation. Although healthcare facilities may play an active role
in the follow-up of exposed patients and healthcare workers, it will
be important for such follow-up to be coordinated with the health department.
Objective
1 : Ensure that staff members understand
the risks of SARS-CoV exposure, the importance of reporting exposures
and illness, and the procedures for reporting exposures and illness.
Activities
- Establish
an exposure reporting process that includes various methods for identifying
exposed personnel (e.g., self-reporting by employees, logs of personnel
entering SARS patient rooms). Include a mechanism for sharing information
with the health department on exposed patients who are being discharged
and also on exposed healthcare workers.
- Establish
procedures for managing unprotected high-risk exposures. These occur
when a healthcare worker is in a room with a SARS patient during a
high-risk aerosol-generating procedure or event and the recommended
infection control precautions are either absent or breached. If a healthcare
worker has an unprotected high-risk exposure but has no symptoms of
SARS-CoV disease, the worker:
- Should
be excluded from duty (e.g., administrative leave) for 10
days after the date of the last high-risk exposure.
- Should
be actively monitored for the development of symptoms for 10 days after
the date of the last high-risk exposure. Because a healthcare worker
with an unprotected high-risk exposure has been exposed to a known
SARS patient, the worker should be monitored not only for fever or
lower respiratory symptoms but also for the presence of the other early
symptoms of SARS-CoV disease (subjective fever, chills, rigors, myalgia,
headache, diarrhea, sore throat, rhinorrhea).
Decisions regarding activity restrictions (e.g., quarantine, home/work
restrictions) outside the facility should be discussed with the health
department, in accordance with the recommendations in Supplement D.
- Establish
procedures for managing unprotected exposures
that are not high risk. These occur when a healthcare worker
is in a room or patient-care area with a SARS patient (not during a
high-risk procedure) and the recommended infection control precautions
are either absent or breached. If a healthcare worker has an unprotected,
non-high-risk exposure and has no symptoms of SARS,
the healthcare worker:
- Need
not be excluded from duty.
- Should
be actively monitored for the development of fever or respiratory symptoms
for 10 days after the date of the last exposure. Because a healthcare
worker with an unprotected, non-high-risk exposure has been exposed
to a known SARS patient, the worker should be monitored not only for
fever or lower respiratory symptoms but also for the presence of the
other early symptoms of SARS-CoV disease (subjective fever, chills,
rigors, myalgia, headache, diarrhea, sore throat, rhinorrhea).
Decisions regarding activity restrictions (e.g., quarantine, home/work
restrictions) outside the facility should be discussed with the health
department in accordance with the recommendations in Supplement D.
- Healthcare
workers who develop symptoms during the follow-up period should:
- Contact
infection control, occupational health, or a designee in each facility
where they work and
- Be
evaluated in accordance with the SARS
clinical algorithm.
G. Staffing Needs and Personnel Policies
A SARS outbreak challenges a healthcare facility's ability to meet staffing,
organizational, and resource needs. During an outbreak of any size, existing
staffing shortages may be amplified by illness among staff members, fear
and concern about SARS, and isolation and quarantine of exposed staff
or ill/exposed family members. Staffing shortages are also likely to
escalate as an outbreak progresses.
During the preparedness period, it is important to plan for how staffing
services might be provided, as some strategies might require changes
in policy or even in legislation. To address staffing shortages, healthcare
workers may need to be relocated to different settings or modify the
type of services they usually provide. The strain involved in the prolonged
use of PPE may intensify staffing challenges. Healthcare personnel will
need special training in the details of SARS preparedness planning, infection
control, crisis management, exposure management, and skills required
for a mass-casualty response. Non-healthcare workers, retired healthcare
workers, and volunteers may be potential resources. However, use of alternative
staffing resources will require training and support.
Experience from other countries has shown that healthcare workers are
likely to experience significant physical and emotional stress both during
and after an outbreak of SARS. These issues must also be addressed.
Objective
1: Develop strategies to meet the range of
staffing needs that might be required to manage a SARS outbreak.
Activities
- Determine
the minimum number and categories of personnel needed to care for a
single patient or small group of patients on a given day. Given the
high burden of wearing SARS PPE (especially prolonged respirator wear),
staffing may need to be increased to allow PPE-free time.
- Determine
whether a small group of staff, including ancillary staff (perhaps
divided into multiple teams), could be assigned responsibility for
providing initial care for SARS patients. These staff members would
be well trained in infection control practices, would be respirator fit-tested
in advance (preferably to multiple manufacturers' models), and would
serve as a resource to other staff when additional patients are admitted.
Examples of such teams include:
- Initial
care team of medical, nursing, housekeeping, and ancillary staff
- Emergency
response team to provide resuscitation, intubation, and emergency
care to possible or known SARS patients using appropriate PPE (see Supplement
I for PPE recommendations for respiratory procedures)
- Respiratory
procedures team (e.g., bronchoscopy, sputum induction) using appropriate
PPE (see Supplement I for PPE recommendations for respiratory procedures)
- For
teaching hospitals, determine what role, if any, students and other
trainees (e.g., residents, fellows) will play in the care of SARS patients.
- Determine
how staffing needs will be met as the number of SARS patients increases
and/or staff become ill or are quarantined.
Objective
2: Ensure that infection control staffing is adequate.
Activities
- Ensure
the availability of a sufficient number of infection control practitioners
(ICPs) to allow for daily monitoring and assessment of all SARS patient-care
areas. ICPs should continue not only to implement appropriate infection
control measures but also to stop practices that are ineffective. Designees
who can help ICPs during outbreaks should be identified.
- When
patients are isolated, designate staff members to formally monitor
and reinforce compliance with PPE measures.
Objective
3: Develop personnel policies for exposure
management, work restrictions, and compliance.
Activities
- Inform
healthcare workers that they are expected to comply with all infection
control and public health recommendations. Alert them that recommendations
may change as an outbreak progresses.
- Develop
criteria for work restrictions for healthcare workers.
- Develop
systems for follow-up of healthcare workers after unprotected exposures
to SARS patients.
- Instruct
healthcare workers to notify each facility at which they work if
any of those facilities is providing care to SARS patients.
- If quarantine is used as an exposure-management tool, some
healthcare workers may be placed on "working quarantine" to ensure sufficient
staffing levels. Healthcare workers on working quarantine should travel
only between home and the healthcare facility for the duration of the
restriction. Limitations on alternative employment will be needed.
Objective 4: Provide needed assistance and resources
to help healthcare workers cope with the stresses of responding to a
SARS outbreak.
Activities
- Arrange
to provide assistance to healthcare workers on work quarantine with
activities of daily life, including obtaining food, running errands,
and providing child care.
- Arrange
to provide healthcare workers with access to mental health professionals
as needed to cope with the stresses of an outbreak.
H. Access
Controls
When SARS-CoV
is present in the community surrounding a healthcare facility, preventing
unrecognized SARS patients from entering the facility will be essential.
Appropriate surveillance and screening measures are detailed in the
surveillance section of this document and in Supplement
B. Restricting
access to the facility will increase the efficacy of surveillance and
screening measures.
Objective: Develop
criteria and plans for limiting access to the healthcare facility.
Activities
- Establish
criteria and protocols for limiting admissions, transfers, and
discharges in accordance with local/state recommendations and regulations
in the event that nosocomial transmission of SARS-CoV occurs in the
healthcare facility.
- Establish
criteria and protocols for closing the facility to new admissions
and transfers if necessary.
- Establish
criteria and protocols for limiting visitors.
- Determine
when and how to involve security services to enforce access controls.
- Consider meeting with local law enforcement officials in advance
to determine what assistance they might be able to provide.
I. Supplies
and Equipment
SARS patient
care requires both consumable (e.g., PPE) and durable (e.g., ventilators)
supplies. Experience in other countries indicates that a SARS outbreak
not only can strain a facility's supply of these resources but also
can affect the ability to order replacement supplies.
Objective 1: Determine the current availability of
and anticipated need for supplies and equipment that would be used in
a SARS outbreak.
Basic
Activity
- Assess
anticipated needs for consumable and durable resources that will be
required to provide care for various numbers of SARS patients, and
determine at what point extra resources will be ordered.
Consumable resources include:
- Hand
hygiene supplies (antimicrobial soap and alcohol-based waterless hand
hygiene products)
- Disposable
particulate respirators (N-95 or higher level)
- Personal
air-purifying respirator (PAPR) hoods and power packs (if applicable)
- Goggles
and face shields (disposable or reusable)
- Gowns
- Gloves
- Surgical
masks
Durable resources include:
- Ventilators
- Portable
HEPA filtration units
- Portable
x-ray units
Enhanced
activity
- Establish
back-up plans in the event of limited supplies.
J. Communication
and Reporting
A SARS outbreak will generate a need for rapid analysis of the status
of patients and transmission in the healthcare facility and reporting
of this information to public health officials and to the public, press,
and political leaders. These needs can overwhelm resources that are essential
to other response activities.
Objective
1 : Communicate regularly with the health
department about SARS-related activities.
Activities
- Establish
a mechanism for regular contact with the local health department to
report SARS activity in the facility and receive information on SARS
activity in the community.
- Establish
a reporting process to review discharge planning of SARS patients and
information on exposed patients and healthcare workers with health
department officials to ensure appropriate follow-up and case management
in the community.
- Discuss
jurisdictional and procedural issues for the investigation of nosocomial
SARS outbreaks.
Objective 2 : Communicate with facility staff and the
public.
Activities
- Determine
how to provide daily updates to the infection control staff and the
hospital administration regarding SARS activity in the facility and
the community.
- Determine
the preferred flow and release of information related to SARS patient
care or transmission in the facility. Public relations/media staff
should work with the SARS coordinator or designee to ensure clarity
and accuracy. Prepare plans for: 1) internal notification and communication
with patients and healthcare workers, 2) external communication with
the media and the public, coordinated with local public health officials,
and 3) development of templates for frequently asked questions, notifications,
press releases, and other communication tools.
- Determine
whether and how the facility will establish a SARS hotline for public
inquiries, if needed.
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