Public Health Guidance for Community-Level Preparedness and Response to
Severe Acute Respiratory Syndrome (SARS) Version 2

Supplement C: Preparedness and Response in Healthcare Facilities

IV\. Recommended Preparedness and Response Activities in Healthcare
Facilities

## 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).

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-   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:

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-   Travel to mainland China, Hong Kong, or Taiwan,[^1] or close
    contact[^2] 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

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-   Be alert for clusters of pneumonia among two or more healthcare
    workers who work in the same facility.

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-   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 (detailed below).

-   Ensure that clinicians know where and how to promptly report a
    potential SARS case to hospital and public health officials (See
    Supplement B).

> **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 Section H: Access Controls). 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

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-   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**

-   Evaluate patients requiring hospitalization for radiographically
    confirmed pneumonia (or acute respiratory distress syndrome) of
    unknown etiology according to the algorithm (Figure 1) in *Clinical
    Guidance on the Identification and Evaluation of Possible SARS-CoV
    Disease among Persons Presenting with Community-Acquired Illness*
    ([www.cdc.gov/ncidod/sars/clinicalguidance.htm](http://www.cdc.gov/ncidod/sars/clinicalguidance.htm)).

-   In the absence of SARS-CoV transmission worldwide, evaluation and
    management for possible SARS-CoV disease should be considered only
    for adults, unless special circumstances make the clinician and
    health department consider a child to be at potentially higher risk.

> **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*
    ([www.cdc.gov/ncidod/sars/clinicalguidance.htm](http://www.cdc.gov/ncidod/sars/clinicalguidance.htm)).

-   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.

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-   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
    ([www.cdc.gov/ncidod/sars/clinicalguidance.htm](http://www.cdc.gov/ncidod/sars/clinicalguidance.htm)).
    Decisions on return to work should be guided by policies or
    regulations defined by the facility and/or health department.

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-   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:

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-   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
    ([www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm](http://www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm)
    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.

## 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
    (*[www.cdc.gov/ncidod/hip/enviro/guide.htm](http://www.cdc.gov/ncidod/hip/enviro/guide.htm)).

-   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
    ([www.cdc.gov/ncidod/hip/enviro/guide.htm](http://www.cdc.gov/ncidod/hip/enviro/guide.htm)).

-   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

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-   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.

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-   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.

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-   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
        (www.cdc.gov/ncidod/sars/clinicalguidance.htm).

## 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)

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-   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.

For more information, visit
[www.cdc.gov/ncidod/sars](http://www.cdc.gov/ncidod/sars/) or call the
CDC public response hotline\
at (888) 246-2675 (English), (888) 246-2857 (Español), or (866) 874-2646
(TTY)

[^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.