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

# Contents

I.  Rationale and Goals

II. Lessons Learned

III. Preparedness Planning for Healthcare Facilities

IV. Recommended Preparedness and Response Activities in Healthcare
    Facilities

    A.  Surveillance and triage

    B.  Clinical evaluation of patients

    C.  Infection control and respiratory hygiene/cough etiquette

    D.  Patient placement, isolation, and cohorting

    E.  Engineering and environmental controls

    F.  Exposure reporting and evaluation

    G.  Staffing needs and personnel policies

    H.  Access controls

    I.  Supplies and equipment

    J.  Communication and reporting

V.  Community Healthcare Delivery Issues

References

Appendix C1: Matrices for SARS Response Healthcare Facilities

> Matrix 1. Recommendations for Inpatient Facilities and Emergency
> Departments
>
> Matrix 2. Recommendations for Outpatient Facilities/Areas
>
> Matrix 3. Recommendations for Long Term Care Facilities

Appendix C2: Checklist for SARS Preparedness in Healthcare Facilities

# Preparedness and Response in Healthcare Facilities

# 

# I. Rationale and Goals

Transmission of SARS-CoV in healthcare facilities was a major factor in
the spread of SARS during the 2003 global epidemic. In areas with
extensive outbreaks, the virus spread most readily among hospital
workers caring for SARS patients, other patients, and visitors. In
Toronto, 77% of the patients in the first phase of the outbreak were
infected in the hospital setting, and half of all SARS cases in Toronto
were in healthcare workers (Booth 2003). Even in Hong Kong, where there
was significant community transmission, 21% of all SARS cases occurred
in healthcare workers (Ho 2003). Factors that likely contribute to the
disproportionate rate of transmission in healthcare settings include: 1)
a higher virus titer in respiratory secretions during the second week of
illness when patients are likely to be hospitalized (Peiris 2003), 2)
use of ventilators, nebulizers, endotracheal intubation, and other
droplet- and aerosol-generating devices and procedures, and 3) frequent
exposures of workers to patients, their secretions, and potentially
contaminated environments (Varia 2003).

The large number of hospital personnel who contracted SARS-CoV disease
demonstrates the importance of early detection, infection control, and
contact tracing in limiting the spread of disease. In every region in
which major outbreaks were reported, a substantial proportion of cases
resulted from delays in clinical recognition and isolation of patients.
SARS-CoV was also transmitted by infected visitors and by hospitalized
patients with other medical conditions that masked the symptoms of SARS
(Varia 2003). Case recognition and implementation of appropriate
precautions greatly reduced the risks of SARS-CoV transmission. However,
even with appropriate precautions, there were isolated reports of
transmission to healthcare workers in the settings of aerosol-producing
procedures and lapses in infection control technique (CDC 2003).

SARS-CoV transmission in a healthcare facility presents occupational and
psychological challenges that, in the 2003 outbreaks, required heroic
efforts to overcome. Experience also indicates, however, that early
detection and isolation of cases, strict adherence to infection control
precautions, and aggressive contact tracing and monitoring can minimize
the impact of a SARS outbreak (Seto 2003). The success of these measures
depends on exhaustive planning, clear communication, collaboration among
disciplines, authoritative leadership, and provision of relevant
support.

This Supplement provides recommendations for how to prepare for and
respond to an introduction of SARS-CoV in a healthcare facility. It
outlines basic response measures as well as the enhanced activities that
may be needed to address larger outbreaks. **As preparedness and
response activities for SARS are in many ways analogous to those
required for other types of emergency and mass-casualty events, planning
for SARS may only require integration of SARS-specific activities into
existing preparedness plans and protocols**.

The goals of a preparedness and response plan in a healthcare facility
are:

-   Rapidly identify and isolate all potential SARS patients.

-   Implement infection control practices and contract tracing to
    interrupt SARS-CoV transmission.

-   Ensure rapid communication within healthcare facilities and between
    healthcare facilities and health departments.

# II. Lessons Learned

The following lessons from the global experience with SARS-CoV in
healthcare settings have been considered in developing this document:

-   Strict adherence to contact and droplet precautions, along with eye
    protection, seems to prevent SARS-CoV transmission in most
    instances. Airborne precautions may provide additional protection in
    some instances.

-   Undetected cases of SARS-CoV disease in staff, patients, and
    visitors contribute to rapid spread of the virus.

-   Optimal control efforts require continuous analysis of the dynamics
    of SARS-CoV transmission in the facility and the community.

-   A response to SARS can strain the resources and capacity of a
    healthcare facility.

-   The social and psychological impact of SARS can be substantial, both
    during and after an outbreak.

-   The most effective systems for controlling a nosocomial outbreak are
    those that are developed and tested before an outbreak occurs.

-   Communication needs can overwhelm and paralyze response capacity;
    good information management strategies are essential to an efficient
    and effective response.

# 

# III. Preparedness Planning for Healthcare Facilities

All U.S. healthcare facilities need to be prepared for the rapid pace
and dynamic features of a SARS outbreak. All hospitals should be
equipped and ready to care for a limited number of SARS patients as part
of routine operations and also to care for a larger number of patients
in the context of escalating transmission. Plans should outline the
administrative, environmental, and communication measures and the
individual work practices required to detect the introduction of
SARS-CoV, prevent its spread, and manage the impact on the facility and
the staff.

This document details planning issues that should be addressed in
preparing for potential SARS outbreaks. It will be important for
planning committees to consider the logistics of both basic and enhanced
control measures. Section IV: Recommended Preparedness and Response
Activities in Healthcare Facilities, below, details activities that
should be discussed by a planning committee. The response matrices in
Appendix C1 provide specific recommendations on implementing these
measures.

Ideally, SARS planning will not occur in a vacuum but will build on
existing preparedness and response plans for bioterrorism or other
infectious disease emergencies and will be addressed by the same groups
responsible for developing those plans.

> **Objective 1:** Develop a planning and decision-making structure that
> ensures the capacity of the healthcare facility to detect and respond
> effectively to SARS.

**Activities**

-   Designate an internal, multidisciplinary planning committee with
    responsibility for SARS preparedness and response. Select persons
    with decision-making authority and appropriate technical expertise,
    and include representatives from all potentially affected groups. An
    existing preparedness team with appropriate membership (e.g.,
    bioterrorism response) could take on this role.

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-   Identify a local or state health department staff member who will
    serve as liaison for SARS preparedness planning and response. If
    possible, include this person on the planning committee.

-   Identify a SARS coordinator to direct planning and response efforts
    and serve as the facility's point of contact for communication
    internally (i.e., in the facility and/or healthcare system) and
    externally (i.e., to public health agencies, other healthcare
    facilities, law enforcement agencies, media, and other partners).

-   Consider including representatives from the following groups on the
    planning committee:

    -   Administration/senior management (including fiscal officer)

    -   Infection control/hospital epidemiology

    -   Hospital disaster/emergency coordinator

    -   Engineering/physical plant/industrial hygiene/institutional
        safety

    -   Nursing administration

    -   Medical staff (including outpatient areas)

    -   Intensive-care unit

    -   Emergency department

    -   Laboratory services

    -   Respiratory therapy

    -   Environmental services (housekeeping, laundry)

    -   Public relations

    -   Security

    -   Materials management

    -   Education/training/staff development

    -   Occupational health

    -   Diagnostic imaging

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-   Consider including representatives from the following areas as
    adjunct members to provide additional expertise and support:

    -   Infectious diseases

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    -   Mental health

    -   Risk management

    -   Labor and unions

    -   Human resources

    -   Pharmacy

    -   Emergency medical technicians ("first responders")

    -   Social work

    -   Director of house staff/fellowship and other training programs

    -   Pulmonary medicine

    -   Pathology

    -   Local law enforcement

# Objective 2: Develop a written SARS preparedness and response plan.

# Activities

## Develop a written plan that considers/accounts for each of the topics addressed in the box below and in Section IV: Components of Preparedness and Response in Healthcare Facilities.

-   Ideally, the logistics of both basic and enhanced measures (see Core
    Document, III.B) should be discussed in advance of a SARS outbreak.

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-   Formulate written policies and work practices to ensure the prompt
    triage, identification, and management of possible SARS patients
    while minimizing the risk of transmission to other patients,
    personnel, and visitors.

-   Devise a system for periodic review and updating of the plan as
    indicated.

######### **Objective 3:** Assess the capacity of the facility to respond to SARS.

# Activities

-   Consider using simulations ("table top" or other exercises) to test
    the facility's response capacities.

-   Identify criteria and methods for measuring compliance with response
    measures (e.g., infection control practices, case reporting, patient
    placement, healthcare worker illness surveillance).

-   Develop strategies to quickly correct deficiencies.

# 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.

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-   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*
    ([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](http://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.

# V. Community Healthcare Delivery Issues

A SARS outbreak may generate issues that exceed the scope of a
particular healthcare facility and must be addressed at the community
level, with representation from healthcare systems, public health, and
industry. Some of these issues include:

[Facilities]{.underline}

-   Designation of certain hospitals to be the primary providers of SARS
    patient care

-   Designation, development, and staffing of community SARS evaluation
    centers

-   Construction and certification of new AIIRs

-   Criteria/procedures for and impact of closure of facilities

-   Establishment of alternative "overflow" facilities

[Personnel]{.underline}

-   Protection and training of first responders

-   Personnel surge capacity for heavily affected hospitals

-   Coordination of volunteer efforts

-   Assistance to healthcare workers in quarantine or on home/work
    restrictions

-   Communication with and coordination of contract staff and
    independent physician groups

[Supplies]{.underline}

-   Implications (e.g., fit-testing) of an emergency change in
    respirator type during an outbreak

-   Adequacy of supplies of PPE and other equipment and materials

-   Coordination of donated items

[Finance]{.underline}

-   Requisition and distribution of emergency funds to assist with
    construction and modifications of facilities to care for SARS
    patients, overtime payment for healthcare and other personnel, costs
    of healthcare worker furloughs, lost revenues, and other expenses

[Legal/regulatory]{.underline}

-   Regulations to ensure that no facility can refuse to care for
    patients with SARS

-   Certification of new AIIRs

-   Liability issues related to healthcare workers in jobs for which
    they are not specifically trained

# References

Booth CM, Matukas LM, Tomlinson GA, Rachlis AR, Rose D, et al. Clinical
features and short-term outcomes of 144 patients with SARS in the
Greater Toronto area. JAMA 2003;289:2801-9.

CDC. Cluster of severe acute respiratory syndrome cases among protected
health-care workers \-- Toronto, Canada, April 2003. MMWR 2003;52:433-6.

Ho AS, Sung JJY, Chan-Yeung M. An outbreak of severe acute respiratory
syndrome among hospital workers in a community hospital in Hong Kong.
Ann Intern Med 2003 139:564-7.

Peiris JSM, Chu CM, Cheng VCC, et al. Clinical progression and viral
load in a community outbreak of coronavirus-associated SARS pneumonia: a
prospective study. Lancet 2003;361:1767-72.

Seto WH, Tsang D, Yung RWH, Ching TY, et al. Effectiveness of
precautions against droplets and contact in prevention of nosocomial
transmission of severe acute respiratory syndrome (SARS). Lancet
2003;361:1519-20.

Varia M, Wilson S, Sarwal S, McGeer A, et al. Investigation of a
nosocomial outbreak of severe acute respiratory syndrome (SARS) in
Toronto, Canada. Can Med Assoc J 2003;169:285-92.

# Appendix C1

# Matrices for SARS Response in Healthcare Facilities

**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**

**Matrix 1: Recommendations for Inpatient Facilities and Emergency
Departments (continued)**

+----------+-----------------------------------------------------------+
| **Level  | **Suggested actions**                                     |
| of SARS  |                                                           |
| ac       |                                                           |
| tivity** |                                                           |
+----------+-----------------------------------------------------------+
| No cases | 1)  Patient placement                                     |
| of SARS  |                                                           |
| in the   | -   **In the presence of person-to-person SARS-CoV        |
| facility |     transmission in the world but NO known transmission   |
|          |     in the area around the facility:**                    |
| (co      |                                                           |
| ntinued) | ```{=html}                                                |
|          | <!-- -->                                                  |
|          | ```                                                       |
|          | -   Patients presenting with fever or lower respiratory   |
|          |     symptoms ***and*** epidemiologic risk factors for     |
|          |     SARS 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 precautions are 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*                           |
|          |     ([www.cdc.gov/ncidod/sars/clinicalguidance.ht         |
|          | m](http://www.cdc.gov/ncidod/sars/clinicalguidance.htm)). |
|          |                                                           |
|          | -   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.                                              |
|          |                                                           |
|          | ```{=html}                                                |
|          | <!-- -->                                                  |
|          | ```                                                       |
|          | -   **In the presence of person-to-person SARS-CoV        |
|          |     transmission in the world but NO known transmission   |
|          |     in the area around the facility:**                    |
|          |                                                           |
|          | ```{=html}                                                |
|          | <!-- -->                                                  |
|          | ```                                                       |
|          | -   Patients presenting with fever or lower respiratory   |
|          |     symptoms 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*           |
|          |     ([www.cdc.gov/ncidod/sars/clinicalguidance.ht         |
|          | m](http://www.cdc.gov/ncidod/sars/clinicalguidance.htm)). |
|          |                                                           |
|          | -   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.                                              |
|          |                                                           |
|          | 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  | # Suggested actions                                    |
| SARS        |                                                        |
| activity**  |                                                        |
+-------------+--------------------------------------------------------+
| A few cases | 1)  Triage activities/facility access controls         |
| in the      |                                                        |
| facility,   | -   Same as for "No cases of SARS in the facility."    |
| but all     |     Add:                                               |
| cases are   |                                                        |
| imported    | -   No visitors to SARS patients unless necessary      |
| (NO         |     (e.g., parents, translators); visitors must        |
| nosocomial  |     receive infection control training.                |
| tr          |                                                        |
| ansmission) | -   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  | # Suggested actions                                    |
| SARS        |                                                        |
| activity**  |                                                        |
+-------------+--------------------------------------------------------+
| A larger    | 1)  Triage activities/access controls                  |
| number of   |                                                        |
| SARS cases  | -   Same as for "A few cases in the facility but all   |
| in the      |     cases are imported." Add:                          |
| facility OR |                                                        |
| nosocomial  | -   Regardless of the level of SARS activity in the    |
| t           |     community around the facility:                     |
| ransmission |                                                        |
| with all    |     -   Limit visitors (e.g., one per patient per      |
| cases       |         day).                                          |
| linked to a |                                                        |
| clearly     |     -   Maintain a log of all visitors to SARS         |
| identified  |         patients to aid in contact tracing.            |
| source      |                                                        |
|             |     -   Limit elective admissions/procedures.          |
|             |                                                        |
|             |     -   All healthcare workers and visitors should     |
|             |         have a fever check and perform hand hygiene on |
|             |         entry.                                         |
|             |                                                        |
|             | 2)  Patient placement                                  |
|             |                                                        |
|             | -   Same as for "A few cases in the facility but all   |
|             |     cases are imported." Add:                          |
|             |                                                        |
|             | 3)  Designated personnel                               |
|             |                                                        |
|             | -   Same as for "A few cases in the facility but all   |
|             |     cases are imported."                               |
|             |                                                        |
|             | 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*                        |
|             |     ([www.cdc.gov/ncidod/sars/clinicalguidance.htm)](  |
|             | http://www.cdc.gov/ncidod/sars/clinicalguidance.htm)). |
|             |                                                        |
|             | -   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 few cases in the facility but all   |
|             |     cases are imported."                               |
+-------------+--------------------------------------------------------+

**Matrix 1: Recommendations for Inpatient Facilities and Emergency
Departments (continued)**

+-------------+--------------------------------------------------------+
| **Level of  | # Suggested actions                                    |
| SARS        |                                                        |
| activity**  |                                                        |
+-------------+--------------------------------------------------------+
| Cases       | 1)  Triage activities/access controls                  |
| attributed  |                                                        |
| to          | -   Same as for "A larger number of cases or linked    |
| nosocomial  |     transmission." Add:                                |
| t           |                                                        |
| ransmission | -   No visitors allowed in hospital unless necessary   |
| with NO     |     (e.g., parents, translators); visitors must        |
| clearly     |     receive infection control training.                |
| identified  |                                                        |
| source      | -   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    | **Suggested actions**                                |
| SARS          |                                                      |
| activity**    |                                                      |
+---------------+------------------------------------------------------+
| No            | 1)  Patient screening and precautions                |
| per           |                                                      |
| son-to-person | -   In accordance with recommendations for           |
| SARS          |     respiratory hygiene/cough etiquette, instruct    |
| transmission  |     all patients with symptoms of a respiratory      |
| reported      |     infection to perform hand hygiene and cover the  |
| anywhere in   |     nose/mouth. Manage these patients with Droplet   |
| the world     |     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)**

**Matrix 3: Recommendations for Long-Term Care Facilities**

+---------------+------------------------------------------------------+
| **Level of    | ## Suggested actions                                 |
| SARS          |                                                      |
| activity**    |                                                      |
+---------------+------------------------------------------------------+
| No            | 1)  Patient precautions                              |
| per           |                                                      |
| son-to-person | -   In accordance with recommendations for           |
| SARS          |     respiratory hygiene/cough etiquette, patients    |
| transmission  |     who develop symptoms of a respiratory infection  |
| reported      |     should be placed on Droplet Precautions until    |
| anywhere in   |     determined that they are not needed.             |
| the world     |                                                      |
|               | 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   | 1)  Patient precautions                              |
| per           |                                                      |
| son-to-person | -   Same as for "No person-to-person SARS            |
| SARS          |     transmission reported anywhere in the world."    |
| transmission  |     Add:                                             |
| worldwide,    |                                                      |
| but no known  | -   Screen all potential admissions for symptoms and |
| transmission  |     epidemiologic links to SARS.                     |
| in the area   |                                                      |
| around the    | 2)  Healthcare worker precautions                    |
| facility      |                                                      |
|               | -   Same as for "No person-to-person SARS            |
|               |     transmission reported anywhere in the world."    |
|               |                                                      |
|               | 3)  Infrastructure issues                            |
|               |                                                      |
|               | -   Same as for "No person-to-person SARS            |
|               |     transmission reported anywhere in the world."    |
|               |                                                      |
|               | 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         | 1\) Patient precautions                              |
| transmission  |                                                      |
| in the area   | -   Same as for "No person-to-person SARS            |
| around the    |     transmission reported anywhere in the world."    |
| facility      |                                                      |
|               | -   All new admissions should be evaluated at an     |
|               |     acute-care facility (no direct admissions).      |
|               |     Patients with fever or lower respiratory         |
|               |     symptoms 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](h |
|               | ttp://www.cdc.gov/ncidod/sars/clinicalguidance.htm)) |
|               |     before being admitted. Patients who are          |
|               |     asymptomatic but had exposures should be         |
|               |     observed for 10 days for the development of      |
|               |     symptoms before they are admitted.               |
|               |                                                      |
|               | -   If there is significant transmission in the      |
|               |     community around the facility, initiate          |
|               |     surveillance for nosocomial lower respiratory    |
|               |     illness, and transfer all patients who develop   |
|               |     such illness to an acute-care facility for       |
|               |     evaluation. Acute-care facilities should be      |
|               |     notified that the patients are being transferred |
|               |     for evaluation of SARS.                          |
|               |                                                      |
|               | 2\) Healthcare worker precautions                    |
|               |                                                      |
|               | -   Same as for "No person-to-person SARS            |
|               |     transmission reported anywhere in the world."    |
|               |                                                      |
|               | -   Healthcare workers should undergo symptom        |
|               |     monitoring. Symptomatic healthcare workers       |
|               |     should be furloughed and 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](ht |
|               | tp://www.cdc.gov/ncidod/sars/clinicalguidance.htm)). |
|               |                                                      |
|               | 3\) Infrastructure issues                            |
|               |                                                      |
|               | -   Same as for "No person-to-person SARS            |
|               |     transmission reported anywhere in the world."    |
|               |                                                      |
|               | 4\) Access controls                                  |
|               |                                                      |
|               | -   Visitors should be actively screened for         |
|               |     symptoms.                                        |
|               |                                                      |
|               | -   Visitors with symptoms should not be allowed     |
|               |     into the facility.                               |
+---------------+------------------------------------------------------+

#  Appendix C2

# Checklist for SARS Preparedness in Healthcare Facilities

The most common source of transmission of SARS-CoV has been healthcare
facilities. Consequently, control of spread in healthcare facilities is
critical to controlling SARS. The keys to quickly controlling SARS are
rapid and appropriate decision making and rapid and effective
implementation of response activities. The need for rapid and effective
responses requires that planning and preparedness activities precede
SARS-CoV activity.

The following checklist is a planning tool for healthcare providers. The
checklist format is not intended to set forth mandatory requirements or
establish national standards for healthcare preparedness. Rather, each
healthcare facility should determine for itself whether it is adequately
prepared for disease outbreaks in accordance with its own procedures.

**Structure for planning and decision making**

-   Designate a planning and response committee that includes
    representatives from a variety of departments (e.g., administration,
    infection control, hospital epidemiology, etc.)

-   Identify the local or state health department contact who will serve
    as liaison for SARS preparedness planning and response.

-   Identify a SARS coordinator to serve as the facility's point of
    contact for communication of information internally and externally.

**Written SARS preparedness and response plan**

-   Develop written policies and work practices for SARS patients that
    minimize the risk of transmission to other patients, healthcare
    workers, and visitors.

-   Define a system to review and update the plan as new information and
    strategies develop.

**Function and capacity of the facility to respond to SARS**

-   Test the facility's SARS response capabilities of the facility by
    using "table top" or other exercises.

-   Identify criteria and methods for measuring compliance with the
    implementation of response activities.

-   Develop strategies to quickly correct deficiencies in implementation
    of response activities.

**Surveillance, screening, triage, and evaluation in healthcare
facilities**

-   Ensure that clinicians can promptly detect, report, and manage
    potential SARS patients.

-   Identify a local or state health department contact to coordinate
    surveillance for cases of SARS.

-   Develop measures for symptom monitoring and reporting of healthcare
    workers and patients potentially exposed to SARS-CoV, in accordance
    with public health recommendations.

-   Educate clinical healthcare providers about signs and symptoms of
    and risk factors for SARS-CoV disease.

-   Be prepared to recognize and report unusual clusters of pneumonia.

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-   Know where and how to promptly report a potential SARS case to
    hospital and public health officials.

-   Develop procedures for rapidly implementing appropriate isolation
    and infection practices for potential SARS patients.

-   Develop procedures to perform an appropriate and safe evaluation of
    patients with SARS-like illnesses that accounts for level of
    SARS-CoV transmission.

**Infection control, isolation, and cohorting measures, and
environmental controls**

-   Develop comprehensive isolation and infection control guidelines and
    strategies for patient-related activities in the hospital and
    optimal overall safety of staff, patients, and visitors.

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-   Develop a patient placement and transport plan that ensures
    appropriate isolation and infection control strategies to minimize
    the risk of transmission to staff, patients, and visitors.

-   Develop a plan to formally monitor and reinforce compliance with PPE
    measures and to update those measures as needed as a SARS outbreak
    progresses.

-   Develop optimal patient placement strategies that account for the
    availability of AIIRs.

-   Review and ensure that air-handling capacity of rooms is adequate
    for isolation and infection control needs of SARS patients.

**Exposure reporting and evaluation of risk**

Educate staff regarding:

-   Modes of SARS-CoV transmission

-   Risks associated with different patient-care procedures

-   Risks to healthcare workers, patients, and visitors

-   Importance of reporting exposures and illness

-   How and to whom to report SARS-CoV exposures and illness

**Administrative and organizational 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.

-   Determine whether a small group of staff, including ancillary staff,
    could be assigned responsibility for providing initial care for SARS
    patients.

-   For teaching hospitals, determine what role, if any, students and
    other trainees (e.g., residents, fellows) will play in the care of
    SARS patients.

-   Develop a strategy to meet the staffing needs as the number of SARS
    patients increases and/or personnel become ill or are quarantined.

-   Develop a strategy to ensure the availability of a sufficient number
    of infection control practitioners (ICPs) to allow for daily
    monitoring and assessment of all patient-care areas.

-   Develop a plan for healthcare workers that includes criteria for
    furloughs and work restrictions, appropriate measures to help
    healthcare workers comply with

> restrictions (including access to mental health professionals),
> follow-up after
>
> unprotected exposures to SARS patients, and notification of multiple
> facilities at
>
> which they work.

-   Establish criteria and protocols for controlling access to
    hospitals, including admissions, transfers, discharges, and
    visitors.

-   Develop a plan that determines when and how to involve security
    services to enforce access limitations.

-   Establish criteria and protocols to determine when to close the
    facility to new admissions and transfers.

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-   Assess anticipated needs for consumable and durable resources
    required to provide care for various numbers of SARS patients, and
    develop a plan to meet the extra need.

-   Develop a back-up plan to deal with the possibility of limited
    supplies.

**Communication and reporting**

-   Establish a mechanism and contacts for regular communications with
    the state and local health departments.

-   Develop a plan to communicate with and report to health departments
    information on SARS activity in the healthcare facility and
    information on exposed visitors.

-   Develop a plan for discharge of SARS patients and appropriate
    follow-up and case management in the community.

-   Address jurisdictional and procedural issues for the investigation
    of nosocomial SARS outbreaks.

-   Develop a plan to provide daily updates to the infection control
    staff and the hospital administration regarding SARS activity in the
    facility and the community.

-   Develop a plan for the flow and release of information related to
    SARS patient care or SARS-CoV transmission in the facility.

-   Develop criteria to determine whether and how the facility will
    establish a SARS hotline for public inquiries.

**Community healthcare delivery**

Determine how the healthcare facility will participate in and be
affected by community-level healthcare-related issues such as:

-   Community management of SARS patients

-   Expansion of AIIR facilities

-   Training of first responders to safely manage SARS patients

-   Development of community-wide strategies to meet healthcare

worker shortages

-   PPE supplies

-   Funding needs

-   Legal regulations

-   Liability issues related to healthcare personnel

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.