# Presentation: 026011

## SARS Preparedness and Response in Healthcare Facilities

## Lessons learned for healthcare

- Healthcare facilities were critical areas in the 2003 outbreak.
- They were essential in controlling the outbreak, despite being among the hardest hit by it.

## Lessons learned for healthcare

- Unprotected exposures to unrecognized cases accounted for significant transmission in healthcare facilities.
- Strict adherence to infection control practices is highly effective in preventing transmission.

## Lessons learned for healthcare

- SARS stretched healthcare resources to their limits.
- Preparedness planning will be essential to limiting the impact of any future outbreaks.

## Key objectives for healthcare facilities

- Multi-disciplinary plan to address a potential outbreak.
- Early identification of cases.
- Rapid and effective isolation of cases.
- Implementation of effective infection control measures.

## Key objectives for healthcare facilities

- Ability to manage a small number of SARS patients without disrupting delivery of care.
- Good communication with HCWs, community and public health.

## Development of a SARS plan

- Given the range of issues involved, and the speed and complexity of the required response, facilities should consider developing a formal SARS preparedness and response plan.
- This plan may simply be an addition to existing bio-terrorism or emergency response plans.

## SARS planning committee

- Designated person to co-ordinate an outbreak response and chair a planning committee.
- Multi-disciplinary planning committee with representation from all groups potentially affected by SARS, e.g.:
- Medical, nursing, laboratory and support staff.
- Administration.
- Infection control

## SARS planning committee

- Other groups may need to be adjunct members to consider certain issues, e.g.
- Labor and unions
- Mental health
- Directors of training/teaching programs

## Key issues to consider

- Surveillance
- Clinical evaluation
- Infection control measures
- Patient isolation
- Engineering controls
- Exposure evaluation
- Staffing needs and personnel policies
- Access controls
- Supplies and equipment
- Communication

## SARS surveillance- The backbone of response

- Early diagnosis and detection can prevent further transmission, while missed cases can lead to large outbreaks.
- Healthcare facilities will play a crucial role in surveillance.
- Surveillance activities must expand as SARS activity escalates.

## Surveillance in the absence of SARS

- Clinical features along with epidemiologic data, especially exposure risks, will drive index of suspicion.
- Challenges-
- How to catch early cases given that SARS is extremely unlikely and the presentation is non-specific.
- How to screen with no epidemiologic links.

## Surveillance in the absence of SARS

- Will need to rely on known risk factors for SARS:
- Travel to previously affected areas
- Contact with healthcare facilities
- Contact with other patients with unexplained pneumonia.

## Surveillance recommendations

- Ask all patients hospitalized with unexplained pneumonia about the known risks.
- Report cases to the health department to aid recognition of clusters of unexplained pneumonia.
- SARS testing should be used judiciously, in consultation with public health representatives.

## Surveillance in the presence of SARS

- If SARS comes back, surveillance must expand.
- Screen all patients with fever or respiratory symptoms (not just those admitted) for known risks, especially travel to areas where SARS is active OR contact with a SARS patient.

## Clinical evaluation

- In the ***absence*** of SARS activity in the world, patients with pneumonia should be evaluated as usual, with addition of screening questions for SARS risks.
- In the ***presence*** of SARS activity, the SARS clinical algorithms (Appendices C2, C3) can help guide evaluation _in patients who have SARS risk factors_.

## Draft-Algorithm to Work Up and Isolate Symptomatic Persons who may have been Exposed to SARS

- Begin SARS isolation precautions, initiate preliminary work up and notify Health Department2

- No Radiographic Evidence of
- Pneumonia

- No Alternative Diagnosis

- Continue SARS isolation and re-evaluate
- 72 hours after initial evaluation

- Persistent fever or
- unresolving respiratory symptoms

-  Perform SARS test
-  Continue SARS isolation for additional
-    72 hours.  At the end of the 72
-    hours, repeat clinical evaluation
-    including CXR

- No radiogrpahic evidence of
- pneumonia

- Symptoms
- improve
- or resolve

**- CXR**

**Draft-Algorithm to Work Up and Isolate Symptomatic Persons who may have been Exposed to SARS**

- + CXR

- Radiographic Evidence
- Of Pneumonia

**+ CXR**

- Perform SARS testing

- Laboratory evidence
- of SARS-CoV or
-  No alternative diagnosis

- Alternative diagnosis
- confirmed3

- Continue SARS isolation until
- 10 days following resolution of
- fever given respiratory
- symptoms are absent or
- resolving

- Consider D/C
- SARS isolation
- precautions5

- Alternative diagnosis
- confirmed3

- Consider D/C
- SARS isolation
- precautions5

- Consider D/C
- SARS isolation
- precautions5

## Clinical evaluation

- Ensure that staff who will evaluate potential SARS cases have access to and appropriate training with personal protective equipment.

## Infection control measures

- Make sure HCWs understand the importance of basic infection control practices like isolation and hand hygiene (whether there is SARS or not!).

## Infection control measures

- Consider adopting a universal, “respiratory hygiene/cough etiquette” strategy.
- Common and important pathogens are transmitted by respiratory secretions: influenza, pertussis, mycoplasma.
- Controlling respiratory secretions can help reduce transmission.

## Respiratory hygiene/ Cough etiquette

- Encourage patients to alert staff if they are suffering febrile respiratory illness.
- Give patients a surgical mask to wear or tissues to cover their noses and mouths.
- Encourage patients to practice hand hygiene after touching their faces.

## Respiratory hygiene/ Cough etiquette

- Separate patients with febrile respiratory illness from other patients in the waiting area.
- Manage patients using droplet precautions until it is determined the cause of the respiratory illness is a pathogen that does not require precautions.

## Patient isolation

- Though most transmission appears to occur from infectious droplets, there are infrequent episodes where airborne transmission cannot be excluded.
- CDC recommends that SARS patients be managed with _airborne PLUS contact precautions_.

## Airborne isolation

- Potential SARS patients should be placed in airborne infection isolation or negative pressure rooms (AIIRs).
- Healthcare workers should wear a fit-tested N95 (or higher) respirator or personal air purifying respirator (PAPR) in addition to gowns, gloves and eye protection.

## Patient cohorting

- Some facilities have few (or no) negative pressure rooms.
- Facilities will need to decide at what point they will choose to cohort patients onto a “SARS unit” in private, but non-negative pressure, rooms.

## Advantages of a SARS unit

- Focuses SARS related resources in one area.
- Physically separates SARS patients from others.
- Was an effective strategy in parts Toronto and Taiwan.

## Engineering controls

- Determine capacity for airborne isolation in both the ICU and non-ICU settings.
- Determine how a SARS unit might be created:
- Can any nursing unit be made negative pressure to surroundings?
- Can rooms on any unit be converted to negative pressure?

## Engineering controls

- Identify a space that might serve as a SARS evaluation center in the event of a larger outbreak.
- Determine how best to get patients to and from the evaluation center.

## Exposure reporting and evaluation

- Surveillance of exposures may help with early case identification.
- Develop a mechanism for reporting and follow-up of exposed HCWs.

## Exposure reporting and evaluation

- Perform symptom surveillance for fever or respiratory symptoms in HCWs with unprotected low-risk exposures.
- Consider furlough of HCWs with unprotected high-risk exposures (i.e. during respiratory procedures).
- Evaluate symptomatic HCWs with the SARS clinical algorithm.

## Staffing needs 

- SARS posed a unique challenge for staffing needs with increased demands but diminished availability of HCWs due to illness and furlough.

## Staffing issues

- Determine staffing needs for varying numbers of SARS patients.
- Consider designating teams to provide initial care in an outbreak:
- General, multi-disciplinary care team
- Emergency care/ ICU team
- Respiratory procedures team
- Consider how teams could be expanded.

## Staffing issues

- Caring for SARS patients is emotionally and physically draining for HCWs, especially with prolonged respirator wear.
- Staffing may have to be increased to allow HCWs to have “PPE free” time.

## Personnel policies

- A variety of issues to consider:
- What will be the criteria for furlough?
- Will furlough be paid or unpaid?
- How will exposure evaluations and follow-up be done?
- What assistance can the facility provide to HCWs on home/work quarantine?
- What mental health assistance can be provided to help HCWs deal with the stress of an outbreak?

## Facility Access Controls

- During an outbreak, careful screening of entrants, combined with access controls to the facility can help keep unrecognized cases from entering.

## Access controls

- Facilities will also need to establish criteria to limit visitors, especially to SARS patients.
- Criteria for limiting elective procedures and even new admissions may be needed in a large outbreak.

## Supplies and Equipment

- Determine the current availability of and anticipated need for supplies that might be needed in an outbreak:
- Personal protective equipment and hand hygiene supplies.
- Ventilators
- Consider what back up plans are in place if supplies are limited.

## Communication

- Clear and quick communication with the health department, facility staff and public will be crucial to manage the outbreak and control panic.

## Health Departments

- Establish a mechanism to share information with the health department:
- SARS activity in the community
- SARS activity in the facility
- Exposures, for contact tracing
- Information on SARS patients about to be discharged for community isolation

## Staff and Public

- Determine ways to update people on SARS activity in the hospital, what control measures are being taken and what they may be asked to do (e.g. entry screening etc).
- Co-ordinate information release with health department so messages are consistent.

## Broader Healthcare System Issues

- A large SARS outbreak will generate resource needs that must be addressed at a larger level than one facility:
- Funding for furlough, lost revenue
- Supply shortages
- Staff shortages
- Regulatory issues

## Conclusions

- SARS poses a major challenge to healthcare facilities and staff.
- Healthcare workers around the world demonstrated enormous courage to meet that challenge last year.

## Conclusions

- Facilities can help by developing plans to manage SARS (and other infectious emergencies) in advance.
- Facilities should be prepared to move “swiftly and boldly” to implement aggressive control measures.

## CDC SARS Preparedness Planhttp://www.cdc.gov/ncidod/sars/sarsprepplan.htm

- Thank you!

## Home/work quarantine

- To ensure adequate staff in facilities in Toronto, some exposed HCWs were placed on home/work quarantine.
- They were only allowed to travel back and forth to work, but were otherwise required to stay home.
- This might be needed if an outbreak become large.