# Presentation: 000288

## Infection Control Preparedness Planning for SARS 

- Linda A. Chiarello, RN, MS

## Planning Goal

- Protect the healthcare community from SARS
- Patients
- Healthcare Workers (HCWs)
- Visitors

## SARS Preparedness Planning

- Preparedness Plan Elements
- Organizational infrastructure
- Logistics of patient care
- Staffing
- Durable and consumable resources
- Exposure management
- Patient focused pre-event planning
- Lessons learned
- Fix the weaknesses in the system

## Lessons Learned:Case Study #1

- Toronto Hospital Emergency Department
- Patient contacts as SARS transmission risks
- Evidence for close contact/droplet spread
- Implement precautions at point of first encounter

## Friday, March 7th 

**(Mother)**

**Admitted to SGH **

**Patient A**

**(Son)**

**SGH**

**Friday, March 7****th**** **

## Night of March 7th

**Night of March 7****th**

**Observation Unit  ER SGH**

- Patient A

- Patient C

- Patient B

## Toronto Hospital

**Toronto Hospital**
**Emergency Department**
**March 16; 22:45-23:30**

## Lessons Learned:Case Study #2

- Toronto Outbreak: Phase II
- Barrier precautions are protective
- Maintain vigilance after outbreak is “over”

## SARS 2 - NYGH

## Lessons Learned:Case Study # 3

- SARS Transmission During
- Aerosol-Generating Procedures
- Risk of transmission may be heightened during aerosol-generating procedures
- Importance of using full barrier precautions and careful use of PPE

## Cluster of Severe Acute Respiratory Syndrome Cases Among Protected Healthcare Workers --- Toronto, Canada, April 2003 
Canadian family physician
April 4: Onset of symptoms
April 13: ICU
Non-invasive positive pressure ventilation (BiPAP)
Intubation (assist-control ventilation)
Frothy secretions that obstructed ventilator tubing, requiring disconnection and drainage
Switched to high-frequency oscillatory ventilation for 7 days

**Canadian family physician**
**April 4: Onset of symptoms**
**April 13: ICU**
**Non-invasive positive pressure ventilation (BiPAP)**
**Intubation (assist-control ventilation)**
**Frothy secretions that obstructed ventilator tubing, requiring disconnection and drainage**
**Switched to high-frequency oscillatory ventilation for 7 days**

**Communicability is heterogeneous: aerosol-generating medical procedures **

## Slide 12

## What have we learned?

- SARS transmission
- Primarily through close contact with infected persons
- Droplet spread most likely
- Cannot rule out fomites and possibility of airborne spread
- Intensity of exposure during aerosol-generating procedures may increase transmission risks

## What have we learned?

- SARS transmission risks are primarily from:
_**Unprotected exposures to**_ _**unrecognized cases**_ in both inpatient and outpatient settings.
- We must look beyond the patient ... contacts may be infectious too.
- Prevention begins when a patient or visitor walks through the door of an Emergency Department or outpatient office.

## What have we learned?

- Use of PPE prevents transmission...however,
- Healthcare personnel need instruction on how to don, use and remove PPE
- Wearing PPE for extended periods of time is a burden and can lead to breaches in technique

## What have we learned?

- Cohorting groups of patients that require airborne isolation is challenging but can be done
- Advance planning is necessary to ensure the protection of HCWs, patients and visitors

## What should be our immediate priorities?

- Improve recognition and prevention of transmission at the initial point of patient encounter
- Improve PPE use practices
- Review precautions for aerosol-generating procedures

## Act Now!Address Prevention Planning Priorities in Emergency Departments and Outpatient Offices

## 	What would happen today if a patient with symptoms of SARS presented to your Emergency Department or outpatient office?

## Opportunities for Prevention Intervention in Emergency Departments and Outpatient Offices 

- Triage and reception encounter
- Waiting room encounter
- Evaluation by the healthcare provider
- Transport (e.g., to radiology)
- Respiratory treatment
- Hospital admission process

## Prepare to make changes at the first point of patient encounter

- Examine your triage, reception and appointment procedures
- Are patients queried about respiratory symptoms?
- Are personnel trained to observe for respiratory symptoms in patients and visitors?
- What instructions are provided to patients who are symptomatic?

## Prepare to make changes at the first point of patient encounter

- Consider ways to prevent exposures....
- Visual alerts with instructions at entrances
- Designate “sick” and “well” waiting areas
- Create physical barriers between patients and triage/reception personnel
- Promote “Respiratory Etiquette”

## Promote “Respiratory Hygiene”

- Instruct ALL patients with respiratory symptoms to cover nose/mouth with tissue when coughing or sneezing
- Make hand hygiene products and tissues available in waiting areas
- Offer masks to symptomatic persons

## Patient-Focused Pre-Event Planning: Emergency Departments and Outpatient Offices

- Patient examination by the healthcare provider
- Where will the patient with respiratory symptoms be examined?
- What PPE will the provider wear?

## Assess Airborne Isolation Capacity in Emergency Departments and Outpatient Areas

- Is there an airborne isolation room available for the initial patient examination?
- If not, what room or area would be appropriate for the initial examination of a patient with symptoms of SARS?
- Distance from other examination rooms
- Ability to redirect air flow

## Assess Current PPE Practices in Emergency Departments  and Outpatient Offices

- Assess availability of PPE
- Are gowns, gloves, respirators or surgical masks, and face/eye protection available?
- Are N95 respirators available and have staff been fit-tested?
- Review PPE use with healthcare providers
- Reinforce importance of hand hygiene

## Patient-Focused Pre-Event Planning: Emergency Departments and Outpatient Offices

- Transport of patient for diagnostic procedures, treatment, admission
- How will the patient be transported?
- Who will be responsible?
- Hospital admission (if necessary)
- Who needs to be notified?
- Infection Control
- Health Department
- Receiving patient care unit

## Act Now!Address Prevention Planning Priorities in Hospitals

## 	What would happen today if a SARS patient is admitted to my hospital?

## Patient-Focused Pre-Event Planning:Hospitals

- Where will the patient be isolated?
- How will we move the patient through the admissions process to the isolation room?
- Who will care for the patient? Have they been trained?

## Patient-Focused Pre-Event Planning:Hospitals

- What if the patient needs to be placed on a ventilator?
- Who will do it?
- Where will it be done?
- What PPE will be worn?
- How will family members and other contacts be managed?
- Who needs to be in the communication loop?
- What if there is an exposure?
- Is there a procedure that tells me what to do?

## 	What would happen today if I learned that a patient who has been hospitalized for one week has been diagnosed with SARS?

## Patient-Focused Pre-Event Planning: Hospitals

- Is the patient isolated? If not, where should he/she be placed?
- Does anyone else have symptoms of SARS?  How would I find out?
- Who has been exposed? How would I find out?
- HCWs?
- Other Patients?
- Visitors?
- What should we do with exposed persons?

## Act Now!!!Test the System!

- Develop “SARS Patient” scenarios for your work area
- Test them out to identify and correct problems

## Organizational Planning:Create the Infrastructure to Detect and Respond to SARS

## SARS Preparedness Planning:Areas of Overlap with Disaster, Bioterrorism and Pandemic Influenza Planning

- Preparedness Plan Elements
- Organizational infrastructure
- Logistics of patient care
- Staffing
- Durable and consumable resources
- Exposure management

## Creating the Organizational Infrastructure

- Multi-disciplinary team
- Scientific leadership – healthcare epidemiology/infection control
- Administrative leadership
- Clinical representation
- Engineering/Environmental Services
- Communications/public relations
- Safety/security
- Other

## Creating the Organizational Infrastructure

- Collaboration with community and public health planning groups
- State and local health department
- Disaster preparedness planning groups
- Healthcare facility planning groups

## Creating the Organizational Infrastructure

- Creation of internal and external communication channels...*solidify these NOW!!*
- Health department contacts
- Chain of internal communication
- Responsibility for media communications
- Scientific spokesperson

## Patient Admission Planning

- Identify areas that will be used for the care of SARS patients
- Decide how patients will be cohorted
- Consider the need to segregate suspect from probable cases
- Exposed asymptomatic patients
-  Involve engineering personnel in determining optimal locations for cohorting

## Evaluate Existing Facility Design and Functioning

- Identify all airborne isolation rooms in facility - ensure proper functioning
- Identify area(s) that can be converted for airborne isolation...should be able to:
- Seal off from other patient areas
- Establish negative pressure relative to surrounding areas
- Exhaust  directly outside (_>_25 ft from intake) or pass through HEPA filter
- Supplement with portable HEPA or UV

## Patient Admission Planning:Configuration of SARS Units

- Designate locations for:
- PPE and other isolation supplies
- Waste and linen receptacles
- Soiled equipment/PPE receptacles
- Assign responsibility for restocking isolation units and removing waste/ linen
- Assign responsibility for reprocessing reusable PPE (e.g., goggles)

## Patient Admission Planning:Configuration of SARS Units

- Determine how to restrict traffic flow
- Consider placing physical barriers and visual alerts
- Establish designated work patterns when moving within unit to limit contamination
- Train personnel on these procedures!

## Environmental Cleaning and Disinfection

- Assess staffing needs to meet requirements for daily and terminal cleaning of SARS patient rooms or units
- Consider dedicating specially trained staff for this assignment
- Review current room cleaning protocols

## Develop Plans for Educating and Training Healthcare Personnel

- “SARS 101”  for clinical and support staff
- Training on Isolation practices
- PPE use -demonstration of competency?
- Isolation practices in a SARS unit
- Plan for caring for SARS patients
- Specialized training?
- Designated SARS care teams
- Aerosol-generating procedures teams
- Designated environmental services personnel
- Respirator fit-testing and training

## Provide Informational and Instructional Materials

- Posters on PPE use and Hand Hygiene
- Patient and visitor information

## Surveillance Planning

- Develop systems for:
- Monitoring patient contacts
- Surveillance for transmission to patients and personnel
- Exposure reporting
- HCW exposure management
- Symptom monitoring
- Work furlough

## Planning for Surge CapacityWhat is “Surge Capacity” for SARS?

## Surge Capacity Planning

- Assessment of human resource needs
- Assessment of durable and consumable resource needs
- Logistics of patient triage, evaluation, admission, discharge, transfer

## Surge Capacity Planning

- Control of traffic into and out of facility
- Ramp up of education and training

## Surge Capacity Planning:Human Resource Needs

- Number and categories of healthcare personnel required to provide SARS care for multiple patients
- Establish policies regarding students and trainees
- Consider need for “PPE breaks”
- Consider how temporary staffing needs will be met if existing resources are exceeded

## Surge Capacity Planning:Consumable and Durable Resources

- Consumable resources
- PPE supply needs per patient/day
- Mechanisms for meeting increased demand for supplies
- Contingency plans for limited resources
- Durable resources
- Respiratory support equipment
- Patient-dedicated equipment

## Surge Capacity Planning:Limiting Hospital Contact

- Restricted entrances
- Fever screening on entry
- Visitor limitations
- Segregated areas for SARS and non-SARS staff?
- Is it necessary?
- What are the implications?

## Surge Capacity Planning:Mental/Social Service Support for Staff

- Mental health counseling
- Family services
- Child care
- Shopping services (food, pharmacy, etc
- Transportation
- Lodging
- Economic support

## Is the plan working?

## Monitor for Adherence

- Identify criteria and methods for measuring adherence and effectiveness of interventions
- Areas to monitor
- Patient placement
- Surveillance for transmission
- Use of PPE

## Final Thoughts

- SARS transmission can be prevented!
- Begin NOW to prepare for SARS
- Shore up procedures for triage and evaluation
- Review use of PPE
- Review precautions for aerosol-generating procedures
- Solidify relationships with health departments
- Engage your colleagues in preparedness planning

## Infection control is EVERYONE’s responsibility!