Special Feature
Dec 03

CDC Releases Draft SARS Infection Control Plan
by Julie E. Williamson

In response to mounting concerns over Severe Acute Respiratory Syndrome, the Centers for Disease Control and Prevention has issued a draft guidance document aimed at guiding healthcare professionals’ decision-making in the event of a SARS outbreak. The draft document’s release is particularly timely given that flu season has made its debut and may make SARS a threat for healthcare organizations and communities at large.

The document, “Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome,” which is posted on the CDC’s website, outlines the concepts and strategies for managing and containing a SARS outbreak. It also describes many of the activities needed at the federal, state and local levels to prepare for and respond rapidly and decisively to a reemergence of SARS. State and local health departments, hospitals and other public health providers will have an opportunity to comment on the draft and provide input to an effective SARS preparedness plan for the United States.

“The plan is designed to assist federal, state and local public health partners in developing or coordinating their own SARS preparedness and response planning activities, while taking into account available healthcare and public health resources, and other factors that are unique at each level,” the CDC noted.

The plan was devised with close collaboration between domestic and international partners, and incorporates many of the concepts and approaches that were successfully used to contain SARS outbreaks in the U.S. and other countries with more widespread outbreaks. The plan integrates and builds on other preparedness and response plans for SARS and for other public health emergencies, such as pandemic influenza and bioterrorism. The plan will be updated regularly and was designed for immediate implementation in the event of a SARS outbreak.Hospital-based strategies

At the core of the draft document are guidelines tailored for various healthcare settings, including acute care hospitals, long-term care facilities and outpatient institutions. What follows is a summary of the CDC recommendations for inpatient facilities and emergency departments.

When no cases of SARS are in the facility, suggested actions include:

Triage activities/facility access controls
• Notify SARS coordinator or designee of any transfers from facilities that do have SARS cases;

• Instruct patients with respiratory symptoms to wear a surgical mask. Manage these patients with droplet precautions until determined that the cause of symptoms is not an infection that requires such precautions. Instruct patients who cannot wear a mask to cover their nose and mouth with tissues when coughing or sneezing.

In the presence of known cases of SARS worldwide but no known SARS-CoV transmission in the area around the facility:

• Place signs at all entry points detailing symptoms of and any current epidemiologic
risk factors for SARS;

• Initiate screening of patients on entry to the emergency department for symptoms and
epidemiologic links suggesting SARS; and

• Intake/triage staff should practice frequent hand hygiene and may wear surgical masks
during respiratory season.

In the presence of known SARS-CoV transmission in the area around the facility:

a. Actively screen all persons entering the facility for symptoms;
all persons should perform hand hygiene on entry;

b. Instruct all patients presenting with febrile illness or respiratory symptoms to wear a surgicalmask; place these patients on airborne precautions. Consider cohorting, with all patients wearing surgical masks, if airborne isolation is not possible;

c. Intake/triage staff should follow full SARS personal protection
guidance;

d. Limit visitors;

e. Screen all visitors for SARS epidemiologic risks and symptoms;

f. Maintain a log of visitors to SARS patients to assist in contact tracing; and

g. Limit elective admissions/procedures.
Designate an area as a SARS evaluation center. Send all febrile patients who present to emergency departments and clinics to the fever assessment clinic.

h. Patient placement
In the presence of known SARS activity worldwide but no known transmission in the area around the facility, instruct all patients presenting with febrile respiratory symptoms and epidemiologic SARS risk factors to wear a surgical mask; place these patients on airborne precautions;

In the presence of transmission in the area around the facility, instruct all febrile patients to wear a surgical mask and place these patients on airborne precautions.

i. Designated personnel
Assign only selected, trained and fit-tested emergency department staff to evaluate possible SARS cases. Staff should follow full SARS personal protective guidance.

j. Surveillance
Depending on directives from local/state health departments, consider reporting all healthcare workers hospitalized with unexplained pneumonia.

k. Healthcare worker restrictions
Healthcare workers should notify the facility’s SARS
coordinator and have daily symptom checks if:
1. They are caring for a SARS patient in another facility;
2. They are also working in another facility that has reported nosocomial SARS-CoV transmission;
3. They have close contact with SARSpatients outside the hospital.

When a few cases are in the facility, but all cases are imported (no nosocomial transmission), suggested actions include:

1. Triage activities/facility access controls
• Same as for no cases of SARS in the facility. Add: No visitors to SARS patient unless necessary (visitors must receive infection control training); Designate specific SARS patient-flow routes(e.g., ED to designate elevator to AIIR; AIIR to radiology); Clean rooms housing SARS patients in accordance with current recommendations.

2. Patient placement
• Same as for no cases of SARS in facility. Add: Place admitted SARS patients in AIIRs, if available; Consider cohorting admitted patients in private rooms on designated SARS units depending on personnel and availability of AIIRs.

3. Designated personnel
• Same as for no cases of SARS in facility. Add: Assign only selected, trained and fit-tested staff to SARS patient care; Assign a selected, trained and fit-tested team with access to highest levels of respiratory protection as a designated response team for emergency resuscitation of known or
potential SARS patients.

4. Surveillance
• Active surveillance targeted to healthcare workers providing care to SARS patients.

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 workers with unprotected exposures to a SARS patient during high-risk procedures
and institute daily checks to evaluate possible symptoms; Healthcare workers with other (non-high risk) unprotected exposures to a SARS patient should have daily checks to evaluate for possible
symptoms. Furlough of these workers may be considered. When a larger number of SARS cases are in the facility, OR any facility which nosocomial transmission has occurred, but in which all nosocomial cases have been clearly identified, suggested actions include:

1. Triage activities/access controls
• Same as for a few cases in the facility but all cases are imported.
Add: Irrespective of SARS activity in community around the facility:
• Limit visitors; maintain a log of all visitors to SARS patients;
• Limit elective admissions/ procedures; and 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: Based on availability of AIIRs, considering cohorting SARS patients in private rooms on designated wards; modify existing rooms and designate staff to accommodate.

3. Designated personnel
• Same as for a few cases in the facility but all cases are imported

4. Surveillance
• Active healthcare worker surveillance throughout the facility;
• Monitor all healthcare worker absenteeism and illnesses through occupational medicine clinic; evaluate for links to known SARS cases;
• Monitor for and evaluate all new fevers and respiratory illnesses in patients and healthcare workers. Place anyone with unexplained fever or any respiratory illness of SARS evaluation algorithm

5. Healthcare worker restrictions
• Same as for a few cases in the facility but all cases are imported
For any facility in which nosocomial transmission has occurred and the nosocomial cases have NO clearly identified source (unlinked transmission), the following actions are suggested:

1. Triage activities/access controls
• Same as for a larger number of cases or linked transmission.
Add: No visitors allowed in hospitals unless necessary;
visitors must receive infection control training; close emergency departments 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:
a. Afebrile patients with no close SARS contact – discharge as soon as medical indicated;
b. Afebrile patients with close SARS contact – discharge with contact restrictions and health
department follow-up per community SARS policy;
c. Febrile or symptomatic patients not meeting case definition; and
d. 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. When in contact with SARS patients, all persons should wear SARS PPE.

4. Surveillance
• Same as larger number of cases or linked transmission.
Add: Place any person with fever (not just unexplained fever) or respiratory symptoms on SARS precautions, and evaluate in accordance with the SARS evaluation algorithm

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.

For more information, or to download the complete SARS plan, visit the CDC’s website at www.cdc.gov/ncidod/sars.