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SARS, some considerations for the future David
S. Kugler, MD MPH FACEP EMT-P; Attending Physician and Associate
Medical Director CEMS, Department of Emergency Medicine, North Shore
University Hospital; Assistant Professor of Emergency Medicine,
New York University School of Medicine; Member, New York ACEP EMS
Committee The Centers for Disease
Control (CDC) website defines SARS as: “Severe acute respiratory
syndrome, a viral respiratory illness caused by a coronavirus, called
SARS-associated coronavirus (SARS-CoV).” 1 SARS, “…was
first seen in Asia in November 2002 in Guangdong Province, China.
In February 2003, an infected person inadvertently exported SARS from
Guangdong. Over the next few months, the illness spread to more than
two dozen countries worldwide, including Canada, the United States,
Singapore, Vietnam and many others.”2 The most recent CDC Health
Update (April 23, 2004) posted the following, “CDC is recommending
that U.S. physicians maintain a greater index of suspicion for SARS
in patients who 1) require hospitalization for radiographically confirmed
pneumonia or acute respiratory distress syndrome (ARDS) and 2) who
have a history of travel to mainland China (or close contact with
an ill person with a history of recent travel to mainland China) in
the 10 days before onset of symptoms. When such patients are
identified, they should be considered at high risk for SARS-CoV infection.” As of this writing, the
Chinese government and the World Health Organization (WHO) are investigating
four to nine possible SARS cases. The Chinese government has hospitalized
and quarantined many of the affected persons’ close contacts.
This indicates that SARS is on the world wide health agenda and must
not be ignored. The Canadian experience
showed that SARS came quickly to incapacitate the hospitals, emergency
departments and the regional EMS systems. This can be partially attributed
to the following: 1) health care workers (HCW’s) did not show
up for assigned shifts or were quarantined at home, 2) HCW’s
became ill or complained of illness, and 3) the public’s worried
well filled emergency departments and clinics in such large numbers
that the system was over burdened. On an email list serve3, a paramedic
described that once the crisis was identified and began to be controlled,
he waited one hour in the back of his ambulance with a SARS patient
while hospital staff prepared an appropriate isolation room. In total,
for 2003, before the epidemic was declared over, the WHO reported
8,098 people were affected by SARS with a mortality of 774.1 In the
United States, eight people were confirmed with the diagnosis. Currently, we should be
preparing our EMS units, our ED’s, and hospitals for this or
any outbreak of infectious or communicable disease. You should train
your staff in what needs to be cleaned, how and how often. Stocks
of drop cloths should be plentiful so that you can cover the walls
and non-movable storage items. One does not want to take a much needed
resource out of service to arrange for a terminal cleaning. Your EMS/health
system/hospital should be leaders in the preparation process. Many
times we received patients, from EMS, in the emergency department
with a minimal history and occasionally no paperwork. Additionally,
due to the hurried nature of emergency medical services, patients
may be left with out all of the
appropriate respiratory protection. NYC REMAC and the NYS DOH have
implemented protocols for SARS.4 The North Shore LIJ Health System,
has a web site for all hospital providers demonstrating how to properly
don and doff isolation clothing for a SARS patient.5 The CDC also
has listed recommendations on their web site. The respiratory protection,
the donning and doffing of protective gear should be available and
appropriate to able to the EMS setting as well as for your ED. A study
just released from the Taiwan experience includes many significant
and concerning factors: 1) Unrecognized cases of SARS were the most
important factor in its spread throughout the health system, 2) The
virus is stable at room temperature for 2 days and has been found
on plastics, steel, glass and paper. The virus lasts for 4 days in
the stool of patients complaining of diarrhea.6 The virus was found
on the following structures (authors note not all items in ED were
swabbed), a bed side chair, an outlet of a vent, a table top, the
button at the water fountain in both triage and patient care areas
and in staff rest areas, bedding, a bed and a bookcase. All air samples
from this one study were found to be negative.6 In January of 2004 the CDC
updated it’s core document on SARS.7 This document has many appendices
including infection control.8 The infection control Supplement I directs
health care providers at the local level with respect to preparedness
and response activities. It describes how to safely transport a SARS
patient. It defines the necessary personal protective equipment needed
for the ambulance crew, patient, and patient’s family. There
are suggestions on how to keep the workplace safe, decontamination
of the ambulance and equipment after transport, and of the patient
exam room. There are recommendations for the members of your service
that cared for the SARS or presumed SARS patient. 9 Our EMS agencies, respiratory,
and emergency department staff, should be using HEPA filters on their
bag valve masks, and on the exhaust circuits of their ventilators
as provided by the CDC guidelines. There should be a mechanism for
taking an ambulance out of service for cleaning and in preparation
for the next patient. After exposure to a SARS
or presumed SARS patient, there are CDC guidelines relating to which
employees must stay home and which are eligible to return to work.
Your agency must be prepared to lose a physician, critical care nurse,
respiratory therapist or paramedic when the patient care volume is
likely to increase. Agencies are responsible
for establishing employee training and having someone available to
answer questions and address concerns. Without this educational component
there will certainly be a large volume of people who “get sick”
and don’t come to work. They will either be afraid of what may
happen, or actually become ill from a rhinovirus. Preparing our staff for
this illness, is the responsibility of the individual agency or hospital.
The benefits of preparation for this disease are many, including a
more efficient staff. Some suggestions for decreasing nosocomial transmission
of the disease aside from the aforementioned, include increasing staffing,
cohorting of SARS patients in same wards, each with a negative pressure
room, and providing adequate personal protective equipment.10 Recently the CDC has made
recommendations to airline carriers transporting travelers that may
have SARS.11 This guideline uses regional EMS transport. With appropriate
training that ambulance and crew will be up to the task. When the
federal government includes the use of local EMS and emergency departments
in their plans we are obliged to maintain continued scrutiny of all
patients presented to us for assistance. It is necessary for each
EMS agency, hospital and ED to prepare for these patients. This includes
increased training of staff in recognition, triage, proper isolation,
and infection control. The decision of who needs to be given a mask
in triage, and who can cohort with the throngs of others in the waiting
room unencumbered, should be defined at each institution. In summary, the CDC has
established protocols for SARS patients, including prehospital care
and transport, hospital care, and follow-up evaluation of health care
workers. As front line care providers we must maintain due diligence
with training preparation and increased surveillance. The responsibility
of training and preparation falls on each agency. Training must include
the housekeeping staff so that they too understand the importance
of a thorough cleaning, and what particular areas should be focused
on. We must understand that this virus can be transmitted through
fomites so thorough hand washing is essential. A significant benefit
of this additional awareness will enhance each organization’s
ability to detect trends in illness and avoid propagation of diseases
initiated as a biological attack. REFERENCES
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