SARS — So Are You Ready for Safety?

In 2005, we live in a world full of lurking danger with biological terrorism, antimicrobial resistance, and new virulent and deadly viruses, always threatening on the horizon. Since 2003, we have seen the emergence of SARS as a major worldwide public health problem. SARS has generated more than 3,100 scientific publications, ranging from the epidemiology¹ and microbiology² of the virus, to the psychological consequences of dealing with mass outbreaks.³ Although the bulk of reflections and recommendations are geared toward emergency departments, there is a clear impact on the entire hospital, including the diagnostic laboratories. In this month’s Journal, Tsui et al. describe their experience in the catheterization laboratory with two patients infected with SARS who underwent catheterization and coronary arteriography.⁴ The authors should be commended for their meticulous approach to infection control and prevention, not only to protect the staff involved in patient care, but in preventing air contamination in adjacent and connected areas of the hospital. Their step-by-step discussion can serve as a template and gold standard for other institutions. We also applaud the Journal for dedicating manuscript space for this unusual procedural discussion. What can we learn from this article? First and foremost, we must recognize the possible need to respond to “mass” illness, whether due to infection and/or terrorism, not only in the catheterization laboratory, but throughout the hospital. Pre-need preparation and planning with clear lines of action, leadership, and communication are essential elements. It is clear from reviewing the literature, that although negative air pressure rooms are beneficial, it is probably economically unrealistic for an individual catheterization suite to be redesigned to create a negative pressure airflow system. In addition, nosocomial infection can still be prevented by patient maneuvers, room disinfection, and by not only defining, but using full personnel protective equipment (proper-fitting masks, gloves, disposable gowns and shoe covers, eye protection, and hand hygiene). The use of N95 or higher masks, as opposed to just wearing a mask, as well as individual air compressors, are controversial issues and may be more than is required.⁵ Hopefully, readers of this article will ask the preparedness question for their own laboratory and their hospital in general, and if the answer is “we do them as a last case and then clean the room,” there is hope that this article will lead to additional planning and preparedness. Second, the care of sick patients is not limited to one specialized unit, and regardless of what is done in the ICU or in isolation areas,⁶ these sick patients end up in X-ray, GI7 and angiography suites so that more general contingency plans must be developed for the lab and health care workers involved in highly specialized areas of the hospital. It is also clear that the appropriate response to this type of patient must be multi-disciplined, with input and support from administration, nursing, and infectious disease staff, as well as the individual diagnostic or therapeutic area. Finally, a word of conservatism in taking care of highly infectious patients. It is a reasonable approach to avoid sending infectious patients with suspected acute coronary syndrome immediately to the catheterization laboratory. Every attempt should be made to achieve hemodynamic stability and to make diagnoses and therapeutic decisions based on clinical parameters and clinical judgment, even using noninvasive testing, and leave the option for coronary angiography as a “last resort” in extremely ill infectious patients. Because there is a significant financial and educational cost to ramp up for this specialized care, there should be regional planning to develop “centers of excellence” so that not every institution has to develop full capabilities. If we all cooperate, it is not unreasonable to hope that the federal government (?under Homeland Security) and other third party payers, will develop a funding and/or reimbursement scheme to make it possible for these regional centers to develop. The closing comments relate to personnel. Just as there should be protocols that can be activated when appropriate, and just as there could be centers of excellence for care in the event of a massive outbreak like SARS, there should be a core group of specially trained individuals within each area who care for these patients. There is adequate evidence that proper use of personal protective equipment and hand hygiene make it safe for personnel. Finally, it is important to emphasize the psychological stresses associated with dealing with a SARS-like disease, and every safety plan should include recognition and support for the nurses and doctors involved in caring for these populations.

1. Isakbaeva ET, Khetsuriani RS, Beard A, et al. SARS-associated conoravirus transmission, United States. Emerg Infect Dis 2004;10:225–231. 2. Ksiazek TG, Erdman CS, Goldsmith SR, et al. A novel conoravirus associated with severe acute respiratory syndrome. N Engl J Med 2003;349:1236–1245. 3. Wong TW, Yau JK, Chan CI et al. The psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope. Eur J Emerg Med 2005;12:13–18. 4. Tsui KL, Li SK, Li MC, et al. Preparadeness of the cardiac catheterization laboratory for severe acute respiratory syndrome (SARS) and other epidemics. J Invas Cardiol 2005;17:149–152. 5. Seto WH, Tswang RW, Yung TK, et al. Effectivness of precautions against droplet and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet 2003;361:1519–1520. 6. Fung CP, Hsich TL, Tan KH et al. Rapid creation of a temporary isolation ward for patients with severe acute respiratory syndrome in Taiwan. Infect Control Hosp Epidemiol 2004;12:1026–1032. 7. Muscarella LE. Recommendations for the prevention of transmission of SARS during GI endoscopy. Gastrointest Endosc 2004;60:792–794.