Outbreak preparedness & control PPHSN Guidelines For the Preparedness, Surveillance And Response To Severe Acute Respiratory Syndrome (SARS) in Pacific Island Countries And Territories April 9th 2003 SARS is a new disease syndrome. Our knowledge about the best way to prevent and treat it is constantly evolving. These guidelines will be continuously updated. Please regularly check PPHSN website for the most up to date guidance. These guidelines have also been ‘harmonised’ with the WHO WPRO guidelines published on 4th April. HOSPITAL INFECTION CONTROL (Updated 09.04.03) [See also NEW ZEALAND MOH Infection Control advice for the management of patients with suspected Severe Acute Respiratory Syndrome (SARS) in ANNEX 8 for an example of measures that can be adapted depending on the resources available. Alternatively see WHO publication Infection Control for VHF in the African Health Care Setting for simple guidance. This is available on the PPHSN website. Key points WHO advises strict adherence with the barrier nursing of patients with SARS using precautions for airborne, droplet and contact transmission. Triage nurses should rapidly divert persons presenting to their health care facility with flu-like symptoms to a separate assessment area to minimise transmission to others in the waiting areas. Suspect cases should wear N 95 masks (surgical masks if N 95 not available) until SARS is excluded. Staff involved in the triage process should wear a N 95 mask and wash hands:
o before and after contact with any patient, o after activities likely to cause contamination and o after removing gloves |
Care for patients with probable SARS o Negative pressure rooms with the door closed o Single rooms with their own bathroom facilities o Cohort placement in an area with an independent air supply and exhaust system. Note Turning off air conditioning and opening windows for good ventilation is recommended if an independent air supply is not possible. Please ensure that if windows are opened they are away from public places. General Principles WHO advises strict adherence with the barrier nursing of patients with SARS using precautions for airborne, droplet and contact transmission Isolation and avoidance of unnecessary contact. Minimise the number of HCWs that will have contact with SARS patient(s). In addition WHO recommends that any specimens for laboratory testing MUST be taken by the physician designated to care for the SARS patient(s). Use of personal protective equipment (PPE) for all in close proximity Strict personal hygiene Masking of patient to reduce respiratory spread
Principles of isolation o Isolation room: patient care room, with no airflow to other rooms. o Changing room. Separate areas in room for storage of outside clothes, and removal of PPE. o Outside the isolation room (in changing-room, where present) - direct access to a biohazard waste bag (with foot-operated lid) and a handbasin is necessary o General access area (ie rest of hospital) o HCWs should disinfect their hands and change PPE between patients o Disinfect or use separate ward equipment (tourniquets etc). o Place a screen between patients. o Staff must wash hands between patients NEVER put suspect cases in the same room as probable cases Central air-conditioning should be turned off unless the room can be isolated from the system. Open external windows to areas with no public access. Keep doors closed Visits by family and non-essential staff should be avoided wherever possible All patient care devices (e.g. tourniquets, tubing) must be restricted to the patient, and disposed of or cleaned and disinfected by staff wearing PPE. Transport of SARS patients should follow the same principles of isolation, including mask on patient, full PPE at all times for all staff, minimal contact, strict hygiene /washing, and complete disinfection of all transport and equipment.
>> Figure 4: General Principles of isolation unit Principles of Personal Protective Equipment (PPE) PPE reduces but does not completely eliminate the possibility of infection. PPE is only effective if used correctly and at all times where contact may occur. Any contact between contaminated (used) PPE and surfaces / clothing / people outside the isolation area must be avoided. Used PPE must be sealed in appropriate disposal bags and incinerated or decontaminated. The use of PPE does not replace basic hygiene measures such as hand-washing, washing is still essential to prevent transmission. Exposure to the infected patient should be kept to an absolute minimum necessary for the level of care required. Visits by non-staff should be avoided where possible. The patient should be as self-caring as possible, and the staff team assigned to care for the patient should be kept to a minimum. Staff should be strictly supervised and be experienced in infection control.
Who should use PPE? o All HCWs who provide direct patient care to SARS cases (keep to minimum necessary for patients' condition); o All support staff including medical aides, cleaners, laundry staff (keep staff to the minimum necessary, designate SARS laundry staff, etc.); o All laboratory staff who handle patient specimens from suspect cases (keep to the minimum necessary for laboratory procedures); o Family members who care for SARS patients (visits should be avoided where possible) o The patient(s) should wear a surgical mask (N95 preferable) when other people are in the isolation area. Minimum PPE to be worn How should PPE be used? o Disposable masks should be discarded after 4-6 hours use. (patient's mask may be reused by patient). o It is essential that the mask makes a complete seal on the face (see manufacturer's fitting instructions) at all times. Ensure seal is complete before approaching patient o Masks cannot be worn with beards / unshaven faces. o If a mask is splashed, wet, it should be changed using strict hand-washing and gloves. o N95 masks are recommended for use in the isolation room where close contact with the patient and direct contamination with saliva / sputum (cough, sneezing etc) is not likely. Ideally, masks should be splash-proof (e.g. 3M 1860 model) if available o The patient should wear an N95 mask at all times when staff / other people are in room. o HEPA (P100, N100) masks are recommended for use during procedures likely to generate aerosols or splattering of body fluids o Standard surgical masks can be used by patients if N95 masks are not tolerated or unavailable o Standard surgical masks are NOT adequate protection for staff or visitors o Goggles should be worn at all times during patient contact o They should be cleaned thoroughly in alcohol-based disinfectant solution prior to re-use o UVEX goggles may be worn with glasses o Safety glasses are not a good substitute for goggles and should only be used if extreme heat and humidity prevents goggles from being tolerated. o Wear scrub suit or old set of thin clothes before entering the designated changing room or area o Put on shoe covers or boots with trousers tucked inside o Put on outer laboratory gown or coveralls o Put on impermeable apron o Put on gloves with gown sleeve cuff tucked into glove o Put on the mask and goggles o Boots should be used for heavily contaminated / wet flooring and floor cleaning o Wash gloved hands in >60% alcohol handwash solution (eg Sterillium). Disinfect boots with 1% bleach. o Using gloved hands, remove aprons, gowns, and shoe covers without contaminating clothing underneath. Touch only outside of clothing. Place in biohazard disposal bag o Remove gloves (fingers under cuff of second glove to avoid contact between skin and outside of gloves). o Wash hands in >60% alcohol hand-cleaning solution. o Remove goggles then boots and place in separate containers (receptacle) with close fitting lids for soaking and cleaning. o Remove head cover and mask, place in biohazard disposal bag. o Wash hands to elbows thoroughly in >60% alcohol hand cleansing solution, followed by soapy water. o Change into street clothing and wash hands in soapy water before leaving facility. o Never wear PPE in general ward area. o Plan ahead when entering the isolation area (or laboratory), so that all necessary equipment is available, and all necessary patient care activities are completed in one visit. o If staff must temporarily leave the isolation area, a complete change of PPE and thorough hand washing (above) must be performed each time. Linen, cleaning and clinical waste Linen from the patients should be prepared on site for the laundry staff. Appropriate PPE should be worn in this preparation and the linen should be put into biohazard bags. The room should be cleaned by staff wearing PPE using a broad spectrum disinfectant of proven antiviral activity. Standard precautions should be applied when handling any clinical wastes. All waste should be handled with care to avoid injuries from concealed sharps (which may not have been placed in sharps containers). Gloves and protective clothing should be worn when handling clinical waste bags and containers. Where possible, manual handling of waste should be avoided. Clinical waste must be placed in appropriate leak-resistant biohazard bags or containers labelled and disposed of safely.
| 
