SPENCER HOSPITAL - IEMSA



AMBULANCE DEPARTMENT

Severe Acute Respiratory Syndrome (SARS) PROTOCOL

Purpose: To provide providers information and precautions concerning patients suspected of Severe Acute Respiratory Syndrome (SARS). The cause of SARS is not known as of this time, but is believed to be likely a virus, but has yet to be confirmed. By definition SARS is considered a: Respiratory illness of unknown etiology, and individuals presenting with the following criteria:

1. Measured temperature > 100.4” F (>38”C) and

2. One or more clinical findings of respiratory illness (e.g. cough, shortness of breath, difficulty breathing, hypoxia, or radiographic findings of either pneumonia or acute respiratory distress syndrome) and

3. Travel within 10 days of onset of symptoms to an area with documented or suspected community transmission of SARS (see list below: excludes areas with secondary cases limited to healthcare workers or direct household contacts)

• Peoples Republic of China (mainland China and Hong Kong Special Administrative region)

• Hanoi

• Vietnam

• Singapore

4. Close contact within 10 days of onset of symptoms with either a person with a respiratory illness who traveled to a SARS area or a person known to be a suspect SARS case.

5. (Note) Close contact is defined as having cared for, having lived with, or having direct contact with respiratory secretions and/or body fluids of a patient known or is suspect SARS case.

Equipment and precautions:

Currently recommended infection control measures for hospitalized patients with SARS include standard precautions (with eye protection to prevent droplet exposure), plus Contact and Airborne precautions. Respiratory protection using respirators providing at least 95% filtering efficiency (N95) with appropriate fit testing is recommended.

• Disposable, non-sterile gloves must be worn for all patient contact.

• Gloves are removed and discarded in biohazard bags after patient care is completed, between patients, or when soiled or damaged.

• Hands must be washed or disinfected with a waterless hand sanitizer immediately after removal of gloves

• Disposable fluid-resistant gowns should be worn for all patient care activity.

• Gowns should be removed and discarded in biohazard bags after patient care is completed or when soiled or damaged.

• Goggles or face shields must be worn in the patient care compartment and when working within six feet of the patient. Corrective eyeglasses alone are not appropriate protection.

• All personnel in the patient care compartment at all times should wear fit tested N95 respirators.

• The driver should wear fit tested N95 respirators if the driver’s compartment is open to the patient care compartment. Drivers that provide direct patient care (including moving patients on stretchers) must wear a disposable gown, face shield, and gloves as described above during patient care activities. Gowns and gloves are no required for personnel whose duties are strictly limited to driving.

• Vehicles that have separate driver and patient compartments and can provide separate ventilation to these areas are preferred for transport of possible SARS patients. If a vehicle without separate compartments and ventilation must be used, main dashboard vents should remain open with rear ventilation fans turned on at the highest setting during transport of SARS patients to maximize air exchange.

• The patient may wear a paper surgical mask to reduce droplet production, if tolerated.

• Oxygen delivery with simple and non-rebreather facemasks may be used for patient oxygen support during transport.

• Cardiopulmonary resuscitation (CPR) should only be performed using a resuscitation bag-valve mask equipped with HEPA filtration of expired air.

Emergency Response: Patient exhibiting s/s consistent with SARS

• Health care providers who are the first points of contact with a person suspected of having SARS should be trained to provide adequate screening, and should be familiar with the case definition concerning SARS ahead of time and be prepared to safely provide care and interventions according to CDC guidelines, and to prevent cross contamination and exposing and/or spreading this dangerous and deadly disease.

• Using the most recent SARS case definition available

1. Question the patient concerning fever

2. Question patient regarding respiratory symptoms

3. Question patient regarding recent travel or association with individuals who meet travel guidelines

• Provide care bordering on the side of extreme concerning patients exhibiting signs and symptoms consistent with SARS. Protect yourself and your crew when providing care to possible SARS patients.

Emergency Medical ground transport of SARS patients, general considerations

• SARS patients should be transported using the minimum number of EMT personnel and without non-SARS patients or passengers in the vehicle

• Sufficient infection control supplies should be on board to support the expected duration of transport plus additional time should the vehicle experience traffic delays

• Receiving facilities must be notified prior to transport of SARS patients to facilitate preparation of appropriate infection control procedures and facilities.

• Concerns regarding movement of possible SARS patients in the United States should be discussed with appropriate local, state and federal health authorities, including the Centers for Disease Control and Prevention (CDC) (24 hour response number: (770)-488-7100.

Mechanically Ventilated Patients

• Mechanical ventilators for SARS patient transport must provide HEPA filtration of airflow exhaust.

• EMT services should consult their ventilator equipment manufacturer to confirm appropriate filtration capability and the effect of filtration on positive pressure ventilation.

Clinical Specimens:

• Standard precautions must be used when collecting and transporting clinical specimens.

• Specimens should be stored only in designated coolers or refrigerators.

• Clinical specimens should be labeled with appropriate patient information and placed in a clean zip-lock bag for storage and transport.

Waste disposal:

• Dry solid waste, used gloves, dressings, etc. should be collected in biohazard bags for disposal as regulated medical waste in accordance with local requirements at the destination medical facility.

• Waste that is saturated with blood, body fluids, or excreta should be collected in leak proof biohazard bags or containers for disposal as regulated medical waste in accordance with local requirements at the destination medical facility.

• Sharp items such as used needles or scalpel blades should be collected in puncture resistant sharps containers for disposal as regulated medical waste in accordance with local requirements at the destination medical facility.

• Suctioned fluids and secretions should be stored in sealed containers for disposal as regulated medical waste in accordance with local requirements at the destination medical facility. Handling that might create splashes or aerosols during transport should be avoided.

• Suction device exhaust should not be vented inside the vehicle without HEPA filtration. Portable suction devices should be fitted with in line HEPA filters.

Cleaning and Disinfection after Transporting a Possible SARS patient

• Upon completion of an assignment involving a suspected SARS patient, EMT’s and Paramedics should decontaminate the vehicle, stretcher and equipment used during the call in accordance with local EMS and public health policy, prior to returning to service and encountering additional patients.

• Compressed air that might re-aerosolize infectious material should not be used for cleaning the vehicle or reusable equipment.

• Non-patient care areas of the vehicle should be cleaned and maintained according to vehicle manufacturer’s recommendations.

• Cleaning personnel should wear non-sterile gloves, disposable gowns and face shields while cleaning the patient-care compartment.

• Patient-care compartments (including stretchers, railings, medical equipment control panels, and adjacent flooring, walls and work surfaces likely to be directly contaminated during care) should be cleaned using an EPA-registered hospital disinfectant in accordance with manufacturer’s recommendations.

• Spills of body fluids during transport should be cleaned by placing absorbent material over the spill and collecting the used cleaning material in a biohazard bag. The area of the spill should be cleaned using an EPA-registered hospital disinfectant. Cleaning personnel should be notified of the spill location and initial clean up performed.

• Contaminated reusable patient care equipment should be placed in biohazard bags and labeled for cleaning and disinfection at the EMY service medical equipment station.

• Personnel should wear non-sterile gloves, disposable gowns and face shields while cleaning reusable equipment.

• Reusable equipment should be cleaned and disinfected according to manufacturer’s instructions.

Follow-up of EMT personnel who transport SARS patients

• After transportation, the EMT team should provide the following information to their medical director.

1. Date and route of transport

2. Duration of patient transport

3. Names

4. Contact information

5. Specific duties or transport personnel, (including estimated duration of direct patient care provided)

6. Patient care interventions performed

• EMT services should designate individuals to closely monitor personnel who have transported SARS patients for evidence of fever or respiratory illness. EMT personnel who transport SARS patients should be assessed at least daily for 10 days after transporting a SARS patient.

• Personnel may continue working during the 10-day follow-up period if they have no symptoms of fever or respiratory illness.

• Personnel who have transported a SARS patient and become symptomatic within the 10-day follow-up period should be directed to seek medical evaluation and should be reported to the state health department and the CDC immediately.

Resources:

who.int/csr/sars/sarsfaq/en/

ncidod/sars/index.htm

ncidod/sars/emtguidance.htm

IDPH: 1-800-362-2736 (normal business hours)

IHP communications center 1-515-323-4360 (after hours)

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