Concerns about the COVID-19 coronavirus outbreak—first detected in China, in late 2019—have prompted ECRI Institute to reissue some of its past guidance related to infectious disease outbreaks. In the current moment, we believe healthcare professionals will find it instructive to revisit issues associated with the 2003 outbreak of severe acute respiratory syndrome (SARS).
In 2003, more than 8,000 people worldwide contracted SARS—a respiratory illness that usually begins with a fever, progresses to include other symptoms, and can lead to the development of pneumonia. During the initial outbreak, 774 deaths were attributed to the disease. In less than two months at the start of 2020, the impact of the novel coronavirus (2019-nCoV) that causes COVID-19 has far surpassed those totals. COVID-19 is spreading faster than SARS did, and has already infected tens of thousands of patients. COVID-19 appears to progress with relatively mild symptoms at first, then develops to pneumonia and potentially to acute respiratory distress syndrome (ARDS), which is hard to treat and often requires the patient to be put on a ventilator (advanced life support).
The mechanism of SARS-CoV transmission was understood to be associated with close contact with a SARS-infected person or exposure to large-droplet secretions from an infected person's cough or sneeze. As reported in The Lancet (subscription or fee required for access) in mid-February 2020, "presently COVID-19 seems to spread from person to person by the same mechanism as other common cold or influenza viruses—ie, face to face contact with a sneeze or cough, or from contact with secretions of people who are infected."
In the case of SARS, transmission of the disease was quickly controlled, and the outbreak was declared over by July 2003. Nevertheless, concern existed that SARS could in fact be a seasonal disease and that another outbreak could occur in later years. The threat of another outbreak underscored the importance of facilities having a response plan in place to safeguard the health of their communities and staff members. ECRI Institute produced a series of articles in 2003 and 2004 discussing the risks associated with SARS, reviewing recommendations from the U.S. Centers for Disease Control and Prevention (CDC), discussing the role of hospital facilities staff and clinical engineers in SARS preparations, and updating ECRI's recommendations for infection control procedures during equipment servicing.
What follows is an excerpt of that content produced during the SARS outbreak. While the information was produced with that specific instance in mind, much of the information would likewise apply to other outbreaks of infectious diseases. Note that in some places, we have updated links or references to other material that has been published since this article was issued.
Source: ECRI Institute. SARS preparedness: revisiting the procedures to protect staff and help prevent or contain an outbreak. Health Devices 2004 Feb;33(2):44-53.
CDC's SARS Recommendations
CDC points out that the key to minimizing the risk of another outbreak is early detection and isolation of the first cases. The best way to achieve this is by preparing now. CDC has presented several teleconferences, issued a draft guideline, and updated the information on its website to provide the most current information and recommendations. CDC's efforts have included guidance for individual practitioners; for national, state, and local government agencies and communities; and for hospitals and healthcare organizations.
Individual practitioners must be alert for patients presenting with possible SARS and must know how to prevent SARS transmission and whom to inform if a suspected case of SARS is discovered.
Government agencies and communities need to
- implement surveillance measures to quickly identify a new outbreak;
- establish rapid and effective communication among agencies, healthcare facilities, and the public; and
- prepare for possible community quarantine measures.
At the hospital level, the emphasis should be on quickly identifying and isolating possible SARS cases to minimize the risk of transmission to other patients and healthcare workers. To help facilities achieve these goals, CDC has issued a series of objectives and recommended activities (CDC 2004 Jan 8 [II]):
- Develop or improve the planning and decision-making structure for SARS detection and response.
- If one is not already in place, develop a written SARS preparedness and response plan.
- Assess the facility's ability to respond to SARS.
- Establish an effective surveillance, triage, and clinical evaluation system.
- Reinforce basic infection control practices.
- Train staff to recognize potential SARS patients, know what actions to take when SARS is suspected, proficiently don and use personal protective equipment (PPE), and recognize and apply precautions during aerosol-generating procedures.
- Reinforce the use of "respiratory hygiene/cough etiquette," including educating patients on respiratory hygiene (such as using hand-hygiene solutions and facial tissues and properly disposing of expended tissues) and providing surgical masks and/or tissues to patients to minimize droplet generation.
- Use engineering controls (e.g., designated waiting rooms for patients with respiratory symptoms and/or Plexiglas barriers at the point of triage) and administrative controls and work practices (e.g., droplet precautions) to manage patients until the cause of their respiratory symptoms is determined.
- Develop a patient transport and isolation plan.
- Implement the proper design, operation, and maintenance of isolation rooms that will house SARS patients.
- Implement a mechanism to report and evaluate exposures and apparent healthcare illness caused by SARS-CoV.
- Have a strategy to meet increased staffing needs and clinical and protective equipment and supplies needs (e.g., ventilators for SARS patients) in the event of a SARS outbreak.
- Develop strategies to limit access to the hospital.
- Have a mechanism to ensure effective communication with public health departments and the public.
CDC recommends that SARS-specific activities be integrated into existing preparedness plans and protocols where possible.
The Role of Facilities and Clinical Engineering
The facilities and clinical engineering departments should be involved in several aspects of SARS preparedness, including the following:
Establishment of adequate airborne infection isolation facilities. While the role of airborne transmission of SARS has not been fully established, CDC recommends that healthcare facilities admit patients with possible SARS to airborne infection isolation rooms (AIIRs) or specially adapted SARS units or wards, where patients can be safely managed. An AIIR minimizes the risk of airborne infectious agents entering surrounding areas and reduces the concentration of airborne contaminants in the room by using negative pressure relative to the surrounding area as well as airflow and exhaust provisions (e.g., exhaust to the outside, filtration, adequate ventilation rates). Facility engineers are likely to be called on to verify performance of existing AIIRs, to implement new AIIRs, and/or to consider what building modifications might be possible to provide a location for a SARS unit.
Even if all SARS patients are not placed in AIIRs, an AIIR may be preferred for patients known to have transmitted SARS-CoV, for patients being assessed for SARS, and for patients undergoing aerosol-generating procedures, including intubation and tracheal suctioning. Noninvasive ventilation (delivered via a mask) and nebulizer and aerosol respiratory therapies are discouraged for SARS patients; however, if these therapies are used, they preferably should be performed in an AIIR.
Equipment procurement and training. Hospitals need to assess availability and anticipated need for consumable and durable medical equipment resources. "SARS patient care requires both consumable (e.g., PPE) and durable (e.g., ventilators) supplies. Experience in other countries indicates that a SARS outbreak not only can strain a facility's supply of these resources but also can affect the ability to order replacement supplies" (CDC 2004 Jan 8 [II]).
Consumable supplies mentioned by CDC include hand hygiene supplies (antimicrobial soap and alcohol-based, waterless hand-hygiene products), disposable particulate respirators (N95 or higher), powered air-purifying respiratory (PAPR) hoods and battery packs (if applicable), goggles and face shields (disposable or reusable), gowns, gloves, and surgical masks. Durable equipment includes ventilators, portable high-efficiency particulate-air (HEPA) filtration units, and portable x-ray units.
ECRI recommends that clinical engineering personnel assist in these preparations, especially for durable equipment, by doing the following:
- Locating and approving suppliers (preferably those suppliers that can reliably provide the models that staff are familiar with) and obtaining guarantees that supplies will be available. (For a list of additional resources on this topic, see Outbreak Preparedness and Response: The Essentials.)
- Making sure that users receive training on models that are new to staff (and that user manuals are available).
- Developing procedures that ensure that rental or other temporary devices are logged in and are safe and functional before clinical use. Clinical engineering personnel should be prepared to conduct safety and functionality checks (including 24-hour on-call availability), should arrange with the device supplier (e.g., rental agency) to inspect devices according to an agreed-upon protocol, or should assist clinical staff in preparing an inspection protocol that they will use before using the devices.
In particular, breathing-circuit filters may need to be added to ventilators. We discuss this topic in Mechanical Ventilation of SARS Patients: Lessons from the 2003 SARS Outbreak.
Hospitals should be taking action now to prepare for possible SARS patients. If preparedness plans and protocols are not already in place, start implementing them. Make sure that facilities and clinical engineering personnel play a role in these preparations. In addition, clinical engineers, respiratory therapists, and others servicing medical equipment should be taking appropriate infection control precautions regardless of whether the patient has or is suspected of having SARS. Take time to review your general infection control policy and practices.