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Johns Hopkins – SARS
Inpatient Isolation Protocal For Patients Who Have or Are Suspected To Have Severe Acute Respiratory Syndrome (SARS)

December, 2003

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Note: Protocol may be updated as new information is available.

Background:
Standard Precautions are indicated for any and all patient contact. In addition to standard precautions, patients placed in “Airborne and Contact” precautions for suspected and confirmed SARS require the following:

  1. IMMEDIATELY notify Hospital Epidemiology and Infection Control for suspected SARS cases.
      Office: 5-8384
      Pager (evenings/weekends): 3-3855

  2. If one suspected case of SARS is admitted the outbreak management policy (IFC025) will be activated.


  3. AIRBORNE and CONTACT precautions are required. A private room with toilet with an anteroom and negative pressure is required. If the number of patients exceeds the number of available isolation rooms as described above, patients will be confined in a negative pressure ward as determined by DCA, hospital administration in consultation with the hospital epidemiologist. Doors must be kept closed. Open only one door at a time. Pressure must be checked and recorded daily by facilities. Cohort staff, as appropriate to the level of care required, limiting unnecessary exposure of additional staff or patients.


  4. HEALTHCARE WORKER STAFFING: The SARS management team (nurses, physicians, respiratory therapists, etc) will be dedicated to care of suspected and confirmed SARS patients. These healthcare workers must not care for patients without SARS or suspected SARS, including outpatients. Medical monitoring will be instructed which includes daily symptom evaluation and twice daily temperature checks. Health care workers will record the temperature on logs which will be reviewed by occupational health. Logs must be maintained for 10 days after last exposure to SARS patients. The SARS management members must be vaccinated for influenza A and B. Any member of the SARS management team who develops respiratory symptoms, diarrhea or fever > 38° must be evaluated by a hospital designated physician. Nurse patient ratios must be maintained at 2:1 for ICU patients or 3:2 in non-ICU settings on all shifts. Healthcare workers may only stay in the room of a suspected or documented SARS patient for 30 minute intervals.


  5. Hand hygiene is required before and after every patient or equipment contact, after removing gloves, gowns, N95 masks/PAPR, face shield and other personal protective equipment, and before leaving the patient’s environment.


  6. PERSONAL PROTECTIVE EQUIPMENT (PPE):
    • 2 PAIRS GLOVES are required to enter the room, and are required while in the patients room; with contact of infectious materials, or items in the patient’s environment. Gloves are required for patient transport.
    • 2 GOWNS are required for all persons entering the room and while in the patients room or with contact of infectious materials. Gowns are required for patient transport.
    • RESPIRATORY PROTECTION: An N95 mask or Powered Air Purifying Respirator (PAPR) is required for all persons entering the room or providing care to the patient.
    • PROTECTIVE EYEWEAR is indicated if an N95 mask is selected as respiratory protection.


  7. PERSONAL PROTECTIVE EQUIPMENT (PPE) REMOVAL: Close the patient’s room door (inner isolation room door) and remove PPE in the anteroom. Clean hands after removing gloves, then remove gown clean hands. Discard all PPE and perform hand hygiene as described above before leaving the anteroom. See table below.
    8.  
    Routine Patient Care
    NP aspirate suctioning sputum induction
    Moderate Risk Care
    Bronchoscopy intubation CPR
    High risk Care
    Patient Transport
    Gloves Double gloves Double gloves Double Gloves Double Gloves
    Disposable Gowns 2 gowns 2 gowns 2 gowns 2 gowns
    Respiratory protection N95 or PAPR PAPR PAPR N95 or PAPR
    Protective eyewear Face shield if using N95     Face shield if using N95
    Other     Shoulder shroud  


  8. HEIC must be contacted prior to all transport of suspected or identified SARS Patients. This transport must be for essential purposes only.

    Transport requirements:

    • Must have a predetermined route
    • Patient should be escorted directly into the procedure/examination room
    • Pts & personnel not involved in procedure should be removed from area

    Prepare Patients for transport

    • Use a stretcher for the non-intubated Patient
    • Patient should have a clean patient gown, sheet and wear a surgical mask
    • Intubated patient portable vent – use bed after wiping down rails, head and footboard. Patient should have a clean gown and sheet.

    Transporters

      Designated Team should transport. Transporters should double gown double glove and wear a PAPR or N95 mask.


    9. Top of Page

  9. PATIENT TRANSPORT: Patient transport outside of the room must be restricted to essential purposes only. Consult HEIC prior to transport. During transport and during the procedure the patient should wear a surgical mask and gown. A predetermined route should be used for patient transport. The patient should be escorted directly into the procedure/examination room. Patients and personnel not involved in the procedure should be removed from the surrounding area prior to patient transport. Staff transporting patients should wear a PAPR, gowns, and gloves during transport. Bed rails should be cleaned prior to leaving the patient’s room with approved disinfectant. Unit Staff will coordinate communication between the primary patient care providers and the staff of the area to which the patient is being moved. This communication is essential to assure that the area/department is fully prepared to receive the patient and to manage the patient appropriately.


  10. PRECAUTIONS OUTSIDE OF THE PATIENT’S ROOM: Tests and studies performed on patients with suspected or documented SARS should be conducted in negative pressure rooms. A HEPA filter should be used. If a test or study is essential and cannot be performed in a negative pressure room, then all other precautions must be followed. Staff conducting studies should adhere to all guidelines for isolation, including wearing gloves, gowns and a PAPR. Staff not involved with the procedure should leave the area. No other patients should be in the area until the procedure is completed. A HEPA filter should be placed in the area. Should have procedure at the end of the day.


  11. NUTRITION DEPARTMENT should deliver the patient’s tray to the Nursing station. Nutrition staff should not enter the isolation room.


  12. NO VISITORS are permitted. In the event visitors are considered crucial to patient care, exceptions will be granted on a case-by-case basis by the Hospital Epidemiologist/designee in consultation with the patient’s physician. Post security outside the room to monitor compliance with visitors and staff.


  13. LAB SPECIMENS: Notify lab before sending any laboratory specimens in suspected SARS cases (5-6510). See accompanying policy for management of laboratory specimens of suspected SARS cases.


  14. DISPOSABLE PATIENT CARE EQUIPMENT must not be reused and should be discarded inside the room. STETHOSCOPES and BLOOD PRESSURE CUFFS should be disposable and should remain inside the patient’s room. They can be reused for the same patient but should be discarded upon the patient’s discharge.


  15. CONTAMINATED REUSABLE EQUIPMENT (electronic thermometers, devices, etc.) must be dedicated to a single patient for the duration of isolation. Equipment must be disinfected using an approved disinfectant before use on another patient.


  16. PORTABLE MONITORING INSTRUMENTS (EKG, ECHO, X-RAY - ventilators, equipment etc.): Any equipment surfaces contaminated must be disinfected with an approved disinfectant prior to removal from the patient’s room.


  17. WHEELCHAIRS AND STRETCHERS are thoroughly cleaned after every transport of a patient on isolation precautions using an approved disinfectant.


  18. Routine ENVIRONMENTAL CLEANING will be performed in isolation rooms twice a day. When a patient is discharged, or isolation is discontinued, the room should be terminally cleaned by appropriate staff. Staff will perform terminal cleaning wearing full isolation gear, including gloves, gowns, a PAPR. All cleaning solutions will be discarded upon completion of the cleaning procedure.


  19. PATIENT clothing will be placed in a bag and sealed at the time of admission. Patient will wear hospital provided attire.


  20. RECREATIONAL ITEMS (books, magazines) must be dedicated to a single patient and discarded after use.


  21. LINEN should be changed when soiled but not more frequently. Once changed, linen should be placed in an appropriate bag, in the room and then sent for processing. Do not put down chute.


  22. URINE AND FECES: Discard urine and feces in the patient bathroom.


  23. NEBULIZERS/HUMIDIFIERS should not be used in patients suspected of having SARS.


  24. HANDLING A DECEASED PATIENT requires the same precautions. Gowns, gloves and PAPR should be worn.


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