ANNEX   D

 

MANILA DOCTORS HOSPITAL WARD PROCEDURE ON SARS

 

 

A.                 OBJECTIVE

 

1.      To provide a set of infection control procedures for the safety of staff nurses and nursing aides/ orderlies and other paramedics and to prevent transmission of SARS to both patients and staff.

 

B.                SCOPE

 

1.      This procedure covers the physical requirements, containment and cleaning of SARS rooms, Use of PPE, collection and transport of specimen obtained from SARS suspects, handling of human remain of SARS patients, management of HCW exposed to SARS and Household precautions of discharged patients.

 

 

C. DEFINITIONS OF TERMS

 

SARS Suspect

 

Person with history of travel to SARS affected areas and close contact with

SARS patients, with fever and respiratory symptoms after 14 days of exposure.

           

            Non SARS                      

 

Person without history of travel or close contact but with fever or respiratory

signs and symptoms.

 

Asymptomatic (No symptoms of SARS)

 

Person with history of travel and close contact but does not manifest  fever,

diarrhea and respiratory signs and symptoms.

 

Undetermined

 

Person with history of travel and close contact, with fever only, or cough only

or diarrhea only.

 

 

D. REFERENCE DOCUMENTS

 

World health organization Interim Guidelines on Severe Acute Respiratory Syndrome (SARS) May 2, 2003

 

 

 

 

 

E. PROCEDURES

 

1.      Physical Requirements of SARS Isolation Room

 

1.1.            The room will be used to isolate special cases of SARS suspect preferably “Codable”.

 

1.2.            The door of isolation rooms must be closed at all times.

 

1.3.            Suspect must be admitted only to single isolation rooms.

 

1.4.            If single private room will not be possible, cohort placement (putting several patients with the same diagnosis in one area) of SARS suspect in one room is an acceptable alternative. Place a screen or other forms of barriers between patients.

 

1.5.            Do not mix SARS suspect and undetermined patients in the same room.

 

1.6.            Do not cohort SARS suspects together as some suspects may be reassessed as Non SARS after work –up, this will be done in case local transmission in the Philippines increases wherein referral hospital will no longer able to accommodate patients.

 

1.7.            Designated single rooms or wards should be equipped with negative – pressure devices. If negative-pressure rooms are not available, single air supply or air-conditioning unit with independent exhaust is acceptable. If not still possible, well ventilated private rooms with windows that open away from public areas should suffice. Exhaust and windows must not open to any area with public access.

 

1.8.            Isolation unit will be divided into isolation area and ante room/ changing area.

 

1.9.            There will be a separate sink and bathroom facilities.

 

1.10.        The Ante room /changing area should have the following facilities:

 

1.10.1.Disinfection station

1.10.2.Biohazard bag for used PPE disposal

1.10.3.wall mounted alcohol hand wash dispenser

1.10.4.Storage general ward clothes, new PPE which includes:

 

1.10.1.1.        N95 mask

1.10.1.2.        gloves

1.10.1.3.        disposable gowns

1.10.1.4.        goggles

1.10.1.5.        cap

1.10.1.6.        shoe cover

 

( Procedures on PPE - SEE pp. 17-21 of this guideline)

 

 

1.11.        Isolation room physical set up:

 

1.11.1.Disinfection station with sink, water and hand towel

1.11.2.Windows or exhaust

1.11.3.Wall mounted alcohol hand wash dispenser

1.11.4.The following equipment should be available inside the isolation

room as ordered or as necessary:

 

·         Pipe in oxygen

·         Suction machine

·         Cardiac monitor (as necessary)

·         Infusion pump (as necessary)

·         Pulse oxymeter (as necessary)

·         Mechanical ventilator (as necessary)

·         BP apparatus

·         Phone

·         Buzzer

·         Others as ordered by doctors

 

1.12.        Nurses Station inside the Isolation room

 

1.12.1.The Isolation room should have a separate mini - nuses station

from general ward and must have the following set up:

 

·         Receiving area

·         Bath room

·         Dinning area

 

1.12.2.The following supplies dhould be available at the station:

 

·         Patient chart

·         Forms

·         Telephone

·         Doctors Directory

 

2.      PERSONNEL REQUIREMENTS OF SARS ROOM /WARD

 

2.1.            If possible, only HCW with defined patient care –related activities should be allowed to enter these areas.

 

2.2.            All persons entering the room should wear an N95 mask. Observe standard precautions (hand hygiene) as well as airborne (mask), droplet (masks and gloves) and contact (Gloves, gowns, goggles) precautions.

 

2.3.            Paramedical Staff such as X-ray technician, Housekeepers, Dietary aides and the like must equally protected with PPE when they enter these rooms.

 

 

2.4.            Personnel Components of Isolation Room

 

2.4.1.      NURSE

 

·         Charge Nurse- aside from her usual duties and

responsibilities  she/he will serves as reliever of Bedside  Nurse when later is taking  her break.

·         Bedside Nurse – performs her usual duties and responsibilities. 

·         Nursing Aide/Orderlie -serves as errand in both the general ward and isolation unit of the 11F. He will be responsible in post mortem care of SARS patient and transport of specimen to the laboratory department.

 

2.4.2.      Medical Technologist (Phlebotomist)

 

·         He will be called only if necessary laboratory examination is being ordered.

 

2.4.3.      X-Ray Technician

 

·         He will be called only if necessary examination will be taken

 

2.4.4.      Pulmonary Therapist

 

·         He will be called only if necessary examination/treatment will be taken.

 

2.4.5.      House Keeping staff

 

·         He will do the routine cleaning every day or terminal cleaning every after patient discharge.

 

3. CONTAINMENT PROCEDURES FOR SARS ROOM/WARD

 

1.1.            Exposure to the SARS-infected patient must be kept to the absolute minimum according to the level of care required.

 

1.2.            HCWs must disinfect hands and change PPE in the designated areas within the Isolation Room/Ward before moving to the next patient.

 

1.3.            Hand washing with soap and water should be practiced after contact with any SARS suspect.  Alcohol-based hand rubs can also be used. 

 

1.4.            Solely the patient should use utilities used by the SARS patient. These include eating utensils, thermometers, BP cuff, tourniquet and the like.

 

1.5.            Discard wastes soiled with body fluids of SARS patients including facial tissues, gloves and surgical masks in the yellow (Infectious wastes) trash bags.

 

1.6.            Trained personnel must collect the linen with the minimum handling, shaking or sorting to minimize generation of contaminated aerosols.  Used linen must be properly put into yellow plastic bags before transport to the laundry area. Linen used by SARS patients must be disinfected with 0.1% sodium hypochlorite for at least 30 minutes before washing with soap and water.  Other SARS patients can reuse disinfected and washed linen.

 

 

4. ROUTINE AND TERMINAL CLEANING OF SARS ISOLATION ROOMS OR WARDS

 

4.1.            The housekeeper assigned to do cleaning and disinfecting tasks in SARS isolation room must be properly trained and supervised.

 

4.2.            The recommended PPE must be worn and includes gown, utility gloves, goggles and N95 masks.

 

4.3.            Daily routine cleaning should include all horizontal surfaces such as floors, tables and nightstands; and all surfaces that are frequently touched by the patient and the HCWs such as bedrails, call buttons, telephones, and the toilet and lavatory in the bathroom.

 

4.4.            Terminal cleaning after patient discharge or transfer must include:

 

4.4.1.      All of the horizontal surface covered in routine cleaning PLUS

4.4.2.      Obviously soiled vertical surfaces

4.4.3.      Surfaces frequently touched by the patient or HCWs such as doorknobs, switches

4.4.4.      All other durable equipment in the room such as bed, wheelchair, commode.

 

4.5.            Equipment such as mechanical ventilators, pulse oximeter and BP cuff must be cleaned and disinfected according to manufacturer’s instructions.

 

4.6.            There is no need to disinfect walls, window drapes and other vertical surfaces unless obviously soiled.

 

4.7.            Disinfectant solutions for this purpose are chemical germicides used in hospital infection control, which provide low to intermediate level disinfection of hospital equipment.  These agents include 0.1% sodium hypochlorite (1part bleach in 100 parts water) or phenolic agents.

 

4.8.            Discard all leftover solutions used for cleaning the SARS-designated areas and do not use anymore in other hospital areas.  The housekeeping equipment such as mops and rugs must be washed thoroughly and allowed to dry.

 

 

 

 

 

 

 

 

5.      NFECTION CONTROL WHILE COLLECTING/PROCESSING SPECIMENS

 

5.1.            Procedures that induce coughing and encourage the production of more respiratory droplets from SARS patients such as aerosolized medications, diagnostic sputum induction, bronchoscopy, airway suctioning and endotracheal intubation should only be performed when absolutely necessary.

 

5.2.            Personnel taking care of the SARS patients instead of the laboratory staff should obtain clinical specimens.

 

5.3.            Healthcare personnel should observe Standard, Airborne, Droplet and Contact Precautions in collecting and handling specimens. Full PPE must be worn including gown, apron, eye protection, gloves and N95 mask. Gloves must be changed between patients.

 

5.4.            Processing of laboratory specimens of SARS suspect and probable cases will be done at the Research Institute for Tropical Medicine virology laboratory.  The reference laboratory must be informed of the plan to collect and send specimens from hospitals so that proper guidance can be given regarding the correct media to use, store and transport specimens.

 

 

6.      INFECTION CONTROL IN HANDLING OFHUMAN REMAINS OF SARS PATIENTS

 

6.1.            As soon as a SARS patient expires, the body must be wrapped in linen and put into a body bag.

 

6.2.            For autopsies and postmortem assessment of SARS patients, all personnel involved in the procedure should wear protective garments: surgical scrub suit, surgical cap, gown with full sleeve coverage, eye protection, shoe cover, double surgical gloves and N95 masks.

 

6.3.            Embalming of the remains of a SARS case MUST NOT BE DONE.

 

6.4.            Ideally, the remains of a SARS patient should be cremated.  If this is not possible, the remains must be put in a durable, airtight and sealed coffin for immediate burial.

 

6.5.            The body can be put in cold storage at -70 degrees centigrade.

 

6.6.            It is recommended that suspected SARS patients who die be autopsied by the designated SARS referral hospitals provided all infection control procedures be followed.

 

 

7. MANAGEMENT OF HEALTH CARE WORKERS EXPOSED to SARS PATIENTS

 

1.1.            The IMSD will be responsible for actively monitoring and recording HCWs according to their date and type of contact with SARS cases and development of symptoms.

 

1.2.            HCWs should do twice-daily monitoring of body temperature and the development of respiratory symptoms such as cough and difficulty of breathing.

1.3.            The designated hospital physician must promptly evaluate, for the possibility of SARS, a healthcare worker who becomes symptomatic with cough and fever. Degree of contact with SARS patients and exclusion of other medical reasons must be considered.  If the health care worker is assessed to be a SARS suspect, he or she should be admitted and managed accordingly.

 

1.4.            Exclusion from duty should be continued for 10 days after the resolution of fever and respiratory symptoms. During this period, the infected workers should avoid contact with persons both in the facility and in the community.

 

1.5.            Exclusion from duty is not recommended for an exposed healthcare worker with proper protective equipment if they do not have either fever or respiratory symptoms.

 

1.6.            Any unprotected exposure (contact without the prescribed PPE) of any hospital personnel to SARS patients should also be reported to the designated health officer immediately. This HCW is at high risk for SARS infection and must be placed on voluntary home confinement for 14 days.

 

1.7.            All healthcare facility workers should be educated concerning the symptoms of SARS.

 

 

 

8. INFECTION CONTROL PRECAUTIONS FOR CLOSE CONTACTS IN HOUSEHOLDS OF DISCHARGED SARS PATIENTS

  

 

8.1.            After discharge, SARS patients should limit interactions outside the home and should not go to work, school, out-of-home child-care, or other public areas until ten days after resolution of fever.

 

8.2.            All members of a household with a SARS patient should carefully follow recommendations for hand hygiene (e.g., frequent hand washing or use of alcohol-based hand rubs), particularly after contact with body fluids (e.g., respiratory secretions, urine, or feces).

 

8.3.            Use of disposable gloves should be considered for any direct contact with body fluids of a SARS patient. However, gloves are not intended to replace proper hand hygiene. Immediately after activities involving contact with body fluids, gloves should be removed and discarded and hands should be cleaned. Never wash or reuse gloves.

 

8.4.            Up to 10 days from resolution of fever, discharged patients with SARS should be advised to continue wearing a surgical mask. 

 

8.5.            Sharing of eating utensils, towels, and bedding between SARS patients and others should be avoided, although others can use such items after routine cleaning (e.g., washing with soap and hot water). Clean all environmental surfaces soiled by body fluids with a household disinfectant according to manufacturer’s instructions; gloves should be worn during this activity.

 

8.6.            Household members or other close contacts of SARS patients who develop fever or respiratory symptoms should seek healthcare evaluation.