Hospital Infection Control Guidance

Background

This document intends to give infection control and other general guidance to those personnel who may be involved in receiving and caring for patients who may have SARS, primarily within acute healthcare settings, and should be used in conjunction with local policies.

In the absence of effective drugs or a vaccine for SARS, control of this disease relies on the rapid identifications of cases, their appropriate management, (including isolation of probable and confirmed cases), and the management of close contacts. These measures have allowed the previous outbreak of SARS to be controlled and prevented imported cases from spreading the disease to others.

In preparation, those who suspect that they may receive and care for any SARS cases should:

  • Review their local policies and ensure that operational procedures are described and staff are familiar with them, for example local infection control policies on where personal protective equipment is stored and how it should be used, policies on allocation of adequate staffing and clarity of roles for undertaking duties during these times.
  • Ensure access to documentation records that will be used, eg surveillance forms, local record sheets, etc
  • Ensure that adequate supplies/equipment are available, including: Masks - supplies of those surgical masks normally used in hospital theatres and of those of the standard FFP3, which are respirator type masks
    • Gloves - disposable latex, and latex free alternatives, eg nitral
    • Aprons/Gowns - disposable plastic aprons and/or disposable fluid resistant full sleeve gowns
    • Eye protection eg tight fitting goggles or face shield (disposable, or if non disposable of a wipable surface, not with elastic straps)
    • Waste disposal bags, preferably leak proof
    • Hand hygiene supplies - supplies of liquid soap, antiseptic hand wash solutions and also alcohol hand solutions in case of lack of water supply or access to this. Disposable paper hand towels, readily available.
    • General-purpose detergent and disinfectant solutions, eg sodium hypochlorite/domestic bleach solutions for decontamination and adequate supply of disposable wipes and other cleaning equipment.
  • Ensure that areas where cases will be isolated are designated (see patient placement flowchart)
  • Ensure that there is guidance available on actions to be taken if a case presents, eg this document and other relevant SARS and local guidance documents
  • Hold sessions to raise awareness and train staff on how to manage a person identified as having SARS
  • Ensure that information for raising public awareness is available eg information leaflets.
  • Ensure that they are aware of the latest guidance from HPS

Introduction

SARS is transmitted mainly via large respiratory droplets and direct or indirect contact with infected secretions. Under certain circumstances airborne transmission can occur from aerosolised respiratory secretions. Meticulous attention to infection control procedures can successfully prevent the spread of SARS within a healthcare setting. Personal protective equipment and good infection control can never completely eliminate risk and therefore staff exposed to SARS should be vigilant for symptoms for ten days after they were last exposed to a SARS patient.

Action to take

Admitting doctor/ward/department to inform
  • Infection Control Team
Infection control team will inform
  • Other members of the infection control team
  • Consultant virologist
  • Occupational health department
  • Chief Executive/Deputy of Hospital Trust
  • Consultant in Communicable Disease Control/Consultant in Public Health Medicine (Scotland)
  • Communicable Disease Surveillance Centre/Scottish Centre for Infection and Environmental Health (Scotland)
Record keeping
  • A record of all staff that have contact with the patient should be kept (Sample Form (pdf) )
  • Completed forms to be sent daily to Occupational Health Department
Isolation
  • Patients should be admitted directly to single rooms wherever possible; admission via Emergency Department or Medical Assessment Unit should be avoided.
  • Patients who present at the Emergency Department should be placed in a single room whilst awaiting assessment. Staff should wear protective clothing as detailed below. Rooms to be appropriately decontaminated before being used again.
  • Patients should be nursed in a single room with negative pressure. If this facility is not available then a single room, preferably with en-suite facilities should be used. Room doors to be kept closed.
  • Suitable information must be placed on the isolation room door indicating the need for isolation, though there will be a need to respect patient confidentiality.
  • Essential staff only should enter the isolation room.
  • Should numbers of affected patients be such that single room isolation is not possible patients may be cohorted together in a bayed area. The above recommendations should still apply. A risk assessment to be carried out with Infection Control Team.
  • Rooms/areas that have air conditioning systems should have them turned off and not restarted until patient discharged and decontamination performed.
Protective clothing

To be worn by all staff entering the room

  • Long sleeved fluid-repellent disposable gown
  • Latex or alternative with similar viral protection gloves with tight fitting long cuffs. Non-sterile surgical gloves are recommended.
  • A FFP3 filtering respirator conforming to EN149:2001. Care should be given to face-fit-testing for this equipment, for more details see the Frequently Asked Questions
  • Respirators to be worn by all personnel carrying out clinical care or in the room during aerosol generating procedures.
  • Goggles/visor (glasses do not provide adequate protection against droplets, sprays and splashes).
  • Dispose of gown and gloves in the yellow (clinical waste) bin inside the room immediately before you leave the room. Remove mask and goggles/visor outside the room. Dispose of respirator into clinical waste, (respirators should not be re-used), goggles to be decontaminated according to manufacturers instructions, eg decontaminate using hypochlorite 1000ppm available chlorine followed by thorough rinsing.
  • Wash hands before re-entering the main ward.

It is vital that the protective clothing above is worn for all airway management including intubation.

Equipment
  • Use dedicated equipment where possible in isolation room.
  • Dispose of single use equipment as clinical waste inside room.
  • No special procedures required for transporting used equipment to CSSD. Follow local policies.
  • Multi-patient use equipment should be avoided. If used, disinfect with a freshly prepared solution of 1000pp m available chlorine. Include usual warning about using hypochlorite solutions on metal.
  • Ventilators should be protected with filters and standard decontamination procedures followed.
  • Closed system suction should be used
  • Crockery should be treated as normal and washed in a dishwasher
  • Use of equipment that re-circulates air (eg fans, hot air warming blankets) should be avoided. If used, they should be decontaminated in accordance with manufacturers’ instructions and any filters changed. However fans cause less air movement than opening windows in the re-aerosolisation of settled particles. Staff changing filters must be instructed in safe working practices.
Hand hygiene
  • Essential before and after all patient contact, removal of protective clothing and cleaning of the environment
  • Use soap and water or use alcohol hand rub if hands are socially clean.
  • Rings, wrist watches and wrist jewellery must not be worn by staff.
Linen
  • Bag linen inside single room – do not carry through ward/department
  • Linen should be bagged in accordance with procedures for infected linen and laundry informed of the high-risk nature.
Waste
  • Dispose of all waste as clinical waste
  • Waste to be handled as per local policy
Visitors
  • The number of visitors should be restricted and in some circumstances it may be preferable to exclude all except essential visitors.
  • Close contacts of a probable or confirmed SARS patient should be screened for signs and symptoms of SARS before being permitted to enter the hospital.
  • Visitors entering the isolation room must wear protective clothing as previously detailed
  • Visitors should be trained in the appropriate use of protective clothing
  • A list of all visitors should be kept
Transfers to other departments
  • Where possible, all procedures and investigations should be carried out in the single room. Only a minimal number of staff should be present in room during any procedures.
  • Only if clinical need dictates should patients be transferred to other departments and the following procedures then apply:
    • The department must be informed in advance
    • The patient must be taken straight to, and return from the investigation/treatment room, and must not wait in a communal area.
    • The patient should wear a 'surgical ' mask - this will prevent large droplets being expelled into the environment by the wearer.
    • Portering and escort staff need not wear masks during transit if the patient is able to wear a mask.
    • Gloves and gowns should be worn for direct contact with the patient.
    • The trolley/chair should be wiped with a 1000ppm available chlorine solution after use
    • Staff carrying out procedures must wear the protective clothing indicated above.
    • The treatment/procedure room and all equipment should be cleaned with a 1000ppm available chlorine solution.
    • SARS coronavirus is an enveloped RNA virus and is therefore susceptible to disinfection methods. It is, however, possible that it can survive in the environment for up to 24hrs, so environmental decontamination is vital.

If ambulance transfer is required, they must be informed in advanced and will transport the patient using category 3 containment measures.

Transfer to other institutions
  • Transfer of SARS cases to another hospital should be avoided unless absolutely necessary.
  • SARS patients should not be transferred solely for the purpose of accommodation in a negative pressure room
  • Transfer of other patients who may have been exposed to SARS and could be incubating disease should also be avoided. If transfer is essential, the Infection Control Team at the receiving hospital must be advised in advance of the transfer.
Clinical care / hospital management of adults with SARS
Medical procedures
  • Procedures that produce aerosols of respiratory secretions should be avoided if at all possible eg nebulisers, bronchoscopy induced sputum, positive pressure ventilation via a face mask, intubation and extubation, airway suctioning.
  • Where these procedures are medically necessary, they should be undertaken in a negative pressure room if available or in single room. The minimum number of required staff should be present and all staff present in the room must wear PPE as described above including goggles/visor. Entry and exit from the room should be minimised during the procedure.
  • The use of powered air purifying respirators during aerosol generating procedures is not recommended. This is because there are concerns over the removal, disposal, cleaning and decontamination of this equipment which may increase the potential risk of self contamination and at this time there is inadequate evidence to determine whether PAPRs further reduce the transmission of SARS. If PAPRs are used, staff must be properly trained in their safe use.
Intensive care
  • To reduce the risk of difficult intubation in an emergency situation without adequate infection control, SARS patients should be transferred early to intensive care if their condition is deteriorating and consideration given to early planned intubation by an experienced operator.
  • All respiratory equipment must be protected with a filter that has viral efficiency to 99.999%.
  • Disposable respiratory equipment should be used wherever possible. Re-usable equipment must at a minimum be disinfected in accordance with manufacturers’ instructions.
  • The ventilatory circuit should not be broken unless absolutely necessary.
  • In-line filters and nebulisers should be used with especial reference to the expiratory circuit.
  • Ventilators must be placed on standby when carrying out bagging.
  • Protective clothing as detailed above to be worn
  • The use of non-invasive positive pressure ventilation equipment should be avoided.
  • Water humidification should be avoided where possible.
  • Only essential staff should be in the patient’s room when airway management, cough inducing activities or nebulisation of drugs is being carried out.
Theatres
  • Theatres must be informed in advance.
  • The patient should be transported directly to the operating theatre and should wear a surgical mask.
  • The patient should be anaesthetised and recovered in the theatre.
  • Staff should wear protective clothing as detailed above.
  • Disposable anaesthetic equipment should be used wherever possible.
  • Re-usable anaesthetic equipment should be decontaminated in line with manufacturers instructions.
  • The anaesthetic machine must be protected by a filter with viral efficiency to 99.999%.
  • Instruments and devices should be decontaminated in the normal manner.
  • The theatre should be cleaned using a 1000ppm available chlorine solution.
  • Theatres should not be used for 15 minutes if conventionally ventilation or 5 minutes if ultraclean ventilation.
Cleaning
  • Domestic staff must be made aware of the need for additional precautions
  • Daily cleaning should be carried out with 1000ppm available chlorine.
  • Domestic staff to wear protective clothing as indicated above
  • The isolation area should be cleaned after the rest of the ward area
  • Dedicated or disposable equipment must be used for cleaning
  • Cleaning equipment must be decontaminated with a 1000ppm available chlorine solution following use
Staff
  • The use of bank or agency staff should be avoided wherever possible
  • Staff involved in the care of SARS cases should avoid working in other parts of the hospital or in other hospitals until they are past the incubation period of SARS. (Ten days following last contact with a suspect or probable case)
  • Staff must comply with all infection control procedures as detailed above
  • A record of all staff caring for the patient must be maintained (record sheet at appendix I). The record sheet should be placed at the door and all staff entering must complete this. This record should be sent to the occupational health Department each day.
  • All HCW should be vigilant for symptoms of SARS in the ten days following last exposure to a case and should not come to work if they have a fever. Further advice should be sought from their infection control team and occupational health department. They should stay off duty for seven days after the resolution of fever and respiratory symptoms. During this period, possibly infected workers should avoid close contact with persons both in the hospital and in the general community.
  • Healthcare workers returning from an affected area should return to work as normal unless, they are unwell and have symptoms consistent with SARS, in which case they should stay off work and phone their GP for assessment or they are well, but have been in close contact with a SARS case, or worked in a healthcare setting where cases were being treated. Healthcare staff in this group should avoid contact with patients for 14 days after departure from an affected area, should contact their local occupational health department, and monitor their own health for 14 days, seeking medical advice if they become unwell.
Specimens
  • All specimens must be treated as biohazard:
    • Label with biohazard label
    • Mark request form accordingly
    • Double bag
  • Specimens will be handled as Containment Level 3
  • The following specimens should be obtained Respiratory samples:
    • Urine
    • Faeces
    • EDTA blood 20ml for PCR
    • 20 mls clotted blood

For more details see:

Arrow Guidance on microbiological sampling and investigation of possible cases of SARS during the inter-epidemic period

Contact tracing
  • Follow up of contacts of SARS patients will be co-ordinated by the local Health Protection Unit see the main HPS SARS page
  • Follow up of staff contacts of SARS patients will be co-ordinated by the Occupational Health Department
Surveillance
  • Enhanced hospital based surveillance for 'atypical pneumonia' should be instigated.
  • Consideration should be given to introducing twice daily temperature monitoring of all in-patients.
Last offices
  • Carry out last offices using the protective clothing and medical procedures identified above.
  • A body bag should be used
  • Mortuary staff must be advised of the biohazard risk

Summary of advice (consistent with guidance provided by HSE and WHO)

If a patient fitting the case definition for SARS is admitted to the hospital, clinicians should notify infection control personnel immediately. Until the cause and route of transmission are known, in addition to Standard precautions, infection control measures for inpatients should include:

  • Airborne precautions, eg
    • Either an isolation room with negative pressure relative to the surrounding area or a single room with own bathroom and toilet facilities
    • Use of FFP3 filtering masks (98% filtering efficiency) conforming to EN 149:2001 for persons entering the room. Care should be given to face-fit testing for this equipment. For more details see the Frequently Asked Questions.
    • In the UK COSHH (and other) Regulations require that PPE shall comply with the Personal Protective Equipment Regulations (2002). Simply this means PPE shall be 'CE' marked, ie conform to the European PPE Directive (89/686/EEC). Conformity is usually met by compliance to a European (EN) standard eg EN149. RPE which conforms to the USA N95 classification will offer similar respiratory protection to an FFP2 respirator (92% filtering efficiency) but will not be 'CE' marked and therefore should not be used.
  • Contact and droplet precautions (including use of long sleeve fluid repellent gown and latex or similar non-latex gloves with tight fitting cuffs for contact with the patient or their environment).
  • Standard precautions to include careful attention to hand washing and hygiene.
  • When caring for patients with SARS, clinicians should wear eye protection for all patient contact. Contact local Infection Control Team for advice.
  • Standard precautions when handling any clinical waste, which must be place in leak-proof biohazard bags or containers and disposed of safely.
  • Laundry should be classified as infected.
  • If hospitals lack isolation facilities and lots of cases occur, then cohort nursing is recommended as per WHO guidelines in collaboration with the infection control team.
  • It is not necessary to use disposable crockery or cutlery when caring for SARS patients in hospital.
  • Hypochlorite is the recommended disinfectant for environmental decontamination of areas where the SARS patient has been in the hospital (eg, A&E department). Note evidence that SARS coronavirus can survive in environment for up to 24hrs.
  • For further advice on clinical management of SARS cases see main HPS SARS page

[Staff contact record sheet (pdf) ]

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