Infection control for SARSIntensive Care Unit Prince of Wales Hospital Shatin Hong Kong

Tutorial prepared by Charles GomersallVersion 1.0April 8th 2003

DisclaimerThe procedures shown in this tutorial reflect current practice in Prince of Wales Hospital ICU and are based on our current understanding of SARSThe author, the Prince of Wales Hospital and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this tutorial

WarningAttention to infection control is vitalThe agent that causes SARS is highly contagious and may cause life-threatening illnessMany healthcare workers, both old and young have been affected and some have died

PersonalInWash handsMaskGogglesCapGownWash handsGloves

OutCapGownWash handsGogglesMaskWash handsOutside maskWash hands

InWash handsMaskGogglesCapGownWash handsGloves

InWash handsMaskGogglesCapGownWash handsGloves

Wash handsPalm to palmPalm to back, fingers interlacedPalm to palm, fingers interlacedFingers claspedThumbs Fingers to palmForearms

Wash handsPalm to palmPalm to back, fingers interlacedPalm to palm, fingers interlacedFingers claspedThumbs Fingers to palmForearms

Wash handsPalm to palmPalm to back, fingers interlacedPalm to palm, fingers interlacedFingers claspedThumbs Fingers to palmForearms

Wash handsPalm to palmPalm to back, fingers interlacedPalm to palm, fingers interlacedFingers claspedThumbs Fingers to palmForearms

Wash handsPalm to palmPalm to back, fingers interlacedPalm to palm, fingers interlacedFingers claspedThumbs Fingers to palmForearms

Wash handsPalm to palmPalm to back, fingers interlacedPalm to palm, fingers interlacedFingers claspedThumbs Fingers to palmForearms

MaskUse N95 or N100 maskSurgical masks do NOT provide protectionCheck fit of mask each time it is usedplace both hands over the mask and exhale vigorouslyif air leaks around the nose adjust the nosepieceif air leaks at mask edges, reposition the straps for a better fitrecheck

InWash handsMaskGogglesCapGownWash handsGloves

InWash handsMaskGogglesCapGownWash handsGloves

InWash handsMaskGogglesCapGownWash handsGloves

InWash handsMaskGogglesCapGownWash handsGloves

InWash handsMaskGogglesCapGownWash handsGloves

InWash handsMaskGogglesCapGownWash handsGloves

ReadyWash handsMaskGogglesCapGownWash handsGloves

InsideChange gloves between patientsChange gloves before using phone, computers, writing notes etcWash your hands whenever you change your glovesDo not touch your face or eyes

OutCapGownRemove glovesWash handsGogglesMaskWash handsOutside maskWash hands

OutCapGownRemove glovesWash handsGogglesMaskWash handsOutside maskWash hands

OutCapGownRemove glovesWash handsGogglesMaskWash handsOutside maskWash hands

OutCapGownRemove glovesWash handsGogglesMaskWash handsOutside maskWash hands

OutCapGownRemove glovesWash handsGogglesMaskWash handsOutside maskWash hands

OutCapGownRemove glovesWash handsGogglesMaskWash handsOutside maskWash hands

OutCapGownRemove glovesWash handsGogglesMaskWash handsOutside maskWash hands

OutCapGownRemove glovesWash handsGogglesMaskWash handsOutside maskWash hands

OutCapGownRemove glovesWash handsGogglesMaskWash handsOutside maskWash hands

Eating and drinkingAlways wash your hands firstUse your own utensilsSit at least 1m apartDo not talkDo not cough or sneeze when not wearing a mask

RespiratoryNo nebulizers or Venturi masksNo non-invasive ventilationMinimize circuit breaksHMEFBacterial filterScavenging

RespiratoryNo nebulizers or Venturi masksNo non-invasive ventilationMinimize circuit breaksHMEFBacterial filterScavenging

RespiratoryNo nebulizers or Venturi masksNo non-invasive ventilationMinimize circuit breaksHMEFBacterial filterScavenging

RespiratoryNo nebulizers or Venturi masksNo non-invasive ventilationMinimize circuit breaksHMEFBacterial filterScavenging

RespiratoryNo nebulizers or Venturi masksNo non-invasive ventilationMinimize circuit breaksHMEFBacterial filterScavenging

RespiratoryNo nebulizers or Venturi masksNo non-invasive ventilationMinimize circuit breaksHMEFBacterial filterScavenging

UrineDirect urine flow against the wall of the collecting jug to avoid splashes

UrineTurn on water to flush away urine

UrineCarefully empty the urine onto the side of the sluice to avoid splashes

UrineClean up any spills immediately with sodium hypochlorite solution

RememberThis disease is highly contagiousIt is potentially life threateningYour safety and the safety of your family and patients depends on your strict adherence to infection control measures

The importance of infection control cannot be overemphasized. It is vital for your own safety, the safety of your families and the safety of your patients. The agent that causes SARS is highly contagious and the condition is potentially life-threatening. Many healthworkers, old and young have been affected and some have diedBefore entering an area in which SARS patients are being cared for it is essential to put on protective clothing. This should be removed immediately after leaving the area. As the viruses thought to cause SARS can persist on inert surfaces for many hours it is essential to strictly follow the correct order for donning and removing protective clothing. Entering the high risk area. Check instructionsClean your hands, preferably by washing. Alcohol hand rub is an alternative. Use your elbow, not your hand to obtain hand rub or disinfectant.Turn on the tap and wet your hands and forearms. Using elbow squirt 3-5 ml of disinfectant scrub solution into your cupped hand and rub your hands together palm to palmThen rub the back of one hand with the palm of the other, interlacing your fingers. Repeat this with the position of your hands reversed.Now rub your hands together palm to palm with your fingers interlacedAfter that clasp your fingers together and rubThen hold the thumb of one hand with your other hand and rub with a rotary movement. Reverse your hand positions and repeat.Finally rub the palm of each hand with the fingers of the other and then wash your forearms. Turn off the tap with your elbow. Alternatively turn if off using a piece of paper to prevent direct contact between you and the tap.Next put on a N95 or N100 mask. Surgical masks do not provide adequate protection.After putting on the mask check the fit by placing both hands over the mask and exhaling vigorously. If air leaks around the nose adjust the nosepiece. If it leaks at the edges of the mask reposition the straps. Check the fit again after adjusting.Then put on your goggles. Eye protection should be worn at all times in high risk areasPut on a cap and thenYour gownMaking sure it is tied at the backThen clean your hands againAnd put on your glovesNow you are readyOnce in the high risk area changes gloves between patients and before using the phone or computers or before writing notes. Wash your hands, or use alcohol hand rub, every time you change your gloves. Do NOT touch your face or eyesLeaving the high risk area. First take off your cap taking care not to touch your face.Then remove your gownAnd your glovesWash your hands.Then remove your gogglesAnd your maskWash your hands againPut on the mask that you wear outside the high risk areaAnd wash your hand for a third timeIn order to prevent staff cross infecting each other a few rules should be observed during meal breaks. Always wash your hands first, use your own utensils, sit at least 1m apart, do not talk and do not cough or sneeze with your mask offRespiratory precautions.Do not use nebulizers or Venturi masks as the production of aerosols and the high flow rates may facilitate transmission of the infecting agentAvoid non-invasive ventilation as it is difficult to filter and scavenge the expiratory gas and many non-invasive ventilators generate very high flow rates during expiration. This may reach 60 l/min

Minimize any breaks in ventilator circuits. For example by using closed suction systems and turn the ventilator to standby mode first if it is necessary to break the circuitUse a combined HME and filter at the Y-pieceAnd a bacterial filter at the expiratory port of the ventilatorFinally, scavenge the waste gases from the ventilatorThere is some evidence that SARS may also be spread via excrement so it is necessary to take extra precautions when disposing of urine. In particular avoid creating splashes. For example, when empyting catheter bags direct the urine flow against the wall of the collecting jug

When empyting the jug turn on the water in the sluice firstThen carefully empty the urine onto the side of the sluiceIf you spill any excrement immediately clean up the spill using sodium hypochlorite