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Perspective |
1 Department of Diagnostic Radiology and Organ Imaging, Prince of Wales
Hospital, 30-32 Ngan Shing St., Shatin, New Territories, Hong Kong,
China.
2 Department of Microbiology, Prince of Wales Hospital, Hong Kong, China.
3 Department of Pediatrics, Prince of Wales Hospital, Hong Kong, China.
Received April 18, 2003; accepted after revision May 5, 2003.
Address correspondence to S. S. Y. Ho.
At the Prince of Wales Hospital, the SARS outbreak first began March 11, 2003. Hong Kong health authorities were alerted about this mysterious flulike illness after it had affected at least 50 health care workers in this hospital, including doctors, nurses, medical students, physiotherapists, and radiographers. The number of patients with SARS rose rapidly to more than 100 in the following week from transmission by infected staff to family members and colleagues and by visitors to the community. In this article, we reveal how our radiology department faced the challenges and managed the outbreak.
General Information About SARS
From the initial experience of reported cases, we found that patients diagnosed with SARS commonly present with flulike signs and symptoms: rapid onset of high fever 100.4°F (38°C), malaise, chills, headache, and body ache. Other symptoms include cough, shortness of breath, or dyspnea [2] (Table 1). Early laboratory findings may reveal thrombocytopenia and leukopenia. Chest radiography may show changes compatible with pneumonia, and high-resolution CT is more sensitive in detecting early pneumonic changes (Figs. 1, 2, 3A, 3B).
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The available evidence suggests that droplet or contact spread through respiratory secretions is the most likely mode of transmission, although airborne or waterborne transmission has not been totally excluded [3]. Human Metapneumovirus and Coronavirus have been implicated as the causative agents [4].
Roles of a Radiology Department in a SARS Outbreak
Because imaging plays an important role in the diagnosis and management of SARS, the role of a radiology department is to provide an immediate and efficient radiologic service for patients with confirmed and suspected SARS. In our department, we have adopted two imaging protocols for examining the patients suspected of having SARS and those discharged (Figs. 4 and 5). Because no previous experience or literature was available to guide us, the imaging protocols were established in collaboration with all departments involved in the treatment of these patients, and we took into account the availability of imaging resources, the number of patients involved, radiation hazards, and the sensitivity of the imaging tests. The services predominantly requested for these patients were chest radiography (ambulatory and bedside) and high-resolution CT of the thorax for detection and monitoring of disease (Figs. 6A, 6B, 6C, 6D and 7A, 7B).
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Chest Radiography
There was a need to minimize the risk of cross-infection of SARS to other
personnel and to protect patients who came to the radiology department for
other radiologic services. Transportation of patients with SARS to the
radiology department was limited. Satellite radiography centers were set up
using portable radiography machines, chest stands, and lead screens in the
vicinity of the SARS wards and clinics for ambulatory patients with SARS. For
nonambulatory patients in the wards and intensive care unit, bedside
radiography was provided. Our radiology department was fortunate to have
enough portable radiography machines and accessories available for the
service.
CT
High-resolution CT of the thorax has become an important diagnostic test
for patients with a high suspicion of having SARS but with normal findings on
chest radiography. However, high-resolution CT should be used with caution to
avoid overdiagnosis and should be used in conjunction with a strong clinical
protocol. Because this examination can be performed only in the radiology
department, stringent infection control measures were introduced and followed.
Designated sessions or hours, either outside office hours or at the end of a
session, were assigned for patients with SARS. After the SARS patient was
examined, the room was disinfected thoroughly before normal service was
resumed. All personnel were familiar with and adhered strictly to the
infection control guidelines.
Reviewing Chest Radiographs
To prevent transmission by fomites, we handled previous radiographs for
review in the main department with care. In our institution, two designated
radiologists reviewed chest radiographs of patients with SARS in the intensive
care unit and SARS wards daily. These radiologists were fully aware of the
risks and took all the necessary infection control measures. The deployment of
radiologists to the high-risk areas could be avoided if a PACS (picture
archiving and communication system) was available.
Infection Control
Because SARS is highly contagious and the mode of transmission is not fully understood, every hospital staff member must remain aware of the infection control measures. At our institution, the hospital was divided into three major areas according to the level of risk of SARS: ultrahigh risk area (SARS isolation areas or intensive care units, medical infection triage wards, operating theater, endoscopy unit, and radiography unit for patients with SARS), high risk area (accident and emergency department, medical and pediatric acute admission wards, infection triage bay, nonmedical wards, and staff clinic), and moderate-risk areas (all other areas). Infection control measures were reinforced, according to risk stratification.
In consultation with the infection control unit, our radiology department was also stratified into areas with different risks on the basis of the types of patients and examinations performed in the individual rooms. All examination rooms were classified as ultrahigh risk areas for the time when patients positive for or suspected of having SARS were being examined. The film-processing area where cassettes are brought back to the department after bedside radiography in the ultrahigh risk areas was also considered as a ultrahigh risk area. Infection control measures necessary for each risk stratification were defined, distributed, displayed, and strictly followed by all department staff [5] (Tables 2, 3, 4).
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In ultrahigh risk areas, all attending staff had to wear masks, protective gowns, and gloves. After radiography or CT of patients with SARS, the gantry table and floor were cleansed, and the bed linens were changed. In addition, radiographers periodically disinfected the control panel, telephones, computer keyboard, and desk surface during decontamination of the examination room. Film cassettes from ultrahigh risk areas were decontaminated properly before film processing.
Our experience has shown that the radiology staff were not familiar with infection control measures and initially were apprehensive in dealing with patients with SARS in the ward and in the department. Enhancing the infection control training and issuing guidelines for infection control measures helped to reduce their anxiety in facing the crisis. We strongly recommend that the department appoint a staff member, preferably a nursing officer, to monitor and ensure that all department staff fully comply with the infection control measures according to guidelines set by the infection control unit. Policing the application of infection control measures should be mandatory in every department.
Role of a Web Site in the SARS Crisis
The role of any Web site is to disseminate information as quickly and as widely as possible. With the advent of broadband transmission, 2.5-G mobile protocol, and many other innovations in telecommunication, the medical and the general community demand instantaneous information. In an epidemic, timely posted information on disease definition, diagnostic criteria and methods, treatment, and precautions may affect the eventual outcome of the outbreak. Additional helpful information includes case examples, protocols, and information for health care workers. The traditional print format for case or epidemic reporting lags behind because of physical constraints and lacks the flexibility of continual updates and changes responsive to feedback, an area in which a dedicated Web page really justifies its existence.
We all tend to panic when first faced with an unknown disease causing an outbreak. The existence of a place for posting and exchanging information acts as a sanctuary for health care professionals at these times of great stress. Radiology departments, usually with access to the best imaging and telecommunication hardware in a hospital, are in a prime position to offer such a service. The role of the Web site of a radiology department would be to provide images, essential information, and links to more detailed information or other resources. On March 19, 2003, amid the developing outbreak of SARS, the Department of Diagnostic Radiology and Organ Imaging of the Prince of Wales Hospital decided to establish a Web page dedicated to SARS [5]. The Web page was online by March 21, 2003, and by April 11, 2003, it had played host to 70,000 visitors, with an average of 5000 visits a day. If these visits were translated into telephone calls, they would average 200 calls an hour. The value of a Web site is obvious.
Crisis Management
The outbreak of SARS in a hospital, especially with involvement of a large number of medical staff, some in critical condition, is undoubtedly a strain for all those who remain healthy and need to help their colleagues recover from the illness. The emotion due to trauma, fear, and anxiety among the hospital staff is intense and may affect their normal performance. In the SARS crisis, radiology departments play an important role in the diagnosis and management of the disease. Because radiographers and nurses are the frontline workers in this battle, their commitment and professionalism are essential. Managers of a radiology departments should be patient, empathetic, reassuring, and determined to motivate the apprehensive staff in the crisis. This motivation is best done by leading from the front. The senior staff in every department should also perform duties that are expected of the others, including working in high-risk areas. This example instills confidence in the junior staff and uplifts their sagging morale. An open line of communication and education about infection control also improves staff morale and performance and ameliorates the negative impact of the SARS crisis on radiology departments.
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