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Perspective |
1 Department of Diagnostic Radiology and Organ Imaging, Faculty of Medicine, The
Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New
Territories, Hong Kong S.A.R. China.
2 Department of Microbiology, The Chinese University of Hong Kong, Prince of
Wales Hospital, Hong Kong S.A.R. China.
3 Department of Clinical Oncology, The Chinese University of Hong Kong, Prince
of Wales Hospital, Hong Kong S.A.R. China.
4 Department of Paediatrics, The Chinese University of Hong Kong, Prince of
Wales Hospital, Hong Kong S.A.R. China.
Received April 25, 2003; accepted after revision April 30, 2003.
Address correspondence to A. D. King.
In regions of the world such as Asia, the outbreak is putting severe stress on health services, resulting in hospitals having to treat SARS patients at the same time as continuing their usual service to patients with other potentially life-threatening illnesses. This causes major problems for a radiology department such as ours that has to offer a service to all these patients, sometimes using the same equipment, in the same room, by the same staff. In these difficult circumstances, the goal is to reduce the risk of cross-infection between patients as well as reducing the risk of infection to staff. The following is an account of the procedures and guidelines that so far we have put in place, with the close involvement of the hospital infection control team, to try to decrease these risks. We have posted our experience on our Web page [1] but hope that this article will be of particular use to those who do not have access to the Internet and will reach a wider audience as well. We have divided this article into two sections, the first discussing general problems and the second covering useful tips when reorganizing services.
General Problems When Reorganizing Services
In terms of reorganizing services, providing protective apparel to staff and patients, and arranging cleaning of equipment, patients must be assessed for relative risk. For practical purposes, four categories of patients arrive at a radiology department: outpatients without suspected or confirmed SARS, outpatients with suspected SARS (for chest radiographic screening), inpatients without suspected or confirmed SARS, and inpatients with suspected or confirmed SARS.
Patients with suspected or confirmed SARS obviously pose the greatest risk to staff and other patients, and outpatients without suspected or confirmed SARS pose the lowest risk. Inpatients without suspected or confirmed SARS cause the greatest difficulty when assessing relative risk. These inpatients may have a provisional diagnosis of a non—SARS-related disease that causes symptoms in common with SARS (e.g., postoperative fever). In addition, these inpatients are at risk of cross-infection. Therefore, we believe that when reorganizing the department, inpatients without suspected or confirmed SARS should be physically segregated from the other groups but the same level of infection control measures should be taken as for inpatients with suspected or confirmed SARS.
Physical segregation of patients can be achieved using location or time. When possible, facilities for imaging patients with SARS should be situated outside the main department, such as the portable radiography and sonography units used in intensive care. However, equipment for some modalities may not be mobile (CT, MR imaging, fluoroscopy, nuclear medicine). In departments that have more than one piece of equipment, it may be possible to dedicate one for SARS and one for non-SARS patients. Alternatively, additional equipment such as a portable CT scanner could be rented. Congestion in the waiting area should be minimized, and waiting areas and patient access should be segregated and clearly marked with barriers and signs. Most departments will be constrained by the amount of equipment and the layout of the department, so the only way to segregate some patients will be by time. Unfortunately, in practice this is quite difficult to implement because the clinical condition of a patient often dictates the timing of the examination.
Useful Tips When Reorganizing Services
Staff Education
Identify a departmental infection control team to draw up and continually
update guidelines and to educate staff. One member must be identified to act
as a "policeman" to ensure the guidelines are enforced. It is
imperative that all staff (cleaners, workers, clerical staff, secretaries,
nurses, radiographers, radiologists, and managers) work as one unit and have
regular education sessions. Protocols for each modality and infection control
instructions should be posted on the walls in all examination rooms. Staff
should also undertake personal measures to reduce infection such as always
wearing a mask; not touching the mask and the eyes; washing hands frequently;
facing away from colleagues when eating, drinking, and talking; and covering
pagers with disposable plastic bags.
Procedure for Allocating Appointments
If a PACS (picture archiving and communication system) is not installed,
reduce clinicians' visits to the department by arranging a fax and telephone
system for inpatient requests. Reduce outpatient appointments to allow time to
properly undertake infection control measures. Allocate appointments in the
sequence of low to high risk, and stress the importance of keeping to
outpatient appointment times. Restrict outpatient visitors to those who
accompany children, the very sick, and the aged. Finally, clinicians must be
prudent in their requests for imaging patients with SARS. Requests should be
made only when the examination result will have a major impact on patient
treatment, and all such radiology procedures must be discussed and performed
by experienced staff.
Procedure for Preparing the Patient
Outpatients should be screened for SARS using a questionnaire on their
arrival for examination. Those suspected of having SARS should have the
appointment postponed and be asked to attend a screening clinic. Patients must
follow personal infection control guidelines.
Inpatients need careful preparation before arriving in the radiology department. The latest SARS status must be checked because it may have changed since the request was made. IV lines should be placed (and removed) on the ward, and appropriate consent forms should be signed on the ward and faxed to the radiology department. Patients must follow personal infection control guidelines; if the patient requires oxygen, a nasal cannula and not an oxygen mask should be used. Finally, the examination room should be ready for the patient to reduce waiting time in the department.
Procedure for Examining the Patient
Staff must change into protective apparel in a designated site close to the
examination room, taking special care to follow instructions as to the
sequence of preparation. Warning signs must be posted outside the room when
suspected or confirmed SARS patients are being scanned. All clinical notes and
radiographic packets from the ward should be left on the patient trolley
outside the examination room, and staff should avoid handling these items
unless doing so is essential. View previous examinations by reloading them
onto monitors rather than by requesting old films. Equipment such as the
examination couch should be protected by a new sheet that is changed between
patients. Two staff members should be present, one to do the transferring and
positioning of the patient and the other to operate the control panels. The
examination should be shortened when appropriate while still ensuring the
clinical question is answered.
Procedure After the Examination
The patient transporter should be ready to collect patients as soon as the
examination is finished. Staff should remove contaminated apparel in
designated rooms according to the sequence on the instructions and place linen
and laundry in designated bags. The cleaning staff should clean according to
infection control guidelines.
Problems of Specific Modalities
General radiography.—Satellite radiography and portable
services should be set up outside the main department for performing chest
radiography of patients with suspected or confirmed SARS. Designate a specific
room in the emergency department for examining such patients. The increased
demand for portable chest radiographs may require the purchase of extra
cassettes. Cassettes from contaminated areas should be disinfected. The
greatest precaution also should be taken when performing radiography in the
emergency department; have a high index of suspicion regarding any patient
undergoing chest radiography for acute chest symptoms, irrespective of the
provisional diagnosis.
CT.—Special attention should be paid to cleaning the injection pump. One pump should be allocated for patients with suspected or confirmed SARS.
Sonography.—Designate rooms and sonographic scanners for high-risk patients. Try to designate sonography machines to be used in specific areas, such as the neonatal unit or the bone marrow transplantation unit. The examination should be kept as short as possible to answer the clinical question; if appropriate, consider CT as an alternative examination. When performing abdominal sonography, attempt to avoid instructing the patient to take deep breaths. If that cannot be avoided, turn the patient on his or her side facing away from you. The transducer should be cleaned after each outpatient and covered with disposable covers for all inpatients. Special precautions must be taken for obstetric patients: designate a specific room and consider discontinuing nonessential routine, regularly scheduled scans.
Fluoroscopy and contrast-enhanced studies.—Many of these examinations, such as barium examinations, potentially carry a high risk of cross-infection. Therefore, the highest level of infection control should be adhered to in all cases; when possible, the examination should be avoided altogether in patients with suspected or confirmed SARS. Ensure that staff know where to dispose of liquids.
MR imaging.—For inpatients, metallic items and false teeth should be removed on the ward, and the patient's mask should not have a metallic bar. The call bell must be covered with a disposable plastic bag. Potentially, MR imaging poses a high risk of cross-infection because of the prolonged time during which a patient's head and body are in close proximity to the equipment.
Angiography and interventional radiology.—A dedicated room and sonography machine should be used for patients with suspected or confirmed SARS, and for all patients the highest level of infection control should be undertaken.
Nuclear medicine.—Ventilation scanning must not be performed.
Areas for Special Attention When Reorganizing the Radiology
Department
Staff should be rotated to reduce the viral load to individuals in
high-risk areas. If possible, staff should have regular allocated times away
from work during which they are monitored for signs of infection. An efficient
patient transportation service is essential to prevent inpatients from waiting
in the radiology department. If patients from the ward require the use of
elevators, one elevator must be dedicated to the transportation of suspected
or confirmed SARS patients. Resuscitation is a hazardous procedure for staff.
The resuscitation trolley must be stocked with protective apparel at all
times, staff must be fully protected before starting resuscitation, and
resuscitator bags must be fitted with a filter before use.
Conclusion
This account is by no means comprehensive. Our protocol is undergoing constant daily review and updating, but we hope this account will provide valuable pointers to those who may find themselves embarking on this daunting task. Readers may find it useful to read this article in conjunction with our Web site [1], where we have posted additional information on the recognition and imaging follow-up of SARS patients.
Acknowledgments
This work was compiled with the support of the dedicated members of our staff. In particular we thank those radiologists and radiographers in charge of the various imaging modalities: Simon Yu, Kwok Tung Lee, Raina Chow, Lawrence Chow, Wynnie Lam, Tom Lee, Gregory Antonio, Tak Yeung Chan, Herman Wong, Robert Howard, Ricky Chan, and Melinda Choi.
References
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