British Journal of Radiology (2005) 78, 606-611
© 2005 British Institute of Radiology
doi: 10.1259/bjr/17161223
Emergency management and infection control in a radiology department during an outbreak of severe acute respiratory syndrome
Y C Lin, BSc
1,2
S L Dong, MSc
3
Y H Yeh, BSc
2
Y S Wu, BSc
2
G Y Lan, MD
2
C M Liu, MD, MPh
4,5 and
T C Chu, PhD
2,3
1 Department of Radiology, Cheng Hsin Rehabilitation Medical Center, Taipei, Taiwan, 2 Department of Radiological Technology, Yuanpei Institute of Science and Technology, Hsinchu, Taiwan, 3 Department of Atomic Science, National Tsing Hua University, Hsinchu, Taiwan, 4 Community Medicine Research Center & Institute of Public Health, National Yang-Ming University, Taipei, Taiwan and 5 Department of Research and Education, Cheng Hsin Rehabilitation Medical Center, Taipei, Taiwan
Correspondence: Tieh-Chi Chu, Professor, Graduate School of Medical Imaging, Yuan-Pei Institute of Science and Technology, 306 Yuanpei Street, Hsinchu, 300 Taiwan, ROC
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Abstract
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The World Health Organization classified Taiwan as a serious epidemic-stricken area when the extent of severe acute respiratory syndrome (SARS) in Taiwan became clear. As of 11 July 2003, 671 probable SARS cases had been identified in Taiwan and 7 healthcare workers had died from the disease. Radiographers were easily infected by SARS because they had close contact with suspected or probable cases while conducting chest X-ray examinations. Three radiographers had been infected by the end of May 2003. Because of the impact of SARS on the Radiology Department, the department established a SARS emergency infection control team and re-designed the department's infection-control and emergency-management procedures based on the concept of risk-grade protection. This effort included installing a radiographic room at the fever-screening station, re-allocating human resources in the Radiology Department, training the department staff in infection control, and drafting new operational procedures for radiographers conducting X-ray examinations on SARS patients. The goal of this program was to reduce the infection rate and distribute materials efficiently in the department. This article introduces the emergency-management procedure of the Radiology Department during the SARS outbreak and the infection-protection experience of the department staff.
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Introduction
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The pathogen that causes severe acute respiratory syndrome (SARS) is a coronavirus mutation [1]. When the human body is infected with this pathogen, diffuse pneumonia and respiratory failure occur, and infection can lead to death. SARS originated from Canton province of mainland China and spread to Hong Kong, Taiwan, Canada, Singapore, and other countries in 2003. Taiwan's first SARS case was diagnosed in February 2003, after which a massive SARS infection event broke out in the Municipal Hoping Hospital of Taipei during April 2003. The World Health Organization (WHO) classified Taiwan as a serious epidemic-stricken area because of the high prevalence of SARS infection in this area. On 24 April 2003, the government ordered the hospital to be isolated. However, because infection controls were not in place at the beginning of the outbreak, internal infections occurred in six Taiwan-area hospitals from April to June 2003. These hospitals were closed and stopped receiving new patients. Thanks to specialists sent by the WHO to help improve protection, the SARS situation in Taiwan has stabilized. As of 30 July 2003, a total of 671 probable cases had been diagnosed [2].
The latent period of SARS is 2–7 days. The initial sign of infection is usually fever (>38°C), which is often accompanied by headache, muscle pain and weakness. Most SARS patients have local pulmonary infiltrates in the early stages. Some have focal consolidation on chest radiographs in the late stage [3, 4]. Research has shown that the SARS virus spreads through physical contact with patients, via secretions and faecal material [5]. Because the healthcare workers who diagnosed and managed SARS had direct contact with patients, those without protection were easily infected. Some staff members were infected when diagnosing patients, and as of mid-June 2003, seven healthcare workers had died of SARS.
As suggested by the WHO, the Health Department of the Republic of China classified SARS into suspected, probable and confirmed cases. Because pulmonary infiltrate is an important indicator by which to judge the condition and progress of SARS, chest X-ray examination plays an important role in the diagnosis of SARS cases [6]. Because radiographers had close contact with patients when they conducted chest X-ray examinations, their infectious potential was high. As of the end of May 2003, three Taiwan-area radiographers were infected with SARS.
The Disease Control Bureau of the Republic of China classified hospital departments into three risk levels: high level, mid-level, and low level. The radiology department was considered a high-level risk department. Because the Radiology Department was required to serve the X-ray imaging of SARS-suspected patients at fever-screening stations and negative pressure isolation rooms, it faced a shortage of manpower and materials. The department had to internally re-allocate its staff [7, 8] and protection materials [9] and establish a complete emergency-management program to maximize infection control efforts and allow the rest of the department to run normally [7].
During the SARS-outbreak period, the department's emergency-management and infection-control plan included four points: (1) distribute protective materials based on the concept of risk-grade protection to use resources efficiently; (2) check the operating load during the SARS period, re-allocate department manpower to use human resources efficiently, and let staff have days off by turns to reduce the potential for cross-infection in the department; (3) draft the Operational Procedures for Radiographers Conducting X-ray Examinations in SARS Patients to reduce infectious potential in the Radiology Department; and (4) plan emergency management to allow the department to run normally if some staff members were infected by SARS and segregated.
During the SARS-outbreak period in Taiwan, Cheng-Hsin hospital participated actively in the efforts to combat SARS. First, the hospital set up a SARS emergency infection-control team in charge of SARS protection control for the whole hospital. It began establishing negative pressure isolation rooms with 48 beds in April 2003 to receive suspected, probable and confirmed SARS cases. A fever-screening station was also created outside the emergency room in May 2003 to protect its staff and patients from SARS infection.
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Hospital SARS protection control plan
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As SARS continued to spread, the hospital set up a trans-department SARS emergency infection control team that was in charge of infection control and protection management for the entire hospital. The team held regular meetings to discuss the SARS situation and control progress, and was empowered to revise operational procedures at any time. The Nursing Department, responsible for patient transport, designated a specific elevator for SARS patients. Negative pressure isolation rooms were designated to receive suspected, probable or confirmed SARS patients and each patient was segregated within a single room. The hospital classified the wards into three regions (A, B, and C). Confirmed SARS patients were put in the A region, probable patients in the B region, and suspected cases in the C region.
To prevent hospital staff and non-SARS patients from being infected with SARS, the hospital set up temperature-taking stations in front of every entrance to test the body temperature of every person. Meanwhile, it also installed a fever-screening station outside the emergency room, where patients with fevers were examined. The fever-screening procedure for suspect SARS patients is indicated in Figure 1
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Figure 1. Screening procedure of suspected severe acute respiratory syndrome (SARS) cases at the Cheng Hsin Medical Center of Taiwan.
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Emergency management and infection control in the Radiology Department
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Because of the impact of SARS on the Radiology Department, a department-specific SARS emergency infection control team was set up. Meanwhile, an X-ray room was established at the fever-screening station, the human resources of the department were re-organized, and operational procedures for radiographers conducting X-ray examinations in SARS patients were drafted.
Establish SARS emergency infection control team in Radiology Department
The department director chaired the Radiology Department SARS emergency infection control team. Its members included representatives of doctors, radiographers, and nurses of the Radiology Department and other related staff. It began working on the same date as the hospital emergency infection-control team and will end on the date the hospital team finishes its duties. Team responsibilities included: (a) Coordination with the hospital infection-control management and planning of infection-control management for the Radiology Department. (b) Classification of the department work according to its risk-grade. Three grades were employed:
- High-level risk. This work is defined as examining suspected, probable or confirmed SARS cases; for example, working with portable chest radiography equipment in the negative pressure isolation rooms and with X-ray equipment at the fever-screening station. Taking radiographs in the emergency room is also a high-level risk task if no fever-screening station exists in a hospital.
- Mid-level risk. With this type of work, the radiographers had close contact with patients who had passed the fever-screening test and were having such tests as routine radiography, CT, ultrasound, and MRI scans.
- Low-level risk. This work involved no patient contact, such as administrative and secretarial tasks.
(c) Re-allocation of the Radiology Department's human resources according to risk-grade. Voluntary examination appointments were reduced or cancelled if necessary and human resources and protective materials were used flexibly [8]. (d) Drafting of the operational procedures for radiographers conducting X-ray examinations in SARS patients to reduce the possibility of staff infections. (e) Drafting of the Radiology Department emergency management plan to allow the department to run normally if some staff members were infected by SARS or isolated. (f) Collection of the latest protection information to educate and train staff in the department. (g) Holding meetings periodically to discuss protection issues.
Set up X-ray examination room in fever-screening station
The Fever-Screening Station X-ray room was established in response to a government decree that regional hospitals and higher hospitals must set up outside emergency rooms, because of the infection of SARS patients. Cheng-Hsin hospital began using its fever-screening station in May 2003, and examined patients with fever outside the building. Because the fever-screening station was created outside the emergency room, the Radiology Department had to set up an X-ray examination room using a portable X-ray machine to obtain chest radiographs. Figure 2 shows the relative position and examination procedures of the fever-screening station in the hospital.
The fever-screening station was constructed using an existing container outside the emergency room in our hospital. When planning the radiography room at the fever-screening station, the Radiology Department had to consider how best to protect patients and staff from radiation and how to coordinate with the traffic flow in the station. The department established a restricted region with a radius of 1.8 m from the portable X-ray machine and shielded the region with a lead screen. Before serving in the fever-screening station, radiographers had been trained in infection protection and radiographic techniques of SARS cases. Radiographers were checked with continuous dose monitoring.
Re-organization of human resources
The Radiology Department had to consider its workload during the SARS period, and re-organize in order to use human resources more efficiently. The re-organization functions to:
Enable the department to run normally
The Radiology Department faced a short-term manpower shortage, after it sent some radiographers to serve at the fever-screening station and at the portable chest radiography room in the negative pressure isolation rooms. The department cancelled some booked appointments and allowed some staff members to have sufficient time to conduct protection management.
Whenever staff members in the department showed symptoms of infection or if they accidentally came into contact with an infectious source, they had to be segregated. Consequently, the department faced a staff shortage that could have seriously affected its function. A group-rotation approach was employed. Staff members in the high-level risk areas were divided into two teams that took turns resting. Meanwhile, the department contacted staff members who were on vacation and had them available for work as needed.
Apply protection within the department
Senior staff were among those who did high-level risk work in our department. To reduce the potential for cross-infection within the department, the two high-level-risk groups tried not to contact each other. After these staff members worked in the high-level risk area for 1 week, they would take a 7-day vacation, during which time they were observed. They would return to work after they were believed not to be infected with SARS. If some staff members were infected, the entire group was segregated. Another group would replace the infected group. We believe this method of group rotation protected staff from cross-infection, made allocation of staff easier, and helped the department to run normally.
Reduce the stress on staff
Because staff members working in the high-level risk areas bore a lot of pressure, rotating periodical time off could lower their stress both physically and mentally. In addition, keeping an eye on the health of workers in high-level risk areas and paying attention to SARS symptoms are necessary. Pregnant staff members must be assigned to work in low-level risk areas.
Protection from SARS
In the beginning of the SARS outbreak, there was a shortage of protective materials. The department equipped workers based on risk level as follows:
Hospital staff protective equipment
The distribution of protective material was strictly supervised to avoid unnecessary waste. Responsibility for this was allocated to a specific individual. This person listed all items in detail, checked the list periodically, and replenished stock as needed. The distribution of protective equipment depended on the risk level each staff member faced. The higher the risk, the more strictly they were equipped. Table 1 indicates the protective equipment the staff wore during the protection period in our department.
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Table 1. Protective equipment of Radiology Department staff during the severe acute respiratory syndrome (SARS)-outbreak period
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Protection at the fever-screening station
Staff at the fever-screening station were at greatest risk because they were in close contact with patients. The following principles were applied while taking X-rays:- Conversation between radiographers and patients was kept to a minimum.
- Cassettes were covered with plastic bags, disinfected after finishing radiographic evaluations, and films developed after removing the outer plastic bags.
- Surgical mask and gloves were changed after finishing imaging of one patient before beginning the next.
- The control panel and imaging table were washed with 75% alcohol and 0.5% liquid bleach at the end of each day.
- Staff would leave after taking a shower at the rest area and changing into clean clothes.
Infection protection for conducting chest radiographic examinations in the negative pressure isolation rooms
Patients in whom SARS was suspected were taken, along with a portable X-ray machine, to the negative pressure isolation rooms. This radiographic machine was kept in the isolation room and was not used for routine radiography in our department. Before sending radiographers to use the portable chest X-ray in the negative pressure isolation rooms, they were educated in the examination procedures, the location of equipment in the isolation room, and sterilization procedure after the machine had been used.
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Procedures for inpatient radiography
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Radiographers could only examine patients after they had completed the protection procedure. They should take X-rays quickly and correctly to shorten the contact time with the patient. Radiography was arranged at one time for all patients in the negative pressure isolation rooms. The order of radiography was taken in accordance with the risk-level grade. The patients at low-level risk were imaged first, and high-level risk patients were imaged last. Figure 3 indicates the imaging procedures of patients in the negative pressure isolation rooms. Operational procedures for radiographers conducting X-ray examination in SARS patients were drafted by the SARS infection control team. The details of this operational procedure are described as follows:
Preparation before radiography
- Request. Communicated by telephone, confirmed the number of patient beds and arranged the order of radiography from C (low risk) to B to A (high risk) regions.
- Preparation of materials. The nursing station in the negative pressure isolation rooms provided all personal protection equipment as listed in Table 1
. However, the radiographer should prepare a set of complete personal protection equipment for emergencies. All cassettes were covered with three layers of plastic bags, and the inner cover was marked with the number of the patient's bed. In addition, the radiographer would prepare a set of clothes to change into after radiography was finished.
- Protection of portable X-ray machine. Parts of the machine that staff and patient might touch were covered.
X-ray imaging procedure
- Radiography. The radiographer obtained all radiographs according to a designated order. Staff closed the door after entering the negative pressure isolation room to obtain the radiographs, and moved the portable X-ray machine out of the room and closed the door after finishing radiography.
- Cassette management. The outer plastic bag of cassettes was removed and the cassettes placed on the ground outside the negative pressure isolation room. Staff sterilized all plastic bags after radiography was completed.
- Removal and sterilization of contaminated equipment. Remove the protection equipment carefully in the following order: surgical cap, shoe covers, outer gown, and surgical gloves. Removed outer face guard and disinfected with 75% alcohol, then removed outer mask. Disinfected the machine with 75% alcohol and removed the third layer of gloves.
- Re-dressing of personal protective equipment. Put protective clothes back on before entering next patient room in the following order: shoe covers, gloves, outer gown, surgical gloves, face guard, and surgical cap.
- Finishing radiography at C region. Remove all equipment and put on a clean inner gown, inner surgical cap, N95 mask, and inner gloves.
- Obtain radiographs at B region. Put on clean personal protection equipments at nursing station in B region and repeat the procedures.
- Obtain radiographs at A region. Put on clean personal protection equipment at nursing station in A region and repeated the procedures.
Protection procedure after radiography was finished
- After finishing radiography in the negative pressure isolation rooms, the radiographer removed outer surgical cap, face guard, outer shoe covers, outer gown and outer gloves.
- Disinfected portable X-ray machine with 75% alcohol and again with 0.5% bleaching liquid. After removing all covers, let it stand for 10 min and put the machine back. Removed all equipment according to the designated order and changed into a clean inner gown. Disinfected all cassettes and removed the second layer of plastic bags. Took a shower and changed into clothes at nursing station.
- Processed films. Took cassettes back to emergency radiographic room. Processed films after removing the inner plastic bags.
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Conclusions
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When a Radiology Department faces the threat of SARS, the first step is to set up a SARS emergency infection-control team and plan emergency-management and infection-control procedures quickly to avoid operational chaos and protection mistakes. From our experiences, the classification of examinations into three risk grades, and application of a protection plan dependent on each risk-grade, not only helps achieve management goals effectively, but also avoids the waste of protective materials.
In the SARS-outbreak period in Taiwan, many hospital staff members were infected, which deeply affected the mental and emotional state of the entire staff, in that every person worried about being exposed to SARS. Before the fever-screening stations were in operation, the staff of the Radiology Department had a high probability of unexpected contact with high-level risk patients. If they had been segregated because of SARS, it not only would have risked the health and life of hospital staff and depleted human resources, but also affected the operation of the Radiology Department. Therefore, it is important to establish a fever-screening station early. The fever-screening station can examine the high-level risk group among arriving patients and help staff members to avoid unexpectedly contacting high-level risk patients. According to the results from municipal hospitals in Taipei, a total of 6% patients were identified as suspected SARS cases through fever-screening stations. This reduced the infection rate in the hospital and was helpful in controlling SARS in Taiwan.
Re-organization of human resources in the Radiology Department was also necessary during the SARS period. Group rotation not only lowered the operating load and mental stress of hospital staff who worked in high-level risk regions, but also segregated the staff in the high risk area to protect the others effectively. In addition, the group-rotation method can keep the Radiology Department running normally.
Radiology departments should draft and issue operational procedures for radiographers conducting X-ray examinations in SARS patients to protect the staff from SARS infection. All radiology department staff members must receive proper protection training. Because of the complexity of SARS control, all members of the radiology department should cooperate and support each other. Trust among team members is an important factor to employ infection protection control. This paper introduces our experiences of emergency management and infection control for a radiology department during an outbreak of SARS, but could also apply in other similar situations.
Received for publication August 20, 2003.
Revision received December 21, 2004.
Accepted for publication January 28, 2005.
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Abstract
Introduction
