Role of SARS screening clinic in the ED

Letters

CJEM 2004;6(2):78-79

To the Editor: Dr. Marcus Ong recently described an emergency physician's perspective on the "War on SARS" in Singapore.¹ Fortunately, the strategy and tactics detailed were effective at that time. We know from the recent appearance of sporadic cases in Guangdong, China, that SARS has returned.²

The SARS crisis has had one positive outcome: it highlighted many of the unique challenges emergency departments (EDs) face in dealing with contagious diseases. In addition, the economic costs of the SARS outbreak demonstrate the need to upgrade EDs to a comprehensive and national standard, as described in the recent CAEP position statement.³

Overcrowding is a key factor that increases the risk of infectious disease transmission in EDs. Overcrowding is increasingly common in urban EDs, where large numbers of patients, some with potentially lethal infectious illnesses, squeeze together in waiting rooms and on stretchers in hallways, exposing ED staff and other patients and increasing the risk of initiating a new infectious outbreak.

Previous ED infection control guidelines are not adequate.^4-6 Significant ED retrofitting and redesign is necessary to address future infectious disease threats.⁷ These proved useful in the Singapore and Hong Kong outbreaks. We strongly propose establishing "SARS screening clinics" or "fever clinics" such as those developed in Hong Kong and Singapore¹ during the 2003 SARS outbreak. These units segregate and manage suspicious patients with fever, contact history, SARS or influenza-like symptoms, using a biohazard model that protects staff and patients.

Fever units should apply a universal and high level of protection by making use of redesigned triage areas, negatively pressurized consultation and resuscitation rooms and full personal protection -- especially when ED staff are performing high-risk procedures. Efficiency of screening is enhanced by designating senior physicians, protective equipment and resources to the clinic, and the chance of cross infection within the department is also reduced.

Also important is a reliable follow-up system to prevent "missed" cases from falling through the cracks.⁸ We cannot afford to lose a single staff member in the battle or to miss a single patient in the community.

We have adopted these principles and run such a "fever clinic" in our department. Realizing the threat of future infectious agents or bioterror events anywhere in the world, we think this is the right strategy to be instituted in other EDs. Because air travel makes these concerns global rather than local, cooperation between different departments, hospitals, nations and countries is critical.

Wong Wing Nam, MB BS, MRCSEd, MFSEM(RCSI)
Medical Officer
Accident & Emergency Department
United Christian Hospital
Hong Kong

References

1. Ong EHM. Wars on SARS: a Singapore experience. Can J Emerg Med 2004;6(1):31-7.
2. WHO Update 3: Announcement of suspected SARS case in southern China. Investigation of source of infection for confirmed case begins tomorrow. Available: www.who.int/csr/don/2004_01_08/en/ (accessed 2004 Jan 16).
3. Ovens H, Thompson J, Lyver M, Murray MJ, Innes G, on behalf of the Canadian Association of Emergency Physicians (CAEP). Implications of the SARS outbreak for Canadian emergency departments [position statement]. Can J Emerg Med 2003; 5(5):343-7. Available: http://www.cjem-online.ca/v5/n5/p343  (accessed 2004 Jan 16).
4. Canadian Association of Emergency Physicians. Guidelines for managing severe acute respiratory syndrome (SARS) in Canadian emergency departments. Available: http://caep.ca/template.asp?id=791CC11B892144FB82957C4B139D723E (accessed 2004 Jan 16).
5. Health Canada. Public health guidelines for infection control guidance for health care workers in health care facilities and other institutional settings. Available: www.hc-sc.gc.ca/pphb-dgspsp/sars-sras/prof_e.html (accessed 2003 Nov 3).
6. US Center of Disease Control & Prevention. Updated interim domestic infection control guidance in the health-care and community setting for patients with suspected SARS, updated 2003 May 1. Available: www.cdc.gov/ncidod/sars/infectioncontrol.htm (accessed 2004 Jan 16).
7. Thompson J. SARS: finding a deadly needle in the haystack [editorial]. Can J Emerg Med 2003;5(6):392-3.
8. Wong WN, Sek ACH, Lau RFL, Li KM, Leung JKS, Tse ML, et al. Accuracy of clinical diagnosis versus the World Health Organization case definition in the Amoy Garden SARS cohort. Can J Emerg Med 2003;5(6):384-91.