SARS infection control guidelines for Radiology Department : An example of Taipei Medical University-Wan Fang Hospital

1. SARS infection control guidelines for Radiology Department : An example of Taipei Medical University-Wan Fang Hospital Wing Chan, MD Dept. of Radiology, School of Medicine, Taipei Medical University and TMU-Wan Fang Hospital, Taipei, Taiwan, Republic of China

2. SARS and X-rays • SARS is a form of lung injury characterized by epithelial-cell proliferation and an increase in macrophages in the lung. • Chest radiography has a crucial role in diagnosis and monitoring of disease progress in the treatment of patients with SARS. • This causes major problems for a radiology department that has to offer a service to all patients, sometimes using the same equipment, in the same room, by the same staff.

3. “SARS infection control guidelines for Radiology Department” • This presentation is an account of our guidelines that have been published in Chinese Journal of Radiology in June of 2003 (Chan WP, Liao Y-M. Chin J Radiol 2003;28:167-173) • We have put the guidelines in place with the close involvement to the hospital infection control team to try our best to decrease the risks.

4. Policies • Radiology Department has been categorized as “high risk area” for SARS infection control in hospitals. • The major role in SARS control is segregation of SARS from non-SARS patients by equipments, examination rooms and time. • The goals in SARS control are to reduce the risk of infection as much as possible to our staffs as well as cross infection between patients.

5. Value • To maintain high quality of patient care and professional respect, especially for our front-line staffs.

6. SARS in Wan Fang Hospital • Till June 1, 03, a total of 43 patients with SARS was admitted in our hospital. • Our radiological technicians performed portable X-rays in negative-pressure rooms for 423 times. • No in-hospital infections to our staffs or cross infections between patients were noted.

7. SARS Infection Control Team in Radiology Chief Staff Radiologists Chief Technician Supervisor technician Administrative Assistant (1) Senior technician (1) Nurse (1)

8. SARS Infection Control Team in Radiology Goals • Zero in-hospital infections to our staffs • Zero cross infections between patients • Maintain high quality of patients care

9. SARS Infection Control Team in Radiology Strategies • Full support to our front-line staffs • Full supply of prevention requirements to our staffs

10. SARS Infection Control Team in Radiology Work descriptions • The infectious control team should review the practices in the radiology department, where there is direct patient contact, to help reinforce proper infection control techniques and close any loopholes. • One member (the leader of technicians) acts as a “policeman” to ensure the guidelines are enforced.

11. Categorization of patients • Outpatients without suspected / confirmed SARS • Outpatients with suspected SARS* • Inpatients without suspected / confirmed SARS* • Inpatients with suspected / confirmed SARS* *Need highest infection control measures

12. Categorization of patients Segregation of patients • Segregation of patients by location and equipments: three portable X-rays for performing those patients in fever screening station, negative-pressure room, and ICU, respectively.

13. Categorization of patients Segregation of patients • Segregation of patients by time: Noon-2:00 for in-patients without SARS in the main department; late evening for in-patients with SARS for CT scan examinations. • Congestion of waiting area should be minimized or avoided.

14. Segregation Segregation of staffs • Radiology department can be divided into two zones: “contamination” and “clean” zones by clear notice plates.

15. Examination requests • SARS patients : requested order by 9:30PM one day before • Patients at fever screening station : scheduled by phone • Other patients: regular time

16. Examination requests Examination policies • Chest films are not suggestive for screening patients without fever. • Attention should be given on the following patients without remarkable symptoms of fever: renal disease, DM, long-term steroid treatment, cancer, and immobile patients.

17. Examination requests Examination policies • Requests for imaging studies only are made when the examination result will have a major impact on patient treatment. • All examinations should be shortened but still ensuring the clinical question is answered. • Reduce out-patients appointments to reduce overload.

18. Radiographic features suggestive for SARS • Initial chest radiographs can be normal (<15%). • Common initial radiographic features: air-space consolidation, ground-glass attenuation, nodules, and mixed consolidation and nodules. • Initial normal radiograph or unifocal lung lesion had a better prognosis outcome.

19. Radiographic features NOT suggestive for SARS • Mediastinal or hilar lymphadenopathy • Cavitation or abscess formation • Pleural effusions

20. X-Rays • Chest PA view only • Taken by computerized digital X-rays • Allocate patients in the sequence of low to high risk for fever screening, and mild to severe for SARS patients in performing X-rays.

21. CT scan • Isolated ventilation system for CT room • Patient and staffs should follow the SARS infection guidelines • For patients who have fever and contact history, HRCT can be performed when chest films reveal negative findings. • Consider CT as an alternative examination to sonogram for patients of whom other causes of fever should be ruled out.

22. X-rays machines • Three portable X-rays in performing SARS patients, fever screening, and ICU patients, respectively. • Disinfection after performing each patient (by 70% alcohol for metallic surfaces)

23. Staffing and visitors • No conferences or meetings is allowed • No visitors is allowed entering our department • Cleaning staffs should be followed by one of our nurse during their cleaning duty. • Two teams of radiological technicians to perform examinations in fever screening station and SARS patients in negative-pressure rooms, respectively. • Rotating staffs twice a month to reduce work overload and viral load.

24. Control Supervision • Two staffs should be worked together for portable X-rays, one as a control supervision to review all procedures • Regular practices for protection dressing before performing portable X-rays procedures • All of our staffs should record their own body temperature before 10AM.

25. Room Cleaning • For general areas, the cleaning schedule are cleaned twice (AM, PM) daily. • For all telephones, fax machines, computer keyboards, table surfaces are cleaned twice daily.

26. Personal Care • Always wearing mask • Washing hands frequently • Not touching the mask and the eyes • Pay attention to every steps in details in performing procedures or examinations • Avoid duty overload • Avoid wear working uniform to go back home

27. Conclusion • To set-up a “SARS infection guidelines in Radiology Department” only is the first step in SARS infection control. A continuous and regular education, practice, and control supervision are the key factors to achieve a good infection control outcome.

28. Thank you for your attention wingchan@tmu.edu.tw