Matrix 1: Recommendations for Inpatient Facilities and Emergency Departments
Level of SARS activity Suggested actions
No cases of SARS in the 1) Triage activities/facility access controls
facility
Notify the SARS coordinator or designee of any transfers
from facilities that have SARS cases.
In accordance with recommendations for respiratory
hygiene/cough etiquette, instruct all patients with respiratory
illnesses to perform hand hygiene and cover the nose/mouth
when coughing or sneezing. Manage these patients
with Droplet Precautions until determined that they are not
needed.
In the presence of person-to person SARS-CoV
transmission in the world but no known transmission in
the area around the facility :
o Place signs at all entry points detailing symptoms of and
current epidemiologic risk factors for SARS and directing
persons meeting these criteria to an appropriate area for
evaluation.
o Initiate screening of patients on entry to the emergency
department for symptoms and epidemiologic links
suggesting SARS. Patients with fever or lower
respiratory symptoms and SARS risk factors should
perform hand hygiene, wear a surgical mask (if
possible), and be isolated in accordance with the
recommendations in Supplement I. If airborne isolation is
not possible, consider cohorting, with all patients wearing
surgical masks. Evaluate patients according to the
algorithm (Figure 2) in Clinical Guidance on the
Identification and Evaluation of Possible SARS-CoV
Disease among Persons Presenting with Community-
Acquired Illness.
o If a patient's risk of exposure to SARS-CoV is high (e.g.,
close contact with a laboratory-confirmed case of SARS-
CoV disease), the clinical criteria should be expanded to
include other early symptoms of SARS-CoV disease.
In the presence of SARS-CoV transmission in the area
around the facility :
o All persons should perform hand hygiene on entry.
o Actively screen all persons entering the facility for fever
Level of SARS activity Suggested actions
and lower respiratory symptoms. All patients presenting
with fever or lower respiratory symptoms should perform
hand hygiene, wear a surgical mask (if possible), and be
isolated for SARS in accordance with the
recommendations in Supplement I. If airborne isolation is
not possible, consider cohorting, with all patients wearing
surgical masks. Evaluate patients according to the
algorithm (Figure 2) in Clinical Guidance on the
Identification and Evaluation of Possible SARS-CoV
Disease among Persons Presenting with Community-
Acquired Illness.
o If a patient's risk of exposure to SARS-CoV is high (e.g.,
close contact with a laboratory-confirmed case of SARS-
CoV disease), the clinical criteria should be expanded to
include other early symptoms of SARS-CoV disease.
o Intake/triage staff should follow SARS infection control
and PPE guidance, as specified in Supplement I.
o Limit visitors (e.g., one per patient per day).
o Screen all visitors for SARS risk factors and symptoms.
o Limit elective admissions and procedures.
o Consider designating an area as a "SARS evaluation
center" and sending all patients presenting with fever or
respiratory symptoms to the center for evaluation.
2) Patient placement
In the presence of person-to-person SARS-CoV
transmission in the world but NO known transmission in
the area around the facility:
o Patients presenting with fever or lower respiratory
symptoms and epidemiologic risk factors for SARS
should perform hand hygiene, wear a surgical mask (if
possible), and be isolated for SARS in accordance with
the recommendations in Supplement I. If airborne
precautions are not possible, consider cohorting, with all
patients wearing surgical masks. Evaluate patients
according to the algorithm (Figure 2) in Clinical Guidance
on the Identification and Evaluation of Possible SARS-
CoV Disease among Persons Presenting with
Community-Acquired Illness.
Level of SARS activity Suggested actions
o If a patient's risk of exposure is high (e.g., close contact
with a laboratory-confirmed case of SARS-CoV disease),
the clinical criteria should be expanded to include, in
addition to fever or lower respiratory symptoms, the other
early symptoms of SARS-CoV disease.
In the presence of person-to-person SARS-CoV
transmission in the world but NO known transmission in
the area around the facility:
o Patients presenting with fever or lower respiratory
symptoms should perform hand hygiene, wear a surgical
mask (if possible), and be isolated in accordance with
the recommendations in Supplement I. If airborne
isolation is not possible, consider cohorting, with all
patients wearing surgical masks. Evaluate patients
according to the algorithm (Figure 2) in Clinical Guidance
on the Identification and Evaluation of Possible SARS-
CoV Disease among Persons Presenting with
Community-Acquired Illness.
o If a patient's risk of exposure is high (e.g., close contact
with a laboratory-confirmed case of SARS-CoV disease),
the clinical criteria should be expanded to include, in
addition to fever or lower respiratory symptoms, the other
early symptoms of SARS-CoV disease.
3) Designated personnel
Assign only selected, trained, and fit-tested emergency
department staff to evaluate possible SARS cases. Staff
should follow SARS infection control and PPE guidance, as
specified in Supplement I.
4) Surveillance
Depending on directives from local/state health departments,
consider reporting of patients requiring hospitalization for
unexplained pneumonia who have risk factors for SARS, as
specified in Supplement B.
5) Healthcare worker restrictions
Healthcare workers should notify the SARS coordinator at
Level of SARS activity Suggested actions
each facility where they work and have at least daily
symptom checks if:
o They are caring for a SARS patient in another facility.
o They are also working in another facility that has
reported nosocomial SARS-CoV transmission.
o They have close contact with SARS patients outside the
hospital.
A few cases in the facility, but 1) Triage activities/facility access controls
all cases are imported (NO
nosocomial transmission)
Same as for "No cases of SARS in the facility." Add:
No visitors to SARS patients unless necessary (e.g., parents,
translators); visitors must receive infection control training.
Designate specific SARS patient-flow routes (e.g.,
emergency department to designated elevator to AIIR; AIIR
to radiology).
Clean rooms housing SARS patients in accordance with
current recommendations (see Supplement I).
2) Patient placement
Same as for "No cases of SARS in the facility." Add:
Place admitted known or potential SARS patients in AIIRs if
available.
Consider cohorting admitted patients in private rooms on
designated SARS units, depending on personnel and
availability of AIIRs. Modify designated floors/rooms as
possible.
3) Designated personnel
Same as for "No cases of SARS in the facility." Add:
Assign only selected, trained, and fit-tested staff to SARS
patient care (includes designated ancillary personnel).
Assign a selected, trained, and fit-tested team with access to
appropriate respiratory protection (see Supplement I) for
emergency resuscitation or respiratory procedures in known
or potential SARS patients.
4) Surveillance
Level of SARS activity Suggested actions
Conduct active surveillance targeted to healthcare workers
providing care to SARS patients (e.g., symptom monitoring).
5) Healthcare worker restrictions
Same as for "No cases of SARS in the facility." Add:
No eating or drinking in SARS patient-care areas.
Furlough healthcare workers with unprotected exposures to
SARS patients during high-risk procedures, and institute
checks to evaluate possible symptoms.
Healthcare workers with other (non-high-risk) unprotected
exposures to a SARS patient should undergo checks for
possible symptoms . Furlough of these workers could be
considered.
A larger number of SARS 1) Triage activities/access controls
cases in the facility OR
nosocomial transmission with
Same as for "A few cases in the facility but all cases are
all cases linked to a clearly
identified source imported." Add:
Regardless of the level of SARS activity in the community
around the facility:
o Limit visitors (e.g., one per patient per day).
o Maintain a log of all visitors to SARS patients to aid in
contact tracing.
o Limit elective admissions/procedures.
o All healthcare workers and visitors should have a fever
check and perform hand hygiene on entry.
2) Patient placement
Same as for "A few cases in the facility but all cases are
imported." Add:
3) Designated personnel
Same as for "A few cases in the facility but all cases are
imported."
4) Surveillance
Implement active healthcare worker surveillance (symptom
Level of SARS activity Suggested actions
monitoring) throughout the facility.
Monitor all healthcare worker absenteeism and illnesses
(e.g., through the occupational medicine clinic); evaluate for
links to known SARS cases.
Monitor for and evaluate all new fevers and lower respiratory
illnesses among patients. Place any patient with unexplained
fever or lower respiratory symptoms on SARS precautions,
and evaluate in accordance with the algorithm (Figure 2)
in Clinical Guidance on the Identification and Evaluation of
Possible SARS-CoV Disease among Persons Presenting
with Community-Acquired Illness.
If a patient's risk of exposure is high (e.g., close contact with
a laboratory-confirmed case of SARS-CoV disease), the
clinical criteria should be expanded to include, in addition to
fever or lower respiratory symptoms, the other early
symptoms of SARS-CoV disease.
5) Healthcare worker restrictions
Same as for "A few cases in the facility but all cases are
imported."
Cases attributed to 1) Triage activities/access controls
nosocomial transmission with
NO clearly identified source
Same as for "A larger number of cases or linked
transmission." Add:
No visitors allowed in hospital unless necessary (e.g.,
parents, translators); visitors must receive infection control
training.
Close emergency department and facility to admissions and
transfers.
2) Patient placement
Same as for "A larger number of cases or linked
transmission." Add:
Consider cohorting patients and staff to care for patients in
the following categories:
o Afebrile patients with no close SARS contact -- discharge
as soon as medically indicated
o Afebrile patients with close SARS contact -- discharge as
Level of SARS activity Suggested actions
soon as medically indicated, with contact restrictions and
health department follow-up per recommendations
in Supplement D
o Febrile or symptomatic patients not meeting case
definition
o Patients meeting case definition
3) Designated personnel
Same as for "A larger number of cases or linked
transmission." Add:
All persons in the facility should wear a surgical mask when
not providing patient care (this is not meant to serve as
SARS PPE but to limit potential SARS-CoV transmission
from someone who develops SARS). When in contact with
SARS patients, all persons should continue to follow SARS
infection control guidance and PPE as specified
in Supplement I.
4) Surveillance
Same as for "A larger number of cases or linked
transmission." Add:
Place any patient with new fever or lower respiratory illness
(not just unexplained) on SARS precautions and evaluate in
accordance with the SARS clinical algorithm.
If a patient's risk of exposure is high (e.g., close contact with
a laboratory-confirmed case of SARS-CoV disease), the
clinical criteria should be expanded to include, in addition to
fever or lower respiratory symptoms, the other early
symptoms of SARS-CoV disease.
5) Healthcare worker restrictions
Same as for "A larger number of cases or linked
transmission." Add:
Depending on staffing issues, either:
o Implement home/work restrictions for all healthcare
workers in the facility, or
o Restrict movement to work and home for all healthcare
workers who worked in an area of the facility where
Level of SARS activity Suggested actions
nosocomial transmission may have occurred.
Matrix 2: Recommendations for Outpatient Facilities/Areas
Level of SARS activity Suggested actions
No person-to-person SARS 1) Patient screening and precautions
transmission reported
anywhere in the world
In accordance with recommendations for
respiratory hygiene/cough etiquette, instruct all patients with
symptoms of a respiratory infection to perform hand hygiene
and cover the nose/mouth. Manage these patients
with Droplet Precautions until it is determined that they are
not needed. If there are likely to be delays in moving patients
out of the waiting area, consider dividing the area so that
patients with respiratory illnesses do not sit near others.
2) Healthcare worker precautions
Healthcare workers seeing patients with respiratory illness
should use Droplet Precautions.
During respiratory illness season, intake/triage staff should
practice frequent hand hygiene and could be given the option
of wearing surgical masks.
3) Infrastructure issues
The facility will need a supply of waterless hand-hygiene
products, surgical masks, and other applicable PPE and will
need to consider the logistics of implementing a respiratory
hygiene/cough etiquette strategy.
Presence of person-to-person 1) Patient screening and precautions
SARS transmission worldwide
but no known transmission in
Same as for "No Person-to-person SARS transmission
the area around the facility
worldwide but no known transmission in the area around the
facility." Add:
Screen all patients and visitors with fever or lower respiratory
symptoms for SARS epidemiologic links (e.g., travel to
endemic areas or contact with known cases).
Level of SARS activity Suggested actions
Instruct anyone with fever or lower respiratory
symptoms and epidemiologic risks for SARS to wear a
surgical mask (if tolerated) and to perform hand hygiene.
Place these patients immediately in a private room. Transfer
these patients as soon as possible to a facility where they
can be isolated appropriately during the evaluation. Notify
receiving facilities that the patient is being sent for evaluation
of SARS.
If a patient's risk of exposure is high (e.g., close contact with
a laboratory-confirmed case of SARS-CoV disease), the
clinical criteria should be expanded to include, in addition to
fever or lower respiratory symptoms, the other early
symptoms of SARS-CoV disease.
Manage outpatients in accordance with Clinical Guidance on
the Identification and Evaluation of Possible SARS-CoV
Disease among Persons Presenting with Community-
Acquired Illness.
2) Healthcare worker precautions
Same as for "No Person-to-person SARS transmission
worldwide but no known transmission in the area around the
facility." Add:
Healthcare workers who are in direct contact with patients
who might have SARS should wear full SARS PPE
(see Supplement I).
3) Infrastructure issues
Same as for "No Person-to-person SARS transmission
worldwide but no known transmission in the area around the
facility." Add:
The facility will need a supply of PPE (e.g., gowns, gloves,
eye protection, respirators [N-95 or higher level]).
Known transmission in the 1) Patient screening and precautions
area around the facility
Screen all patients and visitors for fever and lower
respiratory symptoms both when appointments are made
and when they arrive at the clinic. Refer persons with these
symptoms to a facility where they can be isolated
Level of SARS activity Suggested actions
appropriately during evaluation. Warn receiving facilities that
the patient is being sent for evaluation of SARS.
If a patient's risk of exposure is high (e.g., close contact with
a laboratory-confirmed case of SARS-CoV disease), the
clinical criteria should be expanded to include, in addition to
fever or respiratory symptoms, the other early symptoms of
SARS-CoV disease.
2) Healthcare worker precautions
Same as for "Person-to-person SARS transmission
worldwide but no known transmission in the area around the
facility."
3) Infrastructure issues
Same as for "Person-to-person SARS transmission
worldwide but no known transmission in the area around the
facility."
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Matrix 3: Recommendations for Long-Term Care Facilities
Level of SARS activity Suggested actions
No person-to-person SARS 1) Patient precautions
transmission reported
anywhere in the world
In accordance with recommendations for respiratory
hygiene/cough etiquette, patients who develop symptoms of
a respiratory infection should be placed on Droplet
Precautions until determined that they are not needed.
2) Healthcare worker precautions
Healthcare workers seeing patients with respiratory illness
should use Droplet Precautions and practice frequent hand
hygiene.
3) Infrastructure issues
The facility will need supplies for Droplet Precautions
Level of SARS activity Suggested actions
(masks, gloves and gowns) and hand hygiene.
Presence of person-to-person 1) Patient precautions
SARS transmission worldwide,
but no known transmission in
Same as for "No person-to-person SARS transmission
the area around the facility
reported anywhere in the world." Add:
Screen all potential admissions for symptoms and
epidemiologic links to SARS.
2) Healthcare worker precautions
Same as for "No person-to-person SARS transmission
reported anywhere in the world."
3) Infrastructure issues
Same as for "No person-to-person SARS transmission
reported anywhere in the world."
4) Access controls
Visitors should be screened for symptoms and epidemiologic
links to SARS cases. Visitors with symptoms and
epidemiologic links should not be allowed into the facility.
Known transmission in the 1) Patient precautions
area around the facility
Same as for "No person-to-person SARS transmission
reported anywhere in the world."
All new admissions should be evaluated at an acute-care
facility (no direct admissions). Patients with fever or lower
respiratory symptoms should be evaluated according to the
algorithm (Figure 2) in Clinical Guidance on the Identification
and Evaluation of Possible SARS-CoV Disease among
Persons Presenting with Community - Acquired
Illness before being admitted. Patients who are
asymptomatic but had exposures should be observed for 10
days for the development of symptoms before they are
admitted.
If there is significant transmission in the community around
the facility, initiate surveillance for nosocomial lower
Level of SARS activity Suggested actions
respiratory illness, and transfer all patients who develop such
illness to an acute-care facility for evaluation. Acute-care
facilities should be notified that the patients are being
transferred for evaluation of SARS.
2) Healthcare worker precautions
Same as for "No person-to-person SARS transmission
reported anywhere in the world."
Healthcare workers should undergo symptom monitoring.
Symptomatic healthcare workers should be furloughed and
evaluated according to the algorithm (Figure 2) in Clinical
Guidance on the Identification and Evaluation of Possible
SARS-CoV Disease among Persons Presenting with
Community - Acquired Illness.
3) Infrastructure issues
Same as for "No person-to-person SARS transmission
reported anywhere in the world."
4) Access controls
Visitors should be actively screened for symptoms.
Visitors with symptoms should not be allowed into the facility.
