News & Events

Severe Acute Respiratory Syndrome (SARS): a guide for nurses

From the Massachusetts Nurse Newsletter
June/July 2003 Edition


By Betty Sparks, RN Task Force on Emergency Preparedness and David A. Denneno, RN, MSN Health & Safety Congress, Workplace Violence Task force

  • Severe Acute Respiratory Syndrome (SARS) is a disease caused by a corona virus that presents with symptoms similar to the common cold. The incubation period is two to ten days from the time of exposure. Suspected cases could present with:
  • Measured body temperature greater than100.4° F
  • Headache, body aches
  • Clinical findings of respiratory illness (e.g. cough, shortness of breath, difficulty breathing, hypoxia or radiological findings of pneumonia or acute respiratory distress syndrome)
  • Rales and rhonchi can be heard, oxygen saturation less than 95 percent on room air and
  • Travel within 10 days of onset of symptoms to an area with documented or suspected community transmission of SARS including Singapore, Hong Kong, China, Vietnam, Thailand, Slovenia, Indonesia, Philippines and Toronto, Canada or
  • Close contact within 10 days of onset of symptoms with either a person with a respiratory illness who traveled to a SARS area or a person known to be a suspect SARS case.

Suspect a SARS patient?

What should nurses do if a suspected SARS patient presents to triage or the office? Follow these 10 steps to help you limit exposure to yourself and others.

  1. Suspected SARS patients presenting to healthcare facilities and doctors’ offices who require assessment for SARS should be diverted by triage or staff to a separate area to minimize transmission to others. These patients should immediately be given a surgical mask and should be instructed to wear a surgical mask at all times.
  2. The medical personnel should apply the surgical mask to the patient, preferably one that filters expired air. All healthcare personnel should wear N-95 respirators that have been properly fit tested in advance. If N-95 respirators are not available, surgical masks should be worn by personnel.
  3. Patients presenting with probable SARS should be moved and accommodated in:
    • A negative pressure room with the door closed
    • A single room with their own bathroom
    • A private exam room (turn off air conditioning and open window if independent air supply is unfeasible)
  4. Contact your facility’s infection control personnel and initiate SARS policies and procedures as written by your healthcare facility. Unprotected exposures should be reported immediately and proper documentation completed.
  5. A member of the staff must be identified as the primary care provider, preferably the staff member that initiated contact with the patient upon their arrival to the facility. The designated staff member will use standard precautions (e.g., hand washing), contact precautions (e.g., use of gown and gloves) and airborne precautions (e.g., N-95 respirator and eye protection). Removal of protective equipment should be done by taking off gloves first, then mask, goggles and gown. Immediately wash hands with soap and water or use an alcohol based hand washing solution.
  6. Limit the number of staff members who are in contact with the patient. All non-essential staff, including students, should not be allowed in the unit.
  7. Staff should stay a minimum of 6½-feet away from the patient whenever possible, and avoid exposure to droplets if close to the patient. Note: the virus has been found in stool, urine and sputum for as long as 21 days after onset of symptoms.
  8. Tympanic temperature probes should be used where possible and, if not possible, adult patients should take their own oral electronic temperature and report it to the nurse.
  9. Disinfectants such as fresh bleach solution (1/100) or hospital recommended cleaning agents should be widely available. Stethoscopes, scissors and other equipment have the potential to spread infection and must be properly disinfected. Linen should be rolled up and not shaken. Place used linen in a biohazard bag before sending to the laundry.
  10. Visitors, if allowed by the healthcare facility, should be kept to a minimum. They should be provided with personal protective equipment and supervised.

Excerpted in part from U.S. Department of Health and Human Services, Centers for Disease Control and Prevention—SARS Guidelines, World Health Organization SARS Guidelines and the Ontario SARS Guidelines.