From the Department of Emergency Medicine (Wang TL,Chen KC, Lin IY, Chen CC, Chen HT, Lu KC), Shin-Kong Wu Ho-Su Memorial Hospital

Correspondence to Dr. Tzogn-Luen Wang, Department of Emergency Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95 Wen Chang Road, Taipei, Taiwan. E-mail M002183@ms.skh.org.tw

Disaster is a state of demand-supply imbalance. Traditional classification includes natural, man-made and mixed types of disasters. There has been a major global outbreak of SARS last year.^1-4 Although the confirmatory tests such as polymerase chain reaction and measurements of coronavirus antibody have been undergone in many laboratories,⁵ they still cannot provide instant and correct information for clinicians at the first moment. The WHO criteria may help screen the suspected and probable cases,⁶ but the low specificity may indicate the lacking of cost-effectiveness in an endemic area. During the endemic times, there was usually a chaos when the isolated facilities were not enough and the WHO criteria couldn't discriminate definitely the victims of SARS from the non-SARS febrile cases. We ever demonstrated that the WHO criteria for probable cases had only 44% of specificity for those who met with the WHO criteria for suspected cases.⁷ It means there ought to be at least 2.3-fold reservation of isolated facilities and medical costs if all probable cases were admitted to hospitals. Since then, biological events, either natural or man-made, have been focused on in the field of disaster medicine.
After a severe attack by SARS, Taiwan has been engaged in taking every effort to prevent similar events. The implement of SARS response planning and standard operation procedure seems to be the main task at present. However, it deserves to be investigated that if the planning is designed for only SARS or can be generally applied to any biological event.
Taipei City government has begun to request the emergency response hospitals to revise their disaster response planning since 2002. As our past survey revealed, the implementation of HEICS into emergency response hospitals may be the first goal.^8,9 When SARS made an endemic episode globally this year, most of the response hospitals adjusted their response plans and have actually used HEICS in disaster response. We'd like to further understand whether the response planning has also adjusted to coronaviruser the response plans for SARS or other biological events. We thus evaluated the disaster response plans from emergency response hospitals in Taipei to elucidate the impact of SARS on the planning.

There were 52 emergency response hospitals accounting for 19,960 beds in Taipei City in 2004. Of these hospitals, eight were the tertiary care medical centers and the remaining 44 secondary referral hospitals. We then evaluated the SARS response plans from these hospitals retrospectively.
First, we checked if there is a comparable plan for response to SARS. Second, we reviewed the plans according to the modified ASTHO checklist. The checklist was composed with 25 items which has been highly selected from the original ASTHO checklist and also re-written (Table). We recorded the number of the items that were fulfilled by the plans under review.
After the above reviewing process, we checked if there is a general plan for different types of emerging infectious diseases or for bioterrorism. If such a plan was present, the detailed review would be undergone according to the 25-item checklist. The number of the items fulfilled was also recorded.

All the data were processed and analyzed with Microsoft Excel 2000 for Windows. The techniques applied to data analysis included descriptive statistics generating and independent samples by t-test and chi-square test.

This study demonstrated that most of emergency response hospitals do not take into consideration the financial and legislative problems in their SARS response plans although all of them do have such plans. The possible reason may be the committee responsible for planning does not include the financial and legislative authorities. This observation may imply that most of the disaster response plans in Taiwan still emphasize crisis management instead of consequence management.
After SARS, most of the hospital staffs believe the previous idea that disasters are neither merely large-scale emergencies, and nor is the disaster response an expansion of the routine emergency response, supplemented by the mobilization of extra personnel, supplemented by the mobilization of extra personnel, supplies, accommodations, and equipment.^10-12 Most of the past studies demonstrated that the disasters had unique problems that require different strategies, both quantitatively and qualitatively.^13-15 The disaster response involves variable destruction of communication system, working with different people, solving different problems, and using different resources than those for routine emergencies,^13-15 so it has to be flexible in total operation but constant in role playing. As we mentioned before, the low frequency of devastating disasters always poses a problem for hospital planners, because few planners have had enough disaster experience. There is still no nationally institutionalized process for data collecting, analyzing, and generalizing the education based upon past experiences. Global warning or alerting system may be a good start.
Because of the impact of SARS, many hospitals have been confronted with the problem of possible total isolation. The response plans of isolation, evacuation, relocation, and reception were thereof seriously considered by there hospitals during the period. Other tasks such as resource sharing, widespread search and rescue, triage, patient transport that efficiently utilizes area hospital assets, dealing with the press, and overall coordination of the response have already mentioned in previous guidelines of HEICS.^7,8
According to public health guidance for community-level preparedness and response for SARS provided by the Centers for Disease Control and Prevention (CDC), the plan includes core document and 9 supplements. The 9 supplements include command and control, surveillance, preparedness and response in health facilities, community containment measures, managing international travel-related transmission risk, laboratory guidance, communication and education, plans for investigation and research (in development) and infection control. A complete powerpoint slide set is also available for generalization of education. Although we did not explore if the response plans surveyed in this study met with the recommendations provide by CDC, most of the response hospitals did not have idea about the update guidance mentioned above. The phenomenon suggests that there should be professional committee that regularly updated their response planning. For example, the current version of Supplement C emphasizes that SARS preparedness and response planning in healthcare facilities should not occur in a vacuum but rather should build on existing preparedness activities and relationships with the public health community. Although healthcare facilities will likely play a key role in the follow-up of exposed patients and healthcare workers, it will be important to coordinate these activities with the local health department, especially for patients being discharged and for healthcare workers who live in the community. It recommends that healthcare facilities work with health departments to coordinate this follow-up. Because activity restrictions for healthcare workers who have been exposed to SARS-Coronavirus might depend on the level of SARS-Coronavirus transmission in the community, it now recommends coordinating decisions on these restrictions with the health department, in accordance with the guidance in Supplement D.¹⁶
Accordingly, the recommendations for surveillance in healthcare settings have been revised for consistency with the recommendations in Supplement B.¹⁶ The guidance clarifies that, in patients who have epidemiologic links to SARS-Coronavirus, the presence of either fever or lower respiratory symptoms should prompt further evaluation. In addition, in accordance with the new SARS case definition, when persons have a high risk of exposure to SARS-Coronavirus (e.g., persons previously identified through contact tracing or self-identified as close contacts of a laboratory-confirmed case of SARS-Coronavirus disease; persons who are epidemiologically linked to a laboratory-confirmed case of SARS-Coronavirus disease), the clinical criteria should be expanded to include, in addition to fever or lower respiratory symptoms, the presence of two or more other early symptoms of SARS-Coronavirus disease. The term “universal respiratory etiquette” has been changed to “respiratory hygiene/cough etiquette.” Because patients with respiratory infections may not present with fever, the document clarifies that the recommended practices apply to all patients with symptoms of a respiratory infection. The section on staffing emphasizes that healthcare workers will need logistical and emotional support to help them cope with the challenges of responding to a SARS outbreak. Unfortunately, most of the response plans investigated in this study did not take these new points into considerations.
We believe that facilities should consider developing a formal SARS preparedness and response plan, as CDC suggests.¹⁶ The plan may simply be an addition to existing bioterrorism or emergency response plan. A multi-disciplinary planning committee should be implemented to include different authorities such as medical, nursing, laboratory and support staff, administrative, and infection control. Other groups may need to be adjunct members to consider certain issues such as labor union, mental health, and training/education. The plan should also contain surveillance, clinical evaluation, infection control measures, patient isolation, engineering controls, exposure evaluation, staffing needs and personnel policies, access controls, supplies and equipment, and communication.¹⁶

Tsang KW, Ho PL, Ooi GC, et al. A cluster of cases of severe respiratory syndrome in Hong Kong. N Engl J Med 2003;348:1977-85

Poutanen SM, Low DE, Henry B, et al. Identification of severe acute respiratory syndrome in Canada. N Engl J Med 2003;348:1995-2005