Universal Respiratory Etiquette: A Modest Proposal

The CDC is recommending some simple measures to help prevent the spread of SARS, which will also help contain other potential epidemics such as the flu. These measures include: posting signs at the ED entrance; asking those who are coughing or have other respiratory symptoms to don a mask and to alert staff; providing simple surgical masks to such patients and wearing a mask yourself when you are evaluating them; having these patients sit at least 3 feet away from others; and, to the extent possible, bringing them back into a cubicle or single room. And having them seen as soon as possible. These are just some highlights of a few of the suggested strategies in a long and comprehensive new document1 that the CDC thought was so important in helping to prevent a reemergence of SARS, that it was posted on the Web before a final review.

Emergency nurses can implement these strategies today. Many already have, slowly but surely placing masks, tissues, and paper bags to dispose of them, and even antiseptic hand gel at the ED entrance and at the bedside. A recent NBC Today Show segment about the 2003 flu season, showed a video clip of a Colorado hospital ED waiting area with patients wearing surgical masks as they waited to be examined.

One ED nurse colleague recently suggested that his department begin universal masking. His hospital administrator was concerned that all those masks might alarm others in the department, but the nurse resisted the “hotel syndrome” thinking—when hospitals are pressured to provide an attractive, hotel-like environment. The need to “first, do no harm” and protect others is surely a stronger imperative than sparing the senses and the psyche of those around us. Clinical judgment needs to prevail, and nurses in this emergency department quietly began placing surgical masks on patients who were coughing and, when in close proximity to these patients, wearing a mask themselves. Sandra Mathis, RN, BSN, MPH, CIC, Infection Control Practitioner, at the University of Massachusetts, Worcester, advocates the use of a poster with a picture of a person wearing a mask and explaining the routine use of masks in the emergency department and other hospital entrances. It can say something like, “During this flu season, we ask those with coughs to wear a mask for everyone’s protection.”

According to the CDC, 77% of the patients in the first phase of the SARS outbreak in Toronto were infected in the hospital. Half of all SARS cases in Toronto were healthcare workers exposed to respiratory secretions from SARS patients. The single, simple strategy of providing surgical masks to all patients with respiratory symptoms who enter the emergency department, and having them wear the masks until they can be evaluated could limit epidemics. Evelyn Bain, RN, Med, COHN-S, Occupational Health and Safety Specialist at the Massachusetts Nurses Association, calls using masks “the most relevant infection control strategy to date” with regard to the flu, as well as SARS, and is diligently working to encourage nurses in Massachusetts hospitals and beyond to do so. The importance is not lost on physician experts as well. A prominent Massachusetts epidemiologist recently commented that Universal Respiratory Etiquette may become as important a part of health care as Universal (Standard) Precautions. This is a modest proposal, and emergency nurses will, no doubt, modestly lead the way.