Lessons from Taiwan

During the recent outbreak of severe acute respiratory syndrome (SARS), several medical institutes in Taiwan were closed temporarily because medical staff developed SARS-like symptoms. To help prevent this situation from occurring at our hospital, we built an outdoor emergency department (Fig. 1). In designing the facility, we incorporated some principles from the management of other types of disasters, including “hot” and “cool” areas and a decontamination zone. In addition, the infection control team and emergency physicians implemented a new triage algorithm. No one with a fever, cough, relevant contact or travel history, or any other suspicious symptoms was allowed indoors. Several procedures were performed outdoors, such as chest radiography and the drawing of blood specimens. After complete evaluation and observation, patients who did not have SARS could be discharged directly or moved into the hospital after undergoing a decontamination procedure. Patients with suspected or probable SARS were admitted into an isolation ward via a specific route outside the emergency department. Infectious disease physicians were required to be on call 24 hours a day and were consulted in ambiguous cases. By virtue of the triage algorithm and the outdoor location, our emergency department continued to operate efficiently throughout the critical period, even when the other 2 emergency departments in this city of 3 million people were shut down.

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Fig. 1: Outdoor emergency department at Veterans General Hospital, Taiwan. T = triage area and body temperature screening station, C = cardiopulmonary resuscitation area, L = low-risk area for patients with fever or cough, H = high-risk area for suspect and probable cases of SARS.

Protecting health care workers has been our first priority in the fight against SARS. All staff at our hospital have been under a strict follow-up protocol, and no secondary or tertiary transmission has been discovered. Even though SARS spreads rapidly, has high infectivity and is associated with significant morbidity and mortality,1 we believe that our outdoor emergency department was a factor in protecting the health care workers and in allowing the entire hospital to maintain its normal functions.

Although this novel approach to emergency care has been effective and efficient, it has consumed considerable resources with a low yield of cases (less than 1% of patients seen actually had SARS). However, voluntary quarantine within a hospital also carries significant costs.2

Li-chien Chien Wen-Bin Yeh Hong-Tai Chang Department of Emergency Medicine Veterans General Hospital Kaohsiung City, Taiwan