Aerosol-generating Medical Procedures for COVID-19 Patients

kg

AEROSOL-GENERATING

MEDICAL PROCEDURES

FOR COVID-19 PATIENTS

Prepared by: Provincial COVID-19 PPE Task Force

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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS

Background ................................................................................................................................................... 2

List of AGMPs ................................................................................................................................................ 3

Risk Assessment for AGMPs .......................................................................................................................... 5

Risk Reduction Strategies .............................................................................................................................. 8

Airborne Infection Isolation Rooms (AIIR) .................................................................................................... 9

References……………………………………………………………………………………………………………………………………….. 10

Appendix A: Donning and Doffing PPE with a

respirator…………………………………………………………………....122

Appendix B: Oxygen Therapy Guide…………………………………………………………………………………………………..14

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Background This guideline has been developed by Provincial COVID-19 PPE (Personal Protective Equipment)

Task Force to ensure that healthcare workers (HCWs) utilize a consistent approach when

choosing PPE for aerosol-generating medical procedures on patient with suspect or confirmed

COVID-19.

In addition to Routine Practices, all HCWs who provide care to a suspect or confirmed case of

COVID-19 must use Droplet-Contact Precautions. The PPE for this level of precautions includes:

Level II gown

Level 2 or 3 ASTM medical mask

Eye/face protection

Nitrile gloves

If an aerosol-generating medical procedure (AGMP) is being performed on a patient with

suspect or confirmed COVID-19; Droplet-Contact Precautions are required, with the addition of

a respirator (e.g. N95 respirator).

N95 respirators are used to prevent the transmission of microorganisms via inhalation of

aerosols that can result in an infection in a susceptible host. Infectious pathogens can be

considered on a spectrum of efficiency for airborne transmission classified as:

obligate (infection only occurs via aerosols),

preferential (aerosols predominate),

opportunistic (non-airborne transmission is most common, but aerosols may transmit

under favorable conditions).

Current evidence supports SARSCoV-2 as an opportunistic airborne pathogen. Respiratory virus

transmission occurs on a spectrum from larger droplets that spread at close range to smaller

droplets (or aerosols) that have the potential to be infectious over longer distances (i.e. >2 m)

and may be suspended for longer periods of time (typically hours). Transmission of SARS-CoV-

19 occurs primarily through large respiratory droplet transmission and unprotected close

contact. SARSCoV-2 may also spread when individuals touch contaminated objects (fomites).

Public Health Agency of Canada1 (2017) guideline report that in addition to the proximity of

infected source to the host several factors affect airborne transmission including the particle

sizes containing the infectious agent, the viability of the infectious agent and the animate and

inanimate environment of a room {e.g., the concentration of the viral particles in droplet nuclei,

the concentration of aerosol in the room, the relative humidity, the direction of air flow and the

number of air changes per hour (ACH) in the room}.

1 PHAC. (2017). Routine Practices and Additional Precautions.

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AGMPs include procedures that mechanically create and disperse aerosols (e.g. bronchoscopy

or tracheal intubation) and procedures that induce the patient to produce aerosols (e.g. the

pressure on a patient’s chest during chest compressions can induce a cough like force).2

The following procedures have been approved by the Provincial COVID-19 PPE Task Force

as being aerosol-generating medical procedures (AGMPs).

List of AGMPs Autopsy involving respiratory tissue AND/OR the use of high-speed oscillatory tools

Bag-valve mask ventilation

Bronchoscopy

Chest compressions

Chest tube insertion under positive pressure ventilation

Intubation

Extubation

High flow oxygen/oxygen via nasal prongs > 5L/min **

High frequency oscillatory ventilation

Non-invasive positive pressure ventilation (CPAP, Bi-PAP)

Open airway suctioning (e.g. deep insertion for nasopharyngeal or tracheal suctioning, NOT

inclusive of anterior oral suctioning)

Administration of nebulized medications (Note: Avoid if possible; use of alternatives such as

meter-dose inhaler with spacer are preferred)

Sputum induction (i.e. inhalation of nebulized hypertonic saline solution to liquefy and

produce secretions, NOT natural coughing to bring up sputum) includes cough assist devices

Tracheotomy or tracheostomy insertion/suctioning/tube change/decannulation Note: Dressing

change, tie change or inner cannula change are not considered an AGMP

Upper endoscopy

**Oxygen delivery methods that are not considered AGMPs are:

2 Judson, S. D. & Munster, V. J. (2019).

Aerosol-generating medical procedures are medical procedures that can generate aerosols

as a result of artificial manipulation of a person's airway.1

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Nasal prongs up to and including 5 Lpm

Non-rebreather/HiOX/FLO2 up to 15 Lpm

Simple face mask up to 10 Lpm

Additional information on oxygen delivery methods is in Appendix B.

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Risk Assessment for AGMPs The level of risk and prevalence of COVID-19 will be determined by the Regional Medical Officers of Health (RMOH) and Regional Incident Commanders based on the epidemiology and ongoing surveillance of COVID-19 within the region. This process is replicated at the provincial level through the office of the CMOH and Public Health Division. This is reported to the Department of Health and Community Services Emergency Operations Centre (HCS-EOC) on a weekly basis or more frequently if the surveillance dictates. Monitoring of the epidemiology is ongoing, should there be changes in prevalence; adjustments will be made accordingly under the direction of the CMOH.

Table 1: AGMPs decision tool during a COVID-19 low prevalence period

AGMP Risk assessment

COVID-19 screening tool

COVID-19 test Low Prevalence Action

Known COVID status- low risk Examples of AGMPs include:

Chronic CPAP or BiPAP

Elective surgical procedures

Code Blue if COVID status known.

(Includes ER if COVID tool negative and history completed)

i.e. awaiting admission

Negative (As per current screening tool)

Not required (Surveillance testing is complete for all admissions, however not required for patient placement)

The procedure should be performed with a PCRA and Routine Practices.

Known COVID status -high risk

Positive (As per current screening tool)

Required The procedure should be rescheduled if possible or performed with Droplet-Contact Precautions with a N95 respirator or equivalent.

Unknown COVID status/risk: Examples include:

Code blue

Intubations

Non-invasive ventilation (CPAP, BiPAP for acute indications)

Status unknown

Status unknown The procedure should be performed with Droplet-Contact Precautions with N95 respirator or equivalent.

Legend: Status unknown – The results of the COVID-19 screen is unknown. When the result of the COVID-19 screen is unknown the procedure is considered high risk and the procedure is performed with Droplet-Contact Precautions with N95 respirator. PCRA- point of care risk assessment AGMP- aerosol-generating medical procedure

**PARAMEDICINE: ALL PATIENTS CONSIDERED HIGH RISK/UNKNOWN STATUS

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Is the patient COVID

status Known or

Unknown?

Low Prevalence

AGMP

KNOWN STATUS -LOW RISK

KNOWN STATUS- HIGH

RISK Paramedicine OR

COVID screen

status unknown1

Droplet-Contact

Precautions with

N95 respirator

Is the COVID-19

screening tool

negative (as per

current screening

tool)

Yes

Is the COVID-19

screening tool

positive (as per

current screening

tool)

PCRA and routine practice

Either positive COVID screen OR

positive COVID swab

Legend: 1Status unknown – Either the COVID screen is unknown

or COVID swab has not been done or report is unknown.

Yes

Reschedule, if possible or perform

with Droplet- Contact Precautions

with N95 respirator or equivalent

COVID test not required

(surveillance admission

swab may be done. Not

required for placement)

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Table 2: AGMPs decision tool during a COVID-19 widespread community transmission period

AGMP Risk assessment Patient/resident

COVID-19 screening tool

COVID-19 test required

Widespread Community Transmission Action

Known COVID status-low risk Examples of AGMPs include:

Chronic CPAP or BiPAP

Elective surgical procedures

Code Blue if COVID status known.

Negative (As per current screening tool)

Required

One negative COVID test

Asymptomatic

Negative screening tool (Use Routine Practice and PCRA)

Known COVID status-high risk

Positive (As per current screening tool)

Required

If either the COVID screen or COVID swab is positive

The procedure should be rescheduled, if possible, OR

Perform the procedure with Droplet-Contact Precautions with N95 respirator.

Unknown COVID status/risk: Examples include:

Code blue

Intubations

Non-invasive ventilation (CPAP, BiPAP for acute indications)

Status unknown Status unknown (see legend below)

The procedure should be performed with Droplet-Contact Precautions with N95 respirator.

Legend: Status unknown – Either the COVID-19 screen is unknown, or the COVID-19 test has not been done or the results are unknown. When the status of the COVID-19 screen or test is unknown the procedure is considered high risk and should be performed with Droplet-Contact Precautions with N95 respirator. PCRA- Point of care risk assessment AGMP- aerosol-generating medical procedure

PARAMEDICINE: ALL PATIENTS CONSIDERED HIGH RISK/UNKNOWN STATUS

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Is the patient

COVID screening

tool negative or

positive or status

unknown?

AGMP during widespread community

transmission of COVID-19 (High prevalence)

Positive screening tool or status

unknown (as per current

screening tool)

Negative screening tool (as

per current screening tool)

PCRA

Routine Practices

Reschedule if possible.

OR

Droplet-Contact Precautions with N95

respirator or equivalent

Negative

COVID screen & one

negative COVID swab

Legend: 1Status unknown – Either the COVID screen is unknown, COVID swab has not been done, or report is

unknown.

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Risk Reduction Strategies The following strategies should be applied to reduce the level of aerosol generation when

performing AGMPs for patients with suspected or confirmed COVID-19.

Aerosol-generating medical procedures:

Should be limited to those that are medically necessary;

Should be anticipated and planned for, if possible;

Should be performed in an Airborne Infection Isolation Room (AIIR), whenever feasible

o If an AIIR is not available, the procedure should be performed in a single room with

the door closed

The room should preferably be without recirculation of air from the room to

other rooms and as far away from the rooms of other patients as possible

The number of personnel in the room should be limited to those required to perform the

aerosol-generating medical procedure

Droplet-Contact Precautions with N95 respirator are required for this procedure, which

includes the below PPE:

o N95 respirator which has been fit tested and fit checked for each person

o Eye/face protection

o Level II Gown

o Nitrile gloves

Follow the procedure in Appendix A

It is recommended to have a spotter to ensure that the PPE is removed properly, if available

Equipment use in the room:

o Single use equipment must be disposed of in regular garbage

o Reusable equipment must be cleaned/disinfected prior to use on another person

Environmental Cleaning

o The room must be thoroughly cleaned after the AGMP is completed

o If this cleaning must be done immediately, the Environmental Services staff must use

the PPE as per Droplet-Contact Precautions with N95 respirator

Airborne Infection Isolation Rooms (AIIR) An AIIR is a single-occupancy patient-care room used to isolate persons with a suspected or confirmed airborne infectious disease. Environmental factors are controlled in AIIRs to minimize the transmission of infectious agents that are usually transmitted from person to person by droplet nuclei associated with coughing or aerosolization of contaminated fluids.

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AIIRs should provide: Negative pressure in the room (no air flows out of the room into adjacent areas)

o An air flow rate of 6-12 air exchanges (ACH) (6 ACH for existing structures, 12 ACH for new construction or renovations)

o Direct exhaust of air from the room to the outside of the building or recirculation of air through a HEPA filter before returning to circulation

Following the procedure, sufficient time must be allowed for the air to be cleared of

aerosolized droplet nuclei before the AGMPs posters can be removed from the door of the

room

o This will be determined by the number of ACH in the room

o Facilities management should be contacted to establish the number of ACHs in

rooms that will be used for AGMPs

o Rooms with 6 ACHs would require 69 minutes for removal efficiency of 99.9% and

for rooms with 12 ACH, 35 minutes would be required for 99.9% removal efficiency

Monitoring of the AIIR: o Facilities management should be notified when an AIIR is activated to ensure that

the negative pressure within an AIIR is maintained The negative pressure should be checked prior to placing the patient in an

AIIR and daily when the AIIR is in use

Visual indicators (smoke tubes or flutter strips) or portable manometers may be used to check the differential pressure

The results of monitoring should be documented

Visual or audible alarms should not be inactivated

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References Judson, S. D. & Munster, V. J. (2019). Nosocomial transmission of emerging viruses via aerosol-

generating medical procedures. Retrieved May 18, 2020, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6832307/

Public Health Agency of Canada. (2017). Routine Practices and Additional Precautions for

Preventing the transmission of infection in healthcare settings. Retrieved April 26, 2020, from

https://www.canada.ca/en/public-health/services/publications/diseases-conditions/routine-

practices-precautions-healthcare-associated-infections/part-d.html#D.V

World Health Organization. (2020). Modes of transmission of virus causing COVID-19:

implications for IPC precaution recommendations. Retrieved May 18, 2020, from

https://www.who.int/publications-detail/modes-of-transmission-of-virus-causing-covid-19-

implications-for-ipc-precaution-recommendations

World Health Organization. (2014). Infection prevention and control of epidemic and pandemic

prone acute respiratory infections in health care. WHO guidelines. Retrieved April 25, 2020

from

https://apps.who.int/iris/bitstream/handle/10665/112656/9789241507134_eng.pdf;jsessionid

=46E9218E9F463DEE67D938EDDC12F4DF?sequence=1

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6832307/

https://www.canada.ca/en/public-health/services/publications/diseases-conditions/routine-practices-precautions-healthcare-associated-infections/part-d.html#D.V

https://www.canada.ca/en/public-health/services/publications/diseases-conditions/routine-practices-precautions-healthcare-associated-infections/part-d.html#D.V

https://www.who.int/publications-detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations

https://www.who.int/publications-detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations

https://apps.who.int/iris/bitstream/handle/10665/112656/9789241507134_eng.pdf;jsessionid=46E9218E9F463DEE67D938EDDC12F4DF?sequence=1

https://apps.who.int/iris/bitstream/handle/10665/112656/9789241507134_eng.pdf;jsessionid=46E9218E9F463DEE67D938EDDC12F4DF?sequence=1

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Appendix A: Donning and Doffing PPE with a respirator

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Appendix B: Oxygen Therapy Guide

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Documents

Aerosol-generating Medical Procedures for COVID-19 Patients