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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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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS
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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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS
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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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS
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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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS
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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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS
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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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS
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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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS
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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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS
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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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS
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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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS
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
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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS
Appendix A: Donning and Doffing PPE with a respirator
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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS
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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS
Appendix B: Oxygen Therapy Guide
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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS
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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS
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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS
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AEROSOL-GENERATING MEDICAL PROCEDURES FOR COVID-19 PATIENTS