Guidance for AGMPs During the COVID-19 Pandemic

Version 9 October 30, 2020

Interim Guidance for Patients Requiring an AGMP (aerosol generating medical procedure)

During the COVID-19 Pandemic

The purpose of this document is to guide the use of Personal Protective Equipment (PPE) for all

healthcare providers in the care of patients requiring AGMPs in the setting of the COVID-19 pandemic. The

application of this document will need to be adapted to the characteristics and point of care risk

assessment of each individual, unit and department and to the epidemiologic presence of disease within

the community.

A Point of Care Risk Assessment must be applied to all patients, irrespective of location.

Definition for Aerosol Generating Medical Procedures (AGMPs)

Aerosol-generating medical procedures (AGMPs) are interventions that can produce aerosols as a result of

artificial manipulation of a person's airway. Additional precautions over and above baseline precautions are

required when providing AGMPs.

This document outlines PPE guidance during the COVID-19 pandemic and pertains to patients

who are suspected/probable or confirmed COVID-19 requiring AGMPs.

Refer to the most current COVID-19 signs and symptoms reference document found here

COVID-19 Screening Questions for all patients are assessed on admission/presentation for care

COVID-19 Symptoms Questions for all inpatients are assessed and documented in the electronic

health record Q shift.

Guiding Principles for Patients with Suspect, Probable or Confirmed COVID-19

AGMPs should only be performed when medically necessary. Treatments should be selected that

minimize aerosol or droplet generation. Ie Use MDI inhalers rather than nebulizer treatments.

Healthcare workers and/or additional staff should not be present in a room where an AGMP is

being performed unless it is required for patient safety. When so, the fewest number should be

present to limit exposure/conserve PPE.

AGMPs should be performed by the most experienced health care professional.

Use filters with respiratory apparatus when able

Appropriate PPE must be worn in the room following completion of the AGMP to allow for air

clearance.

https://www.grhallthingscovid.com/wp-content/uploads/2020/09/SEM_20200206_GRH-point-of-care-risk-assessment_PPE.pdfhttps://www.grhallthingscovid.com/2020/09/29/covid-19-signs-and-symptoms/

Guidance for AGMPs During the COVID-19 Pandemic

Version 9 October 30, 2020

What is NOT an AGMP?

• Collection of nasopharyngeal or throat swab • Ventilator circuit disconnect • Needle thoracostomy, thoracocentesis, thoracentesis, paracentesis • Chest tube removal or insertion (unless meets above criteria* in setting of emergent insertion for ruptured

lung/pneumothorax – air leak) • Coughing, spontaneous expectorated sputum • Oral/nasal suctioning, Oral hygiene • Gastroscopy or colonoscopy or endoscopic retrograde cholangiopancreatography • Laparoscopy (gastrointestinal/pelvic) • Cardiac stress tests • Caesarian section or vaginal delivery of baby done with regional anaesthesia • Any procedure done with regional or local anaesthetic • Electroconvulsive therapy • Transesophageal echocardiogram • Nasogastric/nasojejunal tube/gastrostomy/gastrojejunostomy/jejunostomy tube insertion • Bronchial artery embolization • Chest physiotherapy (in the absence of any AGMP) • Oxygen delivered at less than or equal to 6 liters per minute by nasal prongs & less than or equal to 15 liters per

minute by Venturi masks/non-rebreather masks • Intranasal medication administration such as naloxone • All non-airway surgeries with cautery, lasers, saws • Nasopharyngoscopy or nasopharyngeal airway (e.g. trumpet) insertion • Laryngeal Mask Airway (LMA) insertion • Nebulized medication delivery through ventilator circuit for conventional invasive mechanical ventilation • MDI and soft mist inhaler administration +/- spacer

https://www.publichealthontario.ca/-/media/documents/ncov/updated-ipac-measures-COVID-19-19.pdf?la=en

What is an AGMP of relevance for COVID-19? Cardio Pulmonary Resuscitation (CPR)

Intubation, Extubation

Manual Ventilation (bag-valve-mask Note: Use High-efficiency viral/bacterial filter)

Noninvasive ventilation (NIV) eg CPAP, BiPAP Note: a risk reduction is present when caring for infants on NIV in an incubator

High Flow oxygen therapy (eg Optiflow, Airvo)

Open respiratory airway suctioning (eg, deep insertion for nasopharyngeal or tracheal suctioning, not inclusive of oral suction or use of an inline suction device)

Bronchoscopy (avoid if possible for high COVID-19 risk)

Induced sputum (avoid if possible for high COVID-19 risk)

Nebulized therapy/aerosolized medication Administration and large volume nebulizers for humidity (avoid where possible)

High-frequency Oscillation ventilation/Jet ventilation

Oral, pharyngeal, transphenoidal, and airway surgeries (including thoracic surgery and tracheostomy insertion)

Thoracotomy or open thoracostomy where air leak is likely (chest tube insertion for trauma)

Autopsy of lung tissue or airway tissue

Post Mortem Care

Tracheostomy/Tracheotomy Care and insertion, open suctioning, removal

Breathstacking, In/Ex-sufflation (Cough Assist), oscillating positive expiratory pressure devices (OPEP)

Certain dental procedures including ultrasonic and sonic scalers, high-speed dental handpieces (tooth preparation with air abrasion, air turbine handpiece), air polishers, and air-water syringes.

https://www.publichealthontario.ca/-/media/documents/ncov/updated-ipac-measures-covid-19.pdf?la=en

Guidance for AGMPs During the COVID-19 Pandemic

Version 9 October 30, 2020

COVID-19 Risk Negligible COVID-19 Risk

Patient characteristics/factors

Active COVID-19 positive case until case is cleared by time or test based approach

ARI symptoms with test

pending

Atypical COVID-19 symptoms

that MRP confirmed are not

explained by another

underlying diagnosis

COVID-19 test pending for any other reason

In additional precautions from

COVID-19 outbreak facility or in

home isolation for COVID-19 due

to exposure or travel in the last

14 days

No exposures, no symptoms

ARI symptoms with at least 1 negative COVID-19 test or lab proven alternate diagnosis

Atypical COVID-19 symptoms that MRP confirms are explained by underlying diagnosis (no COVID-19 test required)

Initially considered COVID-19 risk (due to symptoms), COVID-19 test returned negative and no further testing required. Note: not applicable to COVID-19 exposed patients

Patient placement cohorting for patients

Single room or

Cohort ONLY laboratory confirmed COVID-19 positives

Any Cohorting

Room Requirements If available, Airborne infection isolation room (AIIR) or Private room (door

closed) with HEPA filter

Any Room

Minimum PPE for Non AGMPs Refer to non AGMP list

Surgical/Procedure mask** Face/Eye Protection

Gown Gloves

Routine Practices and PPE most appropriate for clinical condition

Minimum PPE for AGMPs Refer to the AGMP list

N95 Face/Eye Protection

Gown Gloves

Surgical/Procedure mask Face/Eye Protection

Gown Gloves

Signs for AGMP – see below for ordering information

AGMP Medical Procedure in Progress Droplet Contact plus N95

Appendix A

AGMP Medical Procedure in Progress

Droplet Contact Appendix B

**PCRA for N95 New posters for AGMPs are available through R.R. Donnelly (Custom Point) for ordering. There are two posters – one for AGMPs with minimal droplet contact, and one for AGMPs with droplet contact. The posters can be ordered in packages of 5 using the following order codes:

GRHPOS-36 Minimal Droplet Contact

GRHPOS-37 Droplet Contact N95 Required

Guidance for AGMPs During the COVID-19 Pandemic

Version 9 October 30, 2020

Appendix A: Aerosol Generating Medical Procedure in Progress (Droplet Contact plus N95 PPE)

Guidance for AGMPs During the COVID-19 Pandemic

Version 9 October 30, 2020

Appendix B: Aerosol Generating Medical Procedure in Progress (Droplet Contact PPE)