Department of Health Guidance on Preventing Transmission of SARS-CoV-2 During Aerosol Generating and Other Procedures

The Department of Health (DOH) has created a guidance document covering the prevention of transmission of COVID-19 during aerosol generating procedures (AGPs). While this document does not introduce new requirements, it centralizes information on infection prevention both during and after AGPs including air clearance following an AGP, certain exemptions, and gives a list of common procedures that are considered aerosol generating procedures. The DOH also recommends that health care personnel continue to follow the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. A summary of the DOH AGP document can be found below, and for the purposes of this guidance the DOH defines health care personnel (HCP) as the following:

HCP refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, home healthcare personnel, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, dental personnel, and volunteer personnel).

Infection Prevention During Aerosol Generating Procedures (AGP)

If an AGP is performed on a patient, regardless of COVID-19 status, the following should occur:

• Health care personnel (HCP) in the room or patient care area should wear a NIOSH approved N95 or equivalent, or higher-level respirator, eye protection, gloves, and a gown.
• If respirators are in short supply, facilities should implement the CDC Strategies for Optimizing the Supply of N9 Respirators.
• The number of HCP present during the procedure should be limited to those essential for care and procedure support, and visitors should not be present.
• If possible, AGPs should take place in an airborne infection isolation room (AIIR). If an AIIR is not available, the door to the room should remain closed during the procedure and for the lengths of time after the AGP has been completed as indicated in the next section.

Infection Prevention Following Aerosol Generating Procedure

Facilities should take the following additional measures to reduce the risk of transmission following an AGP:

• Anyone entering the room or patient care area following the procedure must wear a NIOSH approved N95 or equivalent or better respirator.
  • Exemptions for health care personnel can be found in the next section.
• Non-health care personnel such as patients, residents, or visitors should not enter following an AGP until the clearance time calculated below has passed.
  • Exemptions for subsequent patients, visitors, and other non-HCP can be found in the next section.
• The door to the room where the AGP was performed should remain closed for a period of time following the procedure:
  • If the provider knows the ventilation and filtration rate of the room, they may use the CDC clearance rates under differing ventilation conditions to determine the time a room should stay closed.
  • The door should be closed for one hour for clinical space that was constructed under DOH clinical facility requirements (6 air changes per hour).
  • The door should be closed for 15 minutes in the case where an AIIR has been used.
  • If the air changes per hour are unknown, the door should stay closed for a minimum of 3 hours.
• Procedure room surfaces should be cleaned and disinfected promptly with a disinfectant from the EPA List N.

Health Care Personnel Exemptions to Respirator Use Following an Aerosol Generating Procedure

The HCP may be exempt from the requirement to wear a NIOSH approved N95 or equivalent or better respirator in the area following an AGP if:

• The patient undergoing the AGP is not known or suspected of having COVID-19; and,
• The patient undergoing the AGP has not had any known exposure to COVID-19 within 14 days prior to the procedure; and,
• If 100% of the HCP in the health care facility or setting are fully vaccinated or have received an exemption from vaccination per the Governor’s Proclamation 21-14; and either,
  • The patient undergoing the procedure has been tested via PCR or antigen for COVID-19, the test has not been performed more than 24 hours before the procedure, and the test result is negative; or,
  • If before initiating the procedure, the patient is known to be fully vaccinated against COVID-19.

Patient, Resident, Visitor, and other Non-Health Care Personnel Exemptions to Entering a Room Following an Aerosol Generating Procedure

When the following specific risk mitigation measures are implemented, patients, residents, visitors, and other non-HCP may be allowed in the area following an AGP before the end of clearance time. This may happen if:

• The patient undergoing the AGP is not known or suspected of having COVID-19; and,
• The patient undergoing the AGP has not had any known exposure to COVID-19 within 14 days prior to the procedure; and,
• Subsequent patients, residents, visitors, and other non-HCP entering the room or area where the AGP was performed before the end of clearance time are fully vaccinated; and either,
  • The patient undergoing the procedure has been tested via PCR or antigen for COVID-19, the test has not been performed more than 24 hours before the procedure, and the test result is negative; or,
  • If before initiating the procedure, the patient is known to be fully vaccinated against COVID-19.

Aerosol Generating Procedure List

While this is not a comprehensive list of AGPs, commonly performed procedures that are considered AGPs include:

• Endotracheal intubation and extubation
• Manual ventilation
• Open suctioning of airways (including open tracheostomy suctioning)
• Cardiopulmonary resuscitation
• Bronchoscopy (unless carried out through a closed-circuit ventilation system)
• Surgery and post-mortem procedures in which high-speed devices, such as oscillating bone saws are used
• Dental procedures employing the use of ultrasonic scalers; high-speed dental handpieces; air/water syringes; air polishing; and air abrasion
• Non-invasive ventilation (NIV) (e.g., bi-level positive airway pressure ventilation (BiPAP) and continuous positive airway pressure (C-PAP))
• High frequency oscillatory ventilation (HFOV)
• Induction of sputum
• Nebulizer administration except when used with a HEPA filter on the nebulizer
• ENT procedures
• Nasogastric tube placement and/or manipulation
• Transeophageal echocardiogram
• Endoscopy
• High frequency ventilation
• Pulmonary function testing