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Infection Control

Last Updated: May 12, 2020

Health care workers should follow the infection control policies and procedures issued by their health care institutions.

Recommendation:

  • For health care workers who are performing aerosol-generating procedures on patients with COVID-19, the COVID-19 Treatment Guidelines Panel (the Panel) recommends using fit-tested respirators (N95 respirators) or powered air-purifying respirators rather than surgical masks, in addition to other personal protective equipment (PPE) (i.e., gloves, gown, and eye protection, such as a face shield or safety goggles) (AIII).
  • Aerosol-generating procedures include endotracheal intubation and extubation; bronchoscopy; open suctioning; high-flow nasal cannula (HFNC) or face mask; nebulizer treatment; manual ventilation; physical proning of the patient; disconnecting a patient from a ventilator; mini-bronchoalveolar lavage; noninvasive positive pressure ventilation (NIPPV); tracheostomy; or cardiopulmonary resuscitation.

Rationale

During the severe acute respiratory syndrome (SARS) epidemic, aerosol-generating procedures increased the risk infection among health care workers.1, 2 N95 respirators block 95% to 99% of aerosol particles; however, staff must be fit-tested for the type used. Surgical masks block large particles, droplets, and sprays, but are less effective in blocking small particles (<5 μm) and aerosols.3

Recommendation:

  • The Panel recommends minimizing the use of aerosol-generating procedures on COVID-19 intensive care unit patients and carrying out any necessary aerosol-generating procedures in a negative-pressure room, also known as an airborne infection isolation room (AIIR) (AIII).

Rationale

AIIRs lower the risk of cross-contamination among rooms and lower the risk of infection for staff and patients outside the room when aerosol-generating procedures are performed. AIIRs were effective in preventing virus spread during the SARS epidemic.2 If an AIIR is not available, a high-efficiency particulate air (HEPA) filter should be used, especially for patients on HFNC or noninvasive ventilation. HEPA filters reduce virus transmission in simulations.4

Recommendations:

  • For health care workers who are providing usual care for non-ventilated COVID-19 patients, the Panel recommends using surgical masks or fit-tested respirators (N95 respirators), in addition to other PPE (i.e., gloves, gown, and eye protection, such as a face shield or safety goggles) (AII).
  • For health care workers who are performing non-aerosol-generating procedures on patients with COVID-19 who are on closed-circuit mechanical ventilation, the Panel recommends using surgical masks or fit-tested respirators (N95 respirators), in addition to other PPE (i.e., gloves, gown, and eye protection, such as a face shield or safety goggles) (AII).

Rationale

There is evidence from viral diseases including SARS that both surgical masks and N95 masks reduce transmission of infection.5 Current evidence suggests that surgical masks are probably not inferior to N95 respirators for preventing transmission of laboratory-confirmed seasonal respiratory viral infections (e.g., influenza).6, 7 The Surviving Sepsis Campaign COVID-19 Guidelines updated a recent systematic review and meta-analysis of randomized controlled trials that demonstrated no statistical difference in protection between surgical masks and N95 respirators in this setting.8

Recommendations:

  • The Panel recommends that endotracheal intubation for patients with COVID-19 be performed by health care providers with extensive airway management experience, if possible (AIII).
  • The Panel recommends that intubation be achieved by video laryngoscopy, if possible (CIII).

Rationale

Factors that maximize the chances of first-pass success and minimize aerosolization should be used when intubating patients with suspected or confirmed COVID-19.9, 10 Thus, the Panel recommends that the health care operator with the most experience and skill in airway management be the first to attempt intubation. The close facial proximity of direct laryngoscopy can expose health care providers to higher concentrations of viral aerosols. Finally, it is important to avoid having unnecessary staff in the room.

References

  1. Yam LY, Chen RC, Zhong NS. SARS: ventilatory and intensive care. Respirology. 2003;8 Suppl:S31-35. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15018131.
  2. Twu SJ, Chen TJ, Chen CJ, et al. Control measures for severe acute respiratory syndrome (SARS) in Taiwan. Emerg Infect Dis. 2003;9(6):718-720. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12781013.
  3. Milton DK, Fabian MP, Cowling BJ, Grantham ML, McDevitt JJ. Influenza virus aerosols in human exhaled breath: particle size, culturability, and effect of surgical masks. PLoS Pathog. 2013;9(3):e1003205. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23505369.
  4. Qian H, Li Y, Sun H, Nielsen PV, Huang X, Zheng X. Particle removal efficiency of the portable HEPA air cleaner in a simulated hospital ward. Building Simulation. 2010;3:215–224. Available at: https://link.springer.com/article/10.1007/s12273-010-0005-4.
  5. Offeddu V, Yung CF, Low MSF, Tam CC. Effectiveness of masks and respirators against respiratory infections in healthcare workers: a systematic review and meta-analysis. Clin Infect Dis. 2017;65(11):1934-1942. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29140516.
  6. World Health Organization. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. 2020; https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125. Accessed May 9, 2020.
  7. Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings. 2020; https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html. Accessed May 9, 2020.
  8. Smith JD, MacDougall CC, Johnstone J, Copes RA, Schwartz B, Garber GE. Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis. CMAJ. 2016;188(8):567-574. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26952529.
  9. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012;7(4):e35797. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22563403.
  10. Lewis SR, Butler AR, Parker J, Cook TM, Schofield-Robinson OJ, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review. Br J Anaesth. 2017;119(3):369-383. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28969318.