Infection Control

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 an N95 respirator (or equivalent or higher-level respirator) 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, sputum induction, bronchoscopy, mini-bronchoalveolar lavage, open suctioning of airways, manual ventilation, unintentional or intentional ventilator disconnections, noninvasive positive pressure ventilation (NIPPV) (e.g., bilevel positive airway pressure [BiPAP], continuous positive airway pressure [CPAP]), cardiopulmonary resuscitation, and, potentially, nebulizer administration and high-flow oxygen delivery. Caution regarding aerosol generation is appropriate in situations such as tracheostomy and proning, where ventilator disconnections are likely to occur.

Rationale

During the severe acute respiratory syndrome (SARS) epidemic, aerosol-generating procedures increased the risk of infection among health care workers.^1,2 N95 respirators block 95% to 99% of aerosol particles; however, medical staff must be fit-tested for the type used.³ Surgical masks block large particles, droplets, and sprays, but are less effective in blocking small particles (<5 μm) and aerosols.⁴

Recommendation

• The Panel recommends minimizing the use of aerosol-generating procedures on intensive care unit patients with COVID-19 and carrying out any necessary aerosol-generating procedures in a negative-pressure room, also known as an airborne infection isolation room (AIIR), when available (AIII).
• The Panel recognizes that aerosol-generating procedures are necessary to perform in some patients, and that such procedures can be carried out with a high degree of safety if infection control guidelines are followed.

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 high-flow nasal cannula or noninvasive ventilation. HEPA filters reduce virus transmission in simulations.⁵

Recommendations

• For health care workers who are providing usual care for nonventilated patients with COVID-19, the Panel recommends using an N95 respirator (or equivalent or higher-level respirator) or a surgical mask, in addition to other PPE (i.e., gloves, gown, and eye protection such as a face shield or safety goggles) (AIIa).
• 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 an N95 respirator (or equivalent or higher-level respirator) in addition to other PPE (i.e., gloves, gown, and eye protection such as a face shield or safety goggles) because ventilator circuits may become disrupted unexpectedly (BIII).

Rationale

There is evidence from studies of viral diseases, including SARS, that both surgical masks and N95 respirators reduce the risk of transmission.⁶ Moreover, surgical masks are probably not inferior to N95 respirators for preventing the transmission of respiratory viral infections; a recent systematic review and meta-analysis of randomized controlled trials that compared the protective effects of medical masks and N95 respirators demonstrated that the use of medical masks did not increase the incidence of laboratory-confirmed viral respiratory infections (including coronavirus infections) or clinical respiratory illness.⁷

Recommendations

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

Rationale

Practices that maximize the chances of first-pass success and minimize aerosolization should be used when intubating patients with suspected or confirmed COVID-19.^8,9 Thus, the Panel recommends that the health care worker 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. It is also important to avoid having unnecessary staff in the room during intubation procedures.