• ​surgical mask
• face shield and/or eye protection.

Airborne precautions

If infectious particles are transmitted by aerosols.

​In addition to contact and droplet:

• ​N95/P2 mask (or higher) in place of surgical mask
• where possible, the patient should be in a negative pressure room
• patient should wear a surgical mask when possible.

Powered air purifying respirators (PAPR)

For use with airborne precautions if required.

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​​​Patient COVID-1​9 risk 2	​​Lo​w​			​Suspect, probable or confirmed​
AGP 3​​	​No	​Low risk	​High risk	No​	​High or low risk 7
Patient​	nil			​surgical mask	​surgical mask 4
​Anaesthetist (and assistant)	usual theatre attire​			​droplet​	airb​orne  optional PAPR
​Anaesthetic nurse​	​usual theatre attire​​			droplet​	airborne  optional PAPR
​Instrument or circulating nurse	usual theatre attire​			droplet​	airborne  optional PAPR
​Surgical team	usual theatre attire​			droplet​	airborne  optional PAPR
​Operating assistants 5	usual theatre attire​			droplet​	airborne
​Recovery nurse	usual theatre attire​			droplet​	airborne
​Medical imaging or allied health staff 6	usual theatre attire​			droplet​	airborne
​Surgical representatives 6	usual theatre attire​			droplet​​	airborne
​Operating theatres	​Non-COVID-19 theatres			​COVID-19 theatres​​
​Patient transportation​​	usual theatre​ attire​​​			droplet​
​​Perioperative staff  requirements	​​as per the Australian College of Perioperative Nurses guidelines			outside runner for the team
​Recovery of patients	​​ ​​recovery unit			extubate and recover in operating theatre

1. PPE: All include standard precautions. Droplet includes contact. Airborne includes droplet and contact.
2. COVID-19 risk is based on local health district definitions.
3. The AGP list may change based on evidence and/or local definitions.
4. Apply a surgical mask to the at risk COVID-19 patient if they are able to tolerate it (until anaesthetic induced).
   
5. Operating assistants and staff not involved in the procedure are expected to be outside the operating theatre during the procedure. If they must return to the theatre in the 30 minutes following an AGP, appropriate PPE is required.
   
6. Medical imaging, allied health staff and surgical representatives should be outside the operating theatre during an AGP.
   
7. COVID-19 patients having a procedure under regional anaesthesia are managed with droplet precautions.

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COVID-19 procedural PPE: medium facility risk assessment ​¹

​​​Patient COVID-19 risk 2	​​Lo​w				​Suspect, probable or confirmed​
AGP 3​​	​​No		​Low risk	​High risk​	No​	​High or low risk 7
Patient​	nil		nil	nil​	​surgical mask	​surgical mask 4
​Anaesthetist  (and assistant)	​usual theatre attire​		​​droplet	​airborne​	​droplet​	​airborne  optional PAPR
​Anaesthetic nurse​	​usual theatre attire​​		​​droplet	​airborne​	droplet​	​airborne  optional PAPR
​Instrument or  circulating nurse	​usual theatre attire​		​​droplet	​airborne​	​droplet​	​airborne  optional PAPR
​Surgical team	​usual theatre attire​		​​droplet	​airborne​	droplet​	​airborne  optional PAPR
​Operating assistants 5	​usual theatre attire​		​​droplet	​airborne​	​droplet​	​airborne
​Recovery nurse	​usual theatre attire​		​​droplet	​airborne​	​droplet​	​airborne
​Medical imaging or  allied health staff 6	​usual theatre attire​		​​droplet	​airborne​	droplet​	​airbo​rne
​Surgical representatives 6	​usual theatre attire​		​droplet	​airborne​	​droplet​​	​airborne
​Operating theatres	​Non-COVID-19 theatres				​COVID-19 theatres​​
​Patient transportation​	​​​usual theatre attire​				droplet​
​Perioperative staff  requirements	as per the Australian College of Perioperative Nurses guidelines​				​outside runner for the team	outside anaesthetic nurse and circulating nurse; outside operating assistant​​
​​​Recovery of patients	​​ ​​recovery unit​ ​				extubate and recover in operating theatre

  Notes

1. PPE: All include standard precautions. Droplet includes contact. Airborne includes droplet and contact.
2. COVID-19 risk is based on local health district definitions.
3. The AGP list may change based on evidence and/or local definitions.
4. Apply a surgical mask to the at risk COVID-19 patient if they are able to tolerate it (until anaesthetic induced).
   
5. Operating assistants and staff not involved in the procedure are expected to be outside the operating theatre during the procedure. If they must return to the theatre in the 30 minutes following an AGP, appropriate PPE is required.
   
6. Medical imaging, allied health staff and surgical representatives should be outside the operating theatre during an AGP.
   
7. COVID-19 patients having a procedure under regional anaesthesia are managed with droplet precautions.​

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COVID-19 procedural PPE: high facility risk assessment ¹

​​​Patient COVID-19 risk 2	​​​​Lo​w				​Suspect, probable or confirmed​
AGP 3​​	​​No		​Low risk	​High risk​	No​	​High or low risk 7
Patient​	​surgical mask 4				surgical mask 4
​Anaesthetist  (and assistant)	droplet		airborne​		droplet​	​airborne  optional PAPR
​Anaesthetic nurse​	droplet		airborne​		droplet​	airborne  optional PAPR
​Instrument or  circulating nurse	​droplet		​​​airborne​		droplet​	​airborne  optional PAPR
​Surgical team	droplet		​airborne​		​droplet​	airborne  optional PAPR
​Operating assistants 5	​​​droplet		airborne​		​droplet​	airborne
​Recovery nurse	​​droplet		airborne​		​droplet​	airborne
​Medical imaging or  allied health staff 6	droplet		​airborne​ ​		​​droplet​​	​airborne
​Surgical representatives 6	​​​droplet​​​		​​airborne		​droplet​​	​airborne
​​Operating theatres	COVID-19 theatres​​				COVID-19 theatres​​
Patient transportation​​	​​droplet				droplet
​Perioperative staff  requirements	​outside anaesthetic nurse and circulating nurse; outside operating assistant				outside runner for the theatre team
​​Recovery of patients​	extubate and recover in operating theatre​				extubate and recover in operating theatre

 Notes

1. PPE: All include standard precautions. Droplet includes contact. Airborne includes droplet and contact.
   
2. COVID-19 risk is based on local health district definitions.
3. The AGP list may change based on evidence and/or local definitions.
4. Apply a surgical mask to the at risk COVID-19 patient if they are able to tolerate it (until anaesthetic induced).
5. Operating assistants and staff not involved in the procedure are expected to be outside the operating theatre during the procedure. If they must return to the theatre in the 30 minutes following an AGP, appropriate PPE is required.
6. Medical imaging, allied health services and surgical representatives should be outside the operating theatre during an AGP.
7. COVID-19 patients having a procedure under regional anaesthesia are managed with droplet precautions.

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Aerosol generating procedures in relation to COVID-19

COVID-19 is a respiratory tract infection predominantly transmitted by large droplets. ⁱⁱ  Contact and droplet precautions are therefore recommended during routine care of patients with suspected, probable or confirmed COVID-19. ^ii, v  AGPs may need to be performed during the care of these patients. AGPs may lead to the production of droplet nuclei (<5 micrometres in size) or airborne particles (aerosols) due to air or gas flowing rapidly over a moist or wet surface.^vi There are many procedures that may be aerosol generating but whether they lead to an increased risk of respiratory infection transmission is evolving.

In addition to the nature of the procedure itself, the overall risk of transmission of SARS-CoV-2 is also associated with the viral load in the body fluid potentially being aerosolised, and whether the virus is intact and capable of causing infection (which is an important distinction, since many body fluid, airsampling and environmental studies use methods that detect any viral RNA rather than intact, infective virus). 

Studies have shown that SARS-CoV-2 is most commonly detected in respiratory tract samples (lower greater than upper)in those who are infected; thus procedures involving potential exposure to respiratory tract secretions or tissues are of particular relevance with respect to the risk of COVID-19 transmission. ^vii  SARS-CoV-2 has also been detected in nonrespiratory specimens, in particular stool and to a lesser extent blood and ocular secretions, but the role of these sites in transmission is uncertain. Of note, faecal-oral transmission has not been clinically described, and does not appear to be a significant factor in the spread of infection. ^viii

With respect to COVID-19, high risk AGPs are those associated with production of respiratory tractgenerated aerosols. These procedures have the potential to pose an airborne transmission risk of SARS-CoV-2 and therefore airborne precautions are recommended. High risk AGPs should be performed with the minimum number of personnel present and where possible, the most qualified person should carry out the procedure. In contrast, low risk AGPs for COVID-19 transmission or procedures not associated with the potential to produce aerosols, can be performed using contact and droplet precautions, as​ indicated for the routine care of suspected, probable or confirmed cases of COVID-19. In general, it is recommended that nebulised medication is avoided in favour of metered dose inhaler and spacer use. If a COVID-19 patient requires an AGP for optimal care, the procedure should be performed, with institution of appropriate infection control precautions which will minimise risk to staff. See Table 1 for examples of AGPs of varying risk based on current evidence and expert opinion, including considerations of biological plausibility. ^ix, x  It must be noted that at present, the evidence is limited and these classifications may change as new data emerge. For guidance regarding other specialised procedures related to allied health interventions, please refer to the CEC website. 

Cardiopulmonary resuscitation (CPR) is complex in terms of assessing AGP risk. While many procedures (e.g. intubation), undertaken during the course of CPR, are considered high risk AGPs, it is uncertain whether chest compressions or defibrillation result in aerosol generation or transmission of COVID-19. There is very limited, poor quality data in the current literature concerning this issue. ^ix, xi  In many reports, it is likely that  there was simultaneous exposure to airway manoeuvres, such that the isolated effect of either chest compressions or defibrillation could not be reliably identified. In the setting of low rates of community transmission of COVID-19, chest compression and defibrillation are unlikely to pose a risk to first responders who start CPR, without knowledge of the subject’s COVID-19 status. ⁱⁱ

Healthcare workers can safely start chest compression or defibrillation of a patient with suspected, probable or confirmed COVID-19 using contact and droplet precautions, until another clinician arrives, using airborne precautions, to manage the airway. ii

Table 1: Examples of aerosol generating procedures classified according to risk of airborne transmission of SARS-CoV-2​

​​Procedure​​​​​​	High risk AGPs​​	​​Low risk AGPs or not AGPs
​Airway interventions​	tracheal intubation or extubation manual bag-mask ventilation1 non-invasive ventilation1 tracheostomy or tracheotomy (insertion and removal)1 laryngeal mask or supraglottic airway intentional or inadvertent disconnection or reconnection of closed ventilator circuit high flow nasal oxygen2 open-suctioning of airways​	​mechanical ventilation via closed circuit​
Procedures involving the respiratory tract​	sputum induction3 bronchoscopy thoracic surgery involving the lung maxillofacial surgery ear, nose and throat procedures that involve suctioning or high-speed drilling, including transphenoidal surgery​	​swabbing of upper respiratory tract examination of the throat, eyes or ears without invasive instrumentation nasendoscopy​
​Other procedures	​procedures that involve open suctioning of the upper airways (e.g. gastroscopy with suctioning) dental procedures with high-speed drilling post-mortem procedures involving high-speed devices on the respiratory tract​	​insertion of a nasogastric tube transoesophageal echocardiogram colonoscopy laparoscopic surgery orthopaedic procedures with saws, drills or large volume washouts​​

Evidence base

This document has been developed through review of published literature, clinical guidelines from domestic and international organisations, sourced in April and May 2020, defining suitable personal protective equipment in surgical care during the COVID-19 pandemic. This published evidence was supplemented with experiential evidence from subject matter experts to specify the protective equipment suitable for various surgical and perioperative care team members.

A sub-committee of the Surgery Community of Practice developed the document, with further input from the broader Surgery Community of Practice and Anaesthesia Community of Practice. This was obtained through virtual consultation with members with expertise in surgical services, anaesthesia, quality and safety, perioperative care, nursing and allied health over a period of four weeks. Further targeted consultation with the Clinical Excellence Commission led to the inclusion of advice relating to aerosol generating procedures. The final document was approved by the Clinical Leads of the Surgery and Anaesthesia Communities of Practice.​

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References

• i. Commonwealth Department of Health. Coronavirus Disease 2019 (COVID-19): CDNA National Guidelines for Public Health Units​. Canberra; Dept of Health; 2020.
• ii. Commonwealth Department of Health. Guidance on the use of personal protective equipment (PPE) in hospitals during the COVID-19 outbreak​. Canberra: Australian Government; 2020.
• iii. Clinical Excellence Commission. Infection Prevention and Control Practice Handbook​. Sydney: CEC; 2020.
• iv. Clinical Excellence Commission. Transmission-Based Precautions​​
• v. Clinical Excellence Commission. Personal protective equipment​. Sydney: CEC; 2020. Accessed 5 June 2020.
• vi. World Health Organization. Infection prevention and control of epidemic-and pandemic prone acute respiratory infections in health care​. WHO guidelines. WHO; 2014
• vii. Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in Different Types of Clinical Specimens. JAMA. 2020;323:1843‐44.doi:10.1001/jama.2020.3786.
• viii. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-2019)​. February 16-24, 2020.
• ix. Tran K, Cimon K, Severn M, et al. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012;7:e35797. doi:10.1371/journal.pone.0035797.
• x. Health Protection Scotland Literature Review. Assessing the evidence base for medical procedures which create a higher risk of respiratory infection transmission from patient to healthcare worker​. 12 May 2020.
• xi. Couper K, Taylor-Phillips S, Grove A, et al. COVID-19 in cardiac arrest and infection risk to rescuers: A systematic review. Resuscitation. 2020;151:59-66.

Other Publications

• Judson SD, Munster VJ. Nosocomial transmission of emerging viruses via aerosol-generating medical procedures. Viruses. 2019;11:940. doi:10.3390/v11100940.
• Lim WS, Anderson SR, Read RC, et al. Hospital management of adults with severe acute respiratory syndrome (SARS) if SARS re-emerges - updated 10 February 2004. J Infect. 2004; 49:1‐7. doi:10.1016/j.jinf.2004.04.001.
• Christian MD, Loutfy M, McDonald LC, et al. Possible SARS coronavirus transmission during cardiopulmonary resuscitation. Emerg Infect Dis. 2004;10:287‐293. doi:10.3201/eid1002.030700.
• Nam HS, Yeon MY, Park JW, et al. Healthcare worker infected with Middle East Respiratory Syndrome during cardiopulmonary resuscitation in Korea, 2015.
• Epidemiol Health. 2017;39:e2017052. doi:10.4178/epih.e2017052​.

Acknowledgements

​This tool has been adapted from:

• Nepean Blue Mountains Local Heath District PPE for Surgery
• Northern Sydney Local Health District Facility Risk Matrix​.

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Document information

Developed by

Surgery community of practice​.

Consultation

• Anaesthesia community of practice
• NSW Ministry of Health
• Clinical Excellence Commission​.

Endorsed by

Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning, NSW Ministry of Health.

For use by

• District and Network Chief Executives
• Directors of Medical Services
• Clinical Directors of Surgery
• Surgery Operations Manager​s
• Departments of Anaesthesia and Perioperative Service​.​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​