Anaesthetists' current practice and perceptions of aerosol‐generating procedures: a mixed‐methods study

Summary The evidence base surrounding the transmission risk of ‘aerosol‐generating procedures’ has evolved primarily through quantification of aerosol concentrations during clinical practice. Consequently, infection prevention and control guidelines are undergoing continual reassessment. This mixed‐methods study aimed to explore the perceptions of practicing anaesthetists regarding aerosol‐generating procedures. An online survey was distributed to the Membership Engagement Group of the Royal College of Anaesthetists during November 2021. The survey included five clinical scenarios to identify the personal approach of respondents to precautions, their hospital's policies and the associated impact on healthcare provision. A purposive sample was selected for interviews to explore the reasoning behind their perceptions and behaviours in greater depth. A total of 333 survey responses were analysed quantitatively. Transcripts from 18 interviews were coded and analysed thematically. The sample was broadly representative of the UK anaesthetic workforce. Most respondents and their hospitals were aware of, supported and adhered to UK guidance. However, there were examples of substantial divergence from these guidelines at both individual and hospital level. For example, 40 (12%) requested respiratory protective equipment and 63 (20%) worked in hospitals that required it to be worn whilst performing tracheal intubation in SARS‐CoV‐2 negative patients. Additionally, 173 (52%) wore respiratory protective equipment whilst inserting supraglottic airway devices. Regarding the use of respiratory protective equipment and fallow times in the operating theatre: 305 (92%) perceived reduced efficiency; 376 (83%) perceived a negative impact on teamworking; 201 (64%) were worried about environmental impact; and 255 (77%) reported significant problems with communication. However, 269 (63%) felt the negative impacts of respiratory protection equipment were appropriately balanced against the risks of SARS‐CoV‐2 transmission. Attitudes were polarised about the prospect of moving away from using respiratory protective equipment. Participants' perceived risk from COVID‐19 correlated with concern regarding stepdown (Spearman's test, R = 0.36, p < 0.001). Attitudes towards aerosol‐generating procedures and the need for respiratory protective equipment are evolving and this information can be used to inform strategies to facilitate successful adoption of revised guidelines.


Introduction
When SARS-CoV-2 emerged in 2019, it spread rapidly and overwhelmed healthcare services in Wuhan and parts of northern Italy. The predominant modes of disease transmission were thought to be via droplets >5 lm diameter and fomites. Airborne transmission was only considered to occur during medical interventions classified as aerosol-generating procedures (AGP) [1]. Medical practitioners with advanced airway skills were deemed to be at very high risk of contracting COVID-19 due to their performance of AGPs [2]. This message was forcefully imparted on the anaesthetic workforce and the importance of wearing airborne protection personal protective equipment (PPE) for all AGPs was reinforced [3].
Our understanding of the viral dynamics and patterns of SARS-CoV-2 transmission has increased substantially over the course of the pandemic, including the recognition that airborne transmission occurs in the absence of AGPs [4,5]. Emerging clinical aerosol evidence has demonstrated that many AGPs generate less aerosol than natural respiratory activities, such as breathing and coughing [6][7][8][9][10][11], and epidemiological evidence indicates anaesthetists and intensivists may have a lower risk of infection and hospitalisation compared with other frontline healthcare workers [12]. The AGP framework likely impacts on healthcare efficiency and quality, and presents a challenge to addressing the backlog of patients waiting for elective surgery, which in the UK exceeds 6 million people [13]. With the accumulation of evidence around aerosol generation risk from AGPs, there is likely to be a reappraisal of UK infection prevention and control (IPC) guidance.
Changes to guidance may be welcomed by some healthcare workers but generate anxiety in others and this may lead to issues with rollout and implementation. The views of practicing anaesthetists towards existing AGP guidance and possible revision are unknown. This study aims to explore perceptions about the management of AGPs, attitudes to potential guideline alterations and consequent practice change.

Methods
This was a mixed-methods study, comprising a survey disseminated to UK anaesthetists followed by qualitative    Responses were screened for duplicates before analysis. Descriptive analysis was performed using R for respondent characteristics, Likert scale responses and response rates (https://www.R-project.org). Thematic analysis was performed on comments from the free-text sections that allowed respondents to provide additional commentary [16]. Respondents were given the option to submit their email address if they consented to additional contact for qualitative interviews to discuss their perceptions in more detail. This qualitative component enabled exploration of perceptions in greater depth than could be done by the survey alone. Purposeful sampling was used to obtain an initial group of 12 participants that represented the spectrum of respondent characteristics and level of concern about AGPs. Further sampling was driven by the intention to ensure representation across the range of participant characteristics and to achieve data saturation. Following informed consent, semi-structured interviews were conducted and recorded via webconferencing software by a single investigator (CO). A topic guide (designed by CO, AS, AEP and LR before interviewing) was piloted in an interview not included in the final dataset. The topic guide was used to ensure similar areas were explored across all interviews. Audio recordings were transcribed verbatim and imported into NVivo (V12; QSR International Pty Ltd., Daresbury, Cheshire) to support analysis.
Data were analysed thematically, using a grounded constant comparison method [17]. Data analysis occurred concurrent with data collection, to allow emerging findings to inform subsequent data collection efforts through iterations of the topic guide, which underwent four revisions. Individual features of the text (codes) were derived from the raw data inductively. Codes were iteratively developed into themes, by grouping together codes with similar or connected meaning. The process was iterative because theme names, sub-themes and overarching themes evolved as analysis progressed and previously coded transcripts were re-examined considering later data collection [16][17][18]. The study team met regularly throughout the process of data collection and analysis to      (online Supporting Information, Table S1, quotes 7-9).
Interviewees had divergent perspectives on the concept of AGPs. Tracheal intubation was the most contentious as to whether it was high risk and whether it should be classed as an AGP. Some interviewees believe tracheal intubation carries a higher risk of SARS-CoV-2 transmission than speaking to a patient pre-operatively.
However, many felt this increased risk was not from the procedure but from being near the patient, and their airway.
Others felt administering neuromuscular blocking drugs reduced the risk of aerosol generation as the patient was then unable to breathe or cough (online Supporting Information,

Attitudes to change in guidance
Of those surveyed, 112 (34%) were comfortable or keen to move away from using RPE during airway management of Many reported the pandemic and IPC guidelines had changed their practice. Some performed more`deep´t racheal extubations and supraglottic airway device removals to reduce the risk of coughing, while others attempted to avoid AGPs entirely by using more regional or awake techniques. Supraglottic airway device use was more polarised with some avoiding their use as they felt the airway was not secure which was perceived to carry a higher risk of aerosol generation. However, others used supraglottic airway devices more frequently as their use has never been defined as an AGP. The increased use of videolaryngoscopy was frequently mentioned in both the free-text comments and during interviews, and many interviewees stated they performed more rapid sequence inductions to avoid facemask ventilation (online Supporting Information, Table S4, quotes 1,2).
Theme 2: change in perceptions over timè`T he Italian intensivists were seen to be falling apart on live TV almost and that was shocking and greatly concerning and we also thought this terrible thing was coming to us and no one really knew what your personal risk was going to be´´(AE5).
Underpinning perceptions of risk identified by the survey, many interviewees recounted the degree of fear and concern they felt at the start of the pandemic. A key theme to emerge from the qualitative interviews was the temporal changes in their personal perceptions of risk which generally reduced as the pandemic evolved (online Supporting Information, Table S4, quotes 3-6). This The impact of the COVID-19 pandemic on training was frequently raised during interviews and in the survey freetext comments. One trainee commented that many senior anaesthetists had altered their pre-pandemic practice to avoid performing AGPs (online Supporting Information,   reduced virulence were understood. This was following a period of heightened concern regarding the Delta variant.
The qualitative interviews were conducted during the period when Omicron BA.1 was the most common variant.
All these factors may have had an impact on perception of COVID-19 severity. We had a low survey response rate and

Supporting Information
Additional supporting information may be found online via the journal website.
Appendix S1. Original survey questions and link. Table S1. Awareness and perceptions of aerosolgenerating procedure guidelines. Table S2. Impact of COVID aerosol-generating procedure guidelines on practice. Table S3. Personal perception of risk. Table S4. Emergent qualitative themes.