Summary of CDC recommendations relevant for sleep practices during COVID-19

Updated Aug. 27, 2020

The AASM is issuing this summary to help sleep medicine clinicians implement the Centers for Disease Control and Prevention (CDC) recommendations in response to the spread of SARS-CoV-2, the virus that causes the novel coronavirus disease 2019 (COVID-19). During the COVID-19 public health emergency, the American Academy of Sleep Medicine (AASM) advises sleep clinicians to follow the recommendations of the CDC as well as additional policies, guidance and/or mandates from state and local health departments and your local hospital, health system, institution or jurisdictions.

The treating clinician, medical leadership, and the patient, taking into consideration the individual circumstances of the patient, staff members, available treatment options, and resources, must make the ultimate judgment regarding any specific care.

Summary of Changes

This summary, developed by the AASM COVID-19 Task Force, is based on current guidance available from the CDC in its Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. The CDC updated these recommendations on July 15 and reorganized them to include recommended infection prevention and control practices for routine health care delivery during the pandemic. Sleep-related topics from the previous AASM COVID-19 mitigation strategies are now addressed by the AASM COVID-19 Task Force as consensus guidance in the Considerations for the Practice of Sleep Medicine During COVID-19, based on the CDC recommendations updated July 15, 2020.

Framework for Care

The CDC notes that the pandemic has caused the under-utilization of important medical services for patients with non-COVID-19-related urgent or emergency health needs. Therefore, facilities must balance the need to provide necessary services while minimizing risk to patients and health care personnel. Facilities should consider the potential for patient harm if care is deferred when making decisions about providing elective procedures, surgeries, and non-urgent outpatient visits. Refer to the CDC’s Framework for Healthcare Systems Providing Non-COVID-19 Clinical Care During the COVID-19 Pandemic for additional guidance. The Centers for Medicare & Medicaid Services (CMS) also has posted Phase I and Phase II recommendations for reopening facilities to provide non-emergent, non-COVID-19 health care.

  • Use telehealth strategies to provide high-quality patient care and reduce the risk of COVID-19 transmission in health care settings. Note: During this public health emergency, Medicare is expanding coverage for telemedicine services and waiving requirements for face-to-face or in-person encounters.
  • When scheduling appointments for routine medical care, instruct patients to call ahead and discuss the need to reschedule their appointment if they have symptoms of COVID-19 on the day they are scheduled to be seen.
  • Screen everyone who enters the health care facility (e.g., health care providers, patients, visitors) for symptoms consistent with COVID-19 or exposure to others with COVID-19.
    • Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is either measured temperature ≥100.0°F or subjective fever.
  • Use signs, tape marks, or other visual cues such as decals or colored tape on the floor, placed 6 feet apart, to show where to stand when physical barriers are not possible.
  • Patients and visitors should, ideally, wear their own cloth face covering (if tolerated) upon arrival to, and throughout their stay in, the facility. If they do not have a face covering, they should be offered a facemask or cloth face covering, as supplies allow.
    • Masks should not be worn by children younger than 2 years old; anyone who has trouble breathing; anyone who is unconscious, incapacitated, or otherwise unable to remove the mask without assistance.
  • COVID-19 testing might be used to identify those with asymptomatic or pre-symptomatic infection, depending on guidance from local and state health departments, testing availability, and how rapidly results are available. Facilities can consider implementing pre-admission or pre-procedure diagnostic testing with authorized nucleic acid or antigen detection assays.
  • Health care providers should wear a facemask at all times while they are in the health care facility, including in break rooms or other spaces where they might encounter co-workers, unless performing activities that require an N95 or equivalent or higher-level respirator.
  • During patient encounters, clinicians should wear eye protection (i.e., goggles or a face shield that covers the front and sides of the face) in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions.
    • Protective eyewear (e.g., safety glasses, trauma glasses) with gaps between glasses and the face likely do not protect eyes from all splashes and sprays.
    • Face shields are generally worn in addition to a mask; used alone, they still allow leakage of exhaled air around the sides and bottom of the shield.
    • Face shields or goggles should be worn over glasses to provide appropriate protection.
  • During aerosol-generating procedures, clinicians should wear eye protection and a NIOSH-approved, N95 or equivalent or higher-level respirator (instead of a facemask).
    • The CDC highlights three key factors for an N95 respirator to be effective.
    • Perform a user seal check to ensure proper fit each time an N95 is used.
    • Personnel with expected use of N95 respirators will need fit testing prior to use in accordance with OSHA 1910.134. However, facilities can consider temporarily suspending annual fit testing during the COVID-19 outbreak in times of expected shortages, as long as health care providers have undergone an initial fit test with the same model, style, and size.
  • For areas with minimal to no community transmission of COVID-19, eye protection is considered optional, unless otherwise indicated as part of standard precautions or per local or hospital policies. For areas with minimal to no community transmission, the use of eye protection and/or an N95 or equivalent or higher-level respirator should be based on anticipated exposures and suspected or confirmed diagnoses.

Cleaning & Disinfection

  • All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer’s instructions and facility policies.
  • Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol generating procedures are performed.
    • Refer to List N on the EPA website for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program for use against SARS-CoV-2.

Protection from aerosol-based transmission

  • The CDC states that health care workers should, “Explore options to improve indoor air quality in all shared spaces. Optimize air-handling systems (ensuring appropriate directionality, filtration, exchange rate, proper installation, and up to date maintenance). Consider the addition of portable solutions (e.g., portable HEPA filtration units) to augment air quality in areas when permanent air-handling systems are not a feasible option.”
  • In addition to ensuring sufficient time for enough air changes to remove potentially infectious particles, health care personnel (HCP) should clean and disinfect environmental surfaces and shared equipment before the room is used for another patient. The recommendations below are from the CDC’s Clinical Questions about COVID-19: Questions and Answers:
    • The CDC states that, “Although spread of SARS-CoV-2 is believed to be primarily via respiratory droplets, the contribution of small respirable particles to close proximity transmission is currently uncertain. Airborne transmission from person-to-person over long distances is unlikely.
    • “The amount of time that the air inside an examination room remains potentially infectious is not known and may depend on a number of factors including the size of the room, the number of air changes per hour, how long the patient was in the room, if the patient was coughing or sneezing, and if an aerosol-generating procedure was performed. Facilities will need to consider these factors when deciding when the vacated room can be entered by someone who is not wearing PPE.
    • “For a patient who was not coughing or sneezing, did not undergo an aerosol-generating procedure, and occupied the room for a short period of time (e.g., a few minutes), any risk to HCP and subsequent patients likely dissipates over a matter of minutes. However, for a patient who was coughing and remained in the room for a longer period of time or underwent an aerosol-generating procedure, the risk period is likely longer.
    • “For these higher risk scenarios, it is reasonable to apply a similar time period as that used for pathogens spread by the airborne route (e.g., measles, tuberculosis) and to restrict HCP and patients without PPE from entering the room until sufficient time has elapsed for enough air changes to remove potentially infectious particles.
    • General guidance on clearance rates under differing ventilation conditions is available.

Learn more from the CDC about air quality and air changes/hour.

For questions or to provide feedback, please contact the AASM at covid@aasm.org.