Aerosol-generating procedures may have contributed to the spread of a recent COVID-19 outbreak at a Bremerton hospital, which has confirmed at least 70 infections, according to a new report from the state Department of Health.

According to the findings, the outbreak at St. Michael Medical Center — one of CHI Franciscan’s 10 hospitals in Washington state — could possibly be traced to procedures performed on asymptomatic COVID-19 patients. The report, which said 54 cases had been confirmed when the findings were finalized, also stated that hospital staff were using personal protective equipment (PPE) longer than recommended by current national guidelines. 

The report also cites the timing of room turnover as another possible reason for exposure.

“Some staff present for (aerosol generating procedures) were not wearing N95s, only surgical masks and eye protection,” the report said. “Shorter than recommended room turnover may have exposed patients and staff. The rooms were left empty for < two hours and (aerosol generating procedures) were performed in rooms without negative air pressure, which conflicts with (hospital) policy.”

While it wasn’t immediately clear what kinds of procedures were potentially at fault at St. Michael, aerosol-generating procedures often include intubation, extubation, transesophageal echocardiography or endoscopy, according to University of Washington Medicine. It was also not immediately clear from hospital officials Thursday evening why PPE had been used for longer periods than recommended.

The DOH report, finalized over the past week, also identified several areas “requiring immediate action,” including considering admitting oncology patients to hospitals without outbreaks, prioritizing testing staff members with the most vulnerable patients and providing additional staffing resources to assist with employee case investigations and infection prevention.

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The hospital should, according to the report, also halt nonessential surgical procedures until staff testing is completed, hold off on using a float staff that moves from unit to unit, train its staff to socially distance while in break rooms or other congregation spaces, and — if possible — create a unit specifically for exposed patients, among other recommendations. 

“We sincerely value our ongoing partnership with the Washington State Department of Health and Kitsap County Public Health as we continue to care for our patients and staff during the recent outbreak of COVID-19 at St. Michael Medical Center,” wrote Cary Evans, CHI Franciscan vice president for communication and government affairs, in a statement Thursday.We are working to address any concerns in implementing CDC and state guidelines.”

Evans said the hospital already has implemented several of DOH’s recommendations, including honing in on education and retraining of industry standards developed by the Centers for Disease Control and Prevention, increasing its number of N95 masks and other PPE, establishing more resources to fit N95s for employees, boosting resources for contact tracing and reviewing its supply of air-purifying respirators.

The hospital notified the Kitsap Public Health District of its first case — in an employee — on Aug. 4. On Aug. 13, five more cases were connected with one unit at St. Michael, and Kitsap Public Health declared an outbreak the next day. 

Kitsap Public Health confirmed last week that it would test all 2,500 hospital employees. Of the 70 cases, 45 are hospital employees, 23 are patients and one is someone who was at the hospital but wasn’t a staff member or patient, the Kitsap Public Health District said Thursday.

As of Thursday evening, several St. Michael employees had been cleared by Kitsap Public Health to return to work, Evans wrote, reducing the hospital’s number of quarantined staffers. About 120 employees are currently quarantining “out of an abundance of caution” and more than 2,300 staffers have been tested, according to the hospital’s community update page.

“As we face continued community transfer during this global pandemic, our priority is to meticulously follow all public health guidelines to provide the safest care possible to prevent any further spread inside St. Michael, and we are grateful for the tireless and selfless efforts of all of employees,” Evans wrote.