Bristol research transforms Scottish infection control guidelines

The AERATOR (Aerosolisation and transmission of SARS-CoV-2 in healthcare settings) study took place during the COVID-19 pandemic. It aimed to understand whether so-called aerosol generating procedures, such as inserting a breathing tube, produced aerosols in significant numbers.

AERATOR was led by anaesthetic, intensive care, infectious disease and respiratory clinicians at Southmead Hospital and aerosol scientists at the University of Bristol. The study was supported by the National Institute for Health and Care Research Biomedical Centre (NIHR BRC) Bristol. 

Respiratory aerosols are tiny droplets produced when people breathe, talk and cough. They are the main way respiratory infections such as COVID-19 are transmitted. 

The team used PLUME (Portable low-background unit for measuring exhaled aerosol), a cutting-edge device to monitor aerosol production in real time in ultraclean theatre environments usually used for orthopaedic and neurosurgery. This enabled them to study aerosols in a healthcare setting for the first time. 

The study found that most of the aerosol generating procedures considered high risk produced less aerosol emission than coughing or talking. 

Based on this and other evidence, Public Services Delivery Scotland has published updated transmission-based precautions guidance. Reflecting the latest evidence on how respiratory infections spread, the guidance introduces a more consistent, risk-based approach to infection prevention and control across Scotland’s NHS Boards, care homes and wider health and care settings. 

The guidance moves on from procedure-focussed risk assessment to a more holistic consideration of the type of respiratory infection, the patient’s symptoms and the healthcare professional’s exposure and own risk factors. This has effectively ended the use of the term ‘aerosol generating procedure’ in risk assessments. It will lead to a major change in how personal protective equipment (PPE) is deployed in healthcare settings. 

Wales has followed Scotland’s lead and adopted the same risk-based approach. Whilst the English guidelines were the first to remove some of the procedures from the original aerosol generating procedures list, they are yet to drop the list completely.

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Source: NHS Bristol Foundation Trust, 14 September 2026