The Effectiveness and Compliance of Surgical Face Mask Wearing in the Operating Suite Environment: an Integrated Review

Volume 33 Issue 4 Article 2

11-9-2020

The effectiveness and compliance of surgical face mask wearing in the operating suite environment: An integrated review

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Recommended Citation Ogo, Noriko and Foran, Paula (2020) "The effectiveness and compliance of surgical face mask wearing in the operating suite environment: An integrated review," Journal of Perioperative Nursing: Vol. 33 : Iss. 4 , Article 2. Available at: https://doi.org/10.26550/2209-1092.1105 https://www.journal.acorn.org.au/jpn/vol33/iss4/2

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Authors Noriko Ogo The effectiveness and compliance MCN (Perioperative Nursing), BN, RN, MACORN of surgical face mask wearing in Dr Paula Foran PhD, RN, FACORN, FACPAN, MACN the operating suite environment: An integrated review Abstract Problem identification: Surgical face masks have been used for over a century in the operating room (OR); firstly, as it has been believed that they may reduce surgical site infections (SSIs) in patients and, secondly, as personal protective equipment (PPE) for staff. However, recent studies have reported disparities in the efficacy of wearing surgical face masks including inconsistency in their use. This integrative review aims to investigate the effects of surgical masks in the OR, in regard to maintaining both patient and staff safety, and will discuss compliance or lack thereof in face mask usage for the entire multidisciplinary team. Literature search: Four electronic health databases were used to identify the relevant research: CINAHL, Medline, EMCare and Cochrane Library. The reference lists of retrieved articles were also manually searched and appropriate literature retrieved. Data evaluation synthesis: Inclusion and exclusion criteria were used revealing that 15 articles fully met the criteria which were critiqued (see Table 2 in Supplemental material for the literature matrix). Implications for practice: SSIs are multifactorial and no reviewed studies looked at causative considerations such as comorbidities and other variables (such as hypothermia) which could all contribute to this post-operative complication. However, there is evidence to suggest that surgical face masks are useful in decreasing the biological load in the theatre environment. They are also a vital piece of PPE that should be worn to protect the perioperative team from blood and bodily fluid splatter that commonly occur. Keywords: surgical mask, surgical site infection, PPE, operation theatre, staff compliance Introduction length of hospitalisation, the cost of care, mortality and morbidity2. Since Traditionally there are two reasons surgical masks were introduced as for staff to wear surgical masks in the a preventive practice for SSIs, over a OR: firstly, to protect surgical sites hundred years ago, they have been from microorganisms transferred used to provide a physical barrier from the faces and respiratory tract between the mouth and nose of of scrubbed staff and, secondly, to health care personnel and surgical protect health care professionals wounds of patients3. from sprays and splashes of patients’ blood and body fluids during Problem identification surgery1. Surgical site infections (SSIs) contribute to the increase in Despite the long-standing use of the burden of both patients and surgical face masks to prevent wound health care systems by increasing the infection, a Cochrane systematic

Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au e-11 review conducted by Da Zhou, Personnel have a duty to: comprehensive understanding of Sivathondan and Handa4 in 2015 particular problems in health care • wear disposable, high filtration concluded there was no statistically settings7,8. It incorporates a five- masks: significant difference in the risk stage process comprising problem of SSIs between two cohorts, one • whenever a sterile/aseptic field is identification, literature search, masked and one non-masked. In the being prepared or maintained data evaluation and synthesis, data following year a second Cochrane • in the restricted areas during integration, and results presentation 7 systematic review by Vincent and surgical procedures and discussion . Edwards was published which investigated the same question; • whenever there is risk of blood or Literature search methods body fluid splash however, their research only included To identify research on the effect 5 ‘clean’ surgical procedures . The • wear masks that meet the of wearing surgical masks in the cohort (n= 653) included patients Australian standards perioperative environment and the who underwent ‘clean’ surgery – compliance and behaviour of theatre • select the appropriate mask for the where the respiratory, alimentary, staff, electronic health database surgical procedure or infectious genital or urinary tracts, that may searches of the literature were nature of the patient, and contain bacteria, were not surgically conducted using CINAHL, Medline, 5 treated . Armed with the knowledge • apply the mask securely to EMCare and Cochrane Library. The that there may be a lower risk of SSIs completely cover the nose and reference lists of retrieved articles when conducting ‘clean’ surgery, it mouth were also manually examined to was hypothesised that the formation • secure the mask according to identify additional research papers of a SSI in this cohort would make relevant to the topic. it more reasonable to attribute an manufacturer’s instructions and infection to other factors such as avoid touching the mask once it The initial search was limited to a higher airborne bacterial load is applied studies published between 2015 from the use or non-use of surgical • remove the mask completely and 2020 and written in English. face masks. However, results of this when it is no longer required, One salient paper from 2013 was research were inconclusive, and it touching only the tapes/elastic, subsequently retrieved. was unclear whether the use of a and discard into the appropriate surgical face mask impacted the receptacle Inclusion and exclusion occurrence of SSIs in clean surgery5. criteria • perform hand hygiene following Standards for Perioperative Nursing mask disposal Inclusion criteria included peer in Australia (the ACORN Standards) reviewed articles that reported the • avoid hanging masks around the states that surgical masks should be effects of the use of a surgical mask neck when not in use. worn in operating theatres during in the OR, those that investigated procedures, when proximal to open the efficacy of wearing surgical sterile or aseptic clinical supplies Figure 1: Criteria 6.1–6.3 from ACORN masks, and those that investigated and when there is a risk of blood standard ‘Perioperative attire’ the compliance and behaviour of or body fluid splash6. Although This integrative review aims to operating theatre staff towards there are detailed criteria about investigate the effects of wearing wearing surgical masks. the use of surgical masks in the surgical masks in the OR, and related Exclusion criteria included studies ACORN Standards (Figure 1), ACORN compliance and behaviours of the that focused on a surgical helmet acknowledges that using a surgical multidisciplinary perioperative team. system, theatre traffic and respiratory mask remains controversial in some infections. The terms used to conduct health care settings and conflicting Literature search the search in the databases were 6 evidence may exist . ACORN further based on the PICO (population, suggests that individual health care Design intervention, comparison, outcome) settings should make their decision This review follows an integrative acronym, and Boolean operators on best available evidence and approach which enables a ‘OR’ and ‘AND’ were used to combine clinician’s judgment6. broad review of the available synonyms and concepts of the PICO literature. It includes various respectively. Terms were surgical study methodologies to provide a mask OR surgical facemask AND

e-12 Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au Additional records identified through Records identified through database manual searching the reference lists of searching included articles (n =90) (n = 11) Identification

Records screened Records excluded including duplicates (n = 101) (n = 65) Screening

Full-text articles assessed for eligibility Full-text articles excluded, with reasons (n = 36) (n = 21) Eligibility

Studies included in quantitative synthesis (meta-analysis) (n = 15) Included

Figure 2: PRISMA flow diagram of search strategy surgical site infection OR surgical and critiquing process, 15 articles relevant critical appraisal skills wound contamination, with the remained for this review. programme (CASP) checklists10,11. RCTs article title, abstracts and body. provide the strongest evidence for a single study with minimal bias8. Articles that met the study inclusion Data evaluation and However, only one RCT was found criteria were summarised within synthesis as it is considered unethical, due the PRISMA (Preferred reporting to personal risk, for surgical staff items for systematic reviews and Data evaluation to be randomly controlled to wear meta-analyses) flowchart (Figure 2)9. The studies discussed in this or not wear surgical masks during Ninety articles were initially retrieved review employed different procedures. from the electronic health database methodologies including systematic search and additional articles were review, randomised controlled A literature matrix was used to added by manual searching of the trial (RCT), comparative study with organise and critique the chosen reference lists and subsequent concurrent control, observational literature and is attached as citations of the retrieved articles. study, retrospective cohort study supplemental material. After removing duplicates and papers and literature review. The retrieved that failed the inclusion criteria articles were appraised using the

Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au e-13 Data extraction Results presentation and centimetres or longer in length (p < 0.03) although there was no The extracted data included the discussion statistical evidence that a bearded authors, year of publication, country clinician increased the risk of SSIs of research, study aims, study design, Reduction in aerosol colony- by bacterial shedding while wearing level of evidence using National forming units (CFU) in the OR a surgical face mask (p < 0.9)15. Health and Medical Research Council A recent experimental study by Interestingly, the addition of wearing (NHMRC) hierarchy of evidence, Howard et al. investigated the use a non-sterile surgical balaclava hood results and conclusions12. Limitations of different face masks including a was shown not to be statistically of each study were identified and full facepiece powered air-purifying significant in further reducing considered in relation to the validity respirator (PAPR), a full facepiece the amount of bacterial shedding of the quality and findings of the PAPR with a shoulder-length hood, (p < 0.6)15. This indicates that a studies. All the extracted data and a surgical mask, and no facial surgical face mask may provide limitations were summarised and covering (as a positive control to as much protection in reducing demonstrated in the literature matrix determine contamination-reduction biological load as a non-sterile to help the author prepare themes effectiveness)13. Findings revealed surgical balaclava hood, especially and critique and compare the a statistically significant difference among clinicians with beards. outcomes from each article. (p < 0.0115) with the use of surgical Types of surgical mask and Data analysis masks decreasing aerosolised droplet contamination by 98.48 per cent efficacy A narrative approach was used to compared with wearing no facial Patel et al. conducted an in vitro synthesise the data of the included 13 covering . While a small sample study on cough etiquette using two articles in order to compare, contrast, size, this research correlated with manikins under various conditions critically evaluate and interpret the the results from a cohort study by in simulated rooms to assess the findings. The extracted data revealed Stockwell et al. who reported the contributing factors of wearing a nine themes which are presented in amount of aerosol CFU counts was surgical face mask to exposure the discussion. These themes were: significantly decreased when wearing reduction during coughing and • reduction in aerosol colony- any type of surgical mask compared tidal breathing (n = 22)16. They used forming units (CFU) in the OR with no surgical masks during a three types of surgical masks: an cough test (p < 0.001, n = 35)14. These • surgical masks and facial hair N95 class filtering respirator, a findings reveal a decrease in CFU natural fit earloop surgical mask • types of surgical mask and efficacy or biological load from wearing a and a SecureFit UltraTM fitted surgical face mask in the OR. 16 • staff behaviour regarding overall surgical mask . The differences noted between mask types were face and hair coverings Surgical masks and facial significant indicating that the major • compliance with Centre for Disease hair mechanism of protection was the Control and Prevention (CDC) Facial hair has always been a level of filtration, patterns of airflow guidelines contentious issue in infection in a particular setting and the ability • negative impact on the relationship prevention. Perry et al. conducted of the mask to fit the face16. The most with patients research to investigate whether superior mask was the fitted N95 clinicians’ facial hair may contribute respirator with a petroleum jelly seal, • speech intelligibility to increased bacterial shedding as fit testing is complex in manikins16. • personal protective equipment and subsequent SSIs15. The results Tidal breathing revealed that source (PPE) showed a statistically significant control was comparable to or better than mask or respirator protection • limitations of the efficacy of difference with bacterial shedding on the receiver, suggesting that surgical face masks. from bearded men being lower in the face mask cohort than those surgical masks may be an important without surgical masks (p < 0.02)15. additional defence in preventing the Statistical significance was greater spread of respiratory infections16. in participants with beards two

e-14 Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au Staff behaviour regarding higher in ‘clean’ procedures such participants; the countries where the overall face and hair as orthopaedic surgery and lower plastic surgeons actually practiced; in surgeries classified as ‘unclean’. the association between the use of coverings Orthopaedic surgery reported the masks and the types of procedures An observational study by Loison highest compliance (73%)19. These from the questions; and the consent et al.17 assessed compliance with results corresponded with the or ethical considerations were not wearing surgical attire and traffic result from the study conducted mentioned21. However, this study flow during surgery (n = 1615). by Louison et al. which reported was conducted from multiple Compliance with wearing surgical that orthopaedic surgery showed health services worldwide and attire was observed for eight criteria, statistically significant findings of revealed some interesting reasons two of which related to wearing highest compliance compared with for surgeons’ low compliance with masks. Full compliance was seen other specialities (p < 0.01)17. wearing a surgical mask. The majority in 56 per cent of personnel17. The of participants reported they did not The different trends among the position of a surgical mask (placed wear a surgical mask when patients surgical specialities in adhering to incorrectly over the nose and mouth) were entering the theatre to ease the guidelines may be influenced by the was the third highest contributor to patients’ anxiety. Surgeons wearing fact that the majority of SSIs are non-compliance after presence of spectacles also reported they found caused by a patient’s endogenous hand jewelry and position of head it difficult to cope with the fog flora and acquired in the operating cover. Although not statistically effect while breathing in the mask theatre during surgery when significant, it is interesting to note especially when the nose is covered21. microorganisms can reach the open that nursing staff showed the surgical site19. Thus, the surgeons Further results of an RCT by Wong highest compliance (99%) followed who perform ‘unclean’ surgery et al.22 supported one of the by surgeons (95%) and anaesthetists are more likely to consider their findings from Ahmad et al. They (89%)17. These results were similar to aerosolised breath is insignificant reported wearing face masks during an observational study by Dallolio et during procedures, resulting in the consultations negatively impacted al.18 in which data of staff behaviours low compliance with using a surgical on the patient’s perception of was collected (n = 10) showing that mask19. Additionally, an observational the clinician’s empathy (p < 0.04) 65 per cent of theatre staff wore descriptive study conducted by Kang although there was no statistically caps and masks correctly, having et al. investigated the participants’ significant difference in patient completely contained their hair behaviours regarding PPE use20. Their enablement (p < 0.87) and and beard and covering mouth and findings noted staff having doubts satisfaction (p < 0.25) between nose. Scrubbed staff (surgeons and about the effectiveness of PPE, the group in which clinicians instrument nurses) showed the including masks, caused by a lack wore masks and the non-mask highest compliance (89.5%) followed of knowledge or awareness of the group22. This study was conducted by unscrubbed staff (68.7%) and scientific evidence and this may be in a primary care clinic22; thus the personnel who weren’t directly a barrier to compliance with using patients’ expectations of health related to the procedure such as PPE20. care professionals may have been anaesthetists or nurses who came to different to patients’ expectations in ask for information (47.4%)18. Negative impact on the an operating theatre where surgical Compliance with Centre relationship with patients masks may be more acceptable. However, this illustrated that To understand the views of surgeons for Disease Control and removing surgical masks for patients about wearing a surgical mask in Prevention (CDC) guidelines entering the theatres may minimise operating theatres, Ahmad et al.21 19 the negative impact on the quality of Herron et al. conducted an conducted a survey among plastic relationship with the patients. observational study to evaluate surgeons. The quality of the study theatre staff compliance with method and questionnaire were Speech intelligibility manufacturer and CDC guidelines low level and not consistent; thus, for using surgical masks (n = many limitations were identified. When investigating how wearing a 1034). Only 18 per cent of staff For example it was unclear how surgical mask impacts on the ability demonstrated full compliance with many participants, divided into of staff to communicate within the the CDC guideline when applying a two groups, completed the survey; health care environment, Palmiero et surgical mask, with compliance being how the questionnaire was sent to al. reported on speech intelligibility,

Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au e-15 and the perceived quality of sound Furthermore, benefits of wearing and unnecessary talking should be transmission23. The two types of a surgical mask for unscrubbed limited during procedures in order to masks which are typically used in staff were studied in a systematic minimise the risk of contamination the OR are protective face masks and review by Spruce25. In this review, of a surgical mask and to maximise N95 respirators. Results showed that Spruce describes an observational, optimal outcomes for both patients compared to a no-mask condition descriptive and non-experimental and theatre personnel26,27. both types of masks had some study involving 8500 surgical The practice of eliminating non- impact on speech intelligibility. procedures conducted by White essential conversations in critical Protective face masks had lower and Lynch reporting that blood was phases of surgery has also been impact (3% and 4% deviation for detected on the heads and necks shown to decrease distraction and the two models tested) than N95 of 26 per cent of scrubbed staff and enhance patient safety28. respirators (13% and 17% deviation 17 per cent of unscrubbed staff. This 23 for the two models tested) . The highlights that wearing surgical Implications for findings tell us that surgical masks masks can also protect unscrubbed covering the mouth and nose can personnel from potential exposure perioperative nursing decrease speech intelligibility and to splash from the surgical field25. practice and knowledge the wearer’s ability to verbally Thus, surgical masks should also communicate in the operating be used as effective PPE by both translation theatre, which is commonly a very scrubbed and unscrubbed theatre Perioperative nurses play an loud environment23. staff members in operating theatre important role in delivering the for their own infection prevention. best evidence-based outcomes for This study indicated that wearing patients and fellow staff as well as surgical masks may interfere Limitations of the efficacy of coordinating the multidisciplinary with communication between the team in operating theatres to provide perioperative team or between surgical masks evidence-based care. Perioperative theatre staff and patients which are In order to maximise the benefits nurses’ responsibilities are to: surrounded by many types of noises23. of wearing surgical masks, several factors should be noted in addition • remain up to date in their Personal protective to wearing a surgical mask correctly. knowledge of the latest ACORN and equipment Zhiqing et al. concluded that a national standards6 and ensure surgical mask could be a potential the local policies in the individual Cook et al. conducted an source of SSI when it is used for health care settings are up to date experimental study during spinal extended hours, especially over surgery (n = 46) and reported debris • discuss the implications of a higher two hours (n = 40, p < 0.05)26. They was highest on the surgeons’ face airborne biological load with the recommended that the surgical mask shield (83%) followed by the first perioperative team13,14 be changed after each individual assistant (35%) and scrubbed procedure, especially those greater • understand that face masks lower technician/nurse (0%)24. Moreover, than two hours in duration26. This the biological load for bearded debris was identified more in study was followed up by Liu et al.27 men15 procedures where aggressive who investigated several factors instruments were used such as a • realise that face masks should be that could affect surgical mask burr, osteotome or an interbody worn correctly and changed every bioburden including type of surgical 17,19,20 cage. The research by Cook et al. was two hours and after each case mask, conversation during surgery limited to spinal surgery24; however, and face washing before applying a • ensure all perioperative staff and it has been shown that all types of surgical mask. They identified that students in the OR are always surgery have some degree of risk mask bioburden was higher when made aware of the possibility of splash associated with them, the wearer spoke27. Findings revealed of blood spray reaching both and laparoscopic surgery shows a that, in addition to wearing a surgical scrubbed and non-scrubbed team higher risk of splash particularly mask correctly as recommended members and the importance of when the pneumoperitoneum is 19,24,25 by the national standards, surgical wearing appropriate PPE decompressed19. Therefore, scrubbed masks should be changed after staff, especially surgeons, would • speak slowly and clearly when each procedure, especially when benefit from using a surgical mask wearing a face mask because of the usage extended over two hours, during surgery as part of normal PPE.

e-16 Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au impact of face masks on speech spread of respiratory infections References intelligibility23 between theatre staff who work in 1. Baldini A, Blevins K, Del Gaizo D, Enke O, close proximity. • be aware of the possible negative Goswami K, Griffin W et al. General assembly, impact of wearing surgical masks Limitations of this review include prevention, operating room – personnel: Proceedings of international consensus during interaction with conscious the fact that despite a thorough and on orthopaedic infections. J Arthroplasty patients – it may be beneficial systematic search being undertaken 2019;34(2S):S97S104. doi: 10.1016/j. to remove a surgical mask in some papers may have been arth.2018.09.059. the anaesthesic room or during unintentionally missed. Papers from 2. Birgand G, Saliou P, Lucet JC. 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Da Zhou C, Sivathondan P, Handa A. comorbidities such as diabetes, and masks fitted over the face and nose Unmasking the surgeons: The evidence possible causative factors such as and a lower biological load in air base behind the use of facemasks in hypothermia and the wearing of face surgery. J R Soc Med 2015;108(6):223–228. doi: in the OR13–16 and that surgical face masks. The second is to consider 10.1177/0141076815583167. masks are a vital component of PPE. future qualitative research into 5. Vincent M, Edwards P. Disposable surgical For decades one of the reasons that face masks for preventing surgical wound attitudes towards wearing PPE as infection in clean surgery. Cochrane perioperative nurses have worn face attitudes may have changed due to Database Syst Rev 2016;4(4):CD002929. doi: masks was to assist in the prevention new knowledge and thinking that has 10.1002/14651858.CD002929.pub3. of SSIs for patients. The causes of arisen from the COVID-19 pandemic. 6. 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e-18 Journal of Perioperative Nursing Volume 33 Number 4 Summer 2020 acorn.org.au