Re: Wearing of Surgical masks in the Operating room

Dear Colleagues,

Indeed, some of these issues keep re-surfacing again and again. The problem here, as far as I can see, is an overly narrow definition of what constitutes evidence in many circles (e.g. the narrow focus on RCTs and systematic reviews as accepted evidence) and a common inability to analyze and view things from a rational, scientific perspective.

We need to accept the fact that there are many things and practices that (a) have been established historically, (b) have a reasonable scientific (and in this case microbiological) rationale behind it, and (c) have little or no evidence (in the narrow definition as stated above) supporting it, simply because it may be difficult to gather that evidence and/or medicine has moved beyond the point at which it is reasonable to focus evidence-gathering efforts at the question.

Some of the historical aspects are briefly but nicely explained in one of my favourite book chapters in the area:
Grschel DHM, Pruett TL. Surgical antisepsis. In: Block SS, ed. Disinfection, sterilisation and preservation. 4 ed. London: Lea & Febiger; 1991: 642-54.

The authors basically say that many of these things have been established in the late 1800s and early 1900s as part of the post-Listerian system of aseptic surgery, and the practices are often based on what makes scientific and/or microbiologic sense, but are often not proven by evidence in the narrow definition above.

Another good example is surgical hand antisepsis (surgical scrubbing), which has never been tested in a controlled study.

Reasonable indirect evidence is coming from the investigations of Bischoff and/or Sherertz from the USA who show that Staph. aureus is readily dispersed in the air from carriers who have mild viral respiratory tract infections. Such dispersal seems patchy and originates from some people, but not from others.

Finally, the question again highlights the problem of onus of evidence-gathering. It happens again and again that people question the evidence for measures that are inconvenient to them, in the sense of show me the evidence why we must do this. These questions are often very cynical (one may also say frivolous) because these people know very well (even before asking) that the inconvenient practice (to them) is not supported by RCTs or SRs, and they usually know that they will send infection control professionals and microbiologists scrambling and spending their work time and efforts to find evidence.

I think we need to reverse the onus for evidence in such cases. If an established measure, (a) when present, has the potential to enhance patient safety, and (b) when absent, has the potential to lead to lesser patient safety, then it becomes an ethical mandate to reverse this onus and say you show me the evidence that tells us that the practice can be safely omitted without leading to adverse outcomes. (And that evidence should withstand scientific scrutiny).

Best regards, Matthias.

—
Matthias Maiwald, MD, FRCPA
Senior Consultant in Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Glenys Harrington
Sent: Thursday, 10 August, 2017 9:55 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Wearing of Surgical masks in the Operating room

Hi all,

A picture often helps to tell a story.

J Granville-Chapman and R L Dunne review the etiquette of sneezing in surgical masks. BMJ | 22-29 December 2007 | Volume 335

This surgical team looked at sneezing etiquette and the efficacy of masks in the operating theatre. The images on page 1293 of the attached article (and at the link below) will help demonstrate how a mask worn during an operating procedure can help protect the patient. i.e. Surgical masks are effective at containing a lot of droplets.

http://www.bmj.com/content/335/7633/1293

Regards

Glenys

Glenys Harrington
Infection Control Consultancy (ICC)
P.O. Box 6385
Melbourne
Australia, 3004
M: +61 404816434
E: infexion@ozemail.com.au

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Lesley Alway
Sent: Thursday, 10 August 2017 11:28 AM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: [ACIPC_Infexion_Connexion] Wearing of Surgical masks in the Operating room

Dear Cathryn and Michael, agree wholeheartedly have had to fit this fight for to many years, found it helpful ( and typical not to see the value to the patient) to focus on the wearer not the patient safety. I use the example would they do procedures without glove – of course not!!!!! Same applies to masks and eye protection.

Lesley Alway
Director
Strategic Health Resources.
Post Graduate Education Services.
0408 324 727
03 94390534

Director Australian Health Design Council
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From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Cathryn Murphy
Sent: Wednesday, 9 August 2017 4:17 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Wearing of Surgical masks in the Operating room

Dear All

I agree with Michaels rationale and agree there are cases of occupational transmission of serious bloodborne illness from mucousal splashes reported in the literature. So from an OCH&S obligation the HCW should comply.

This is one of those frustrating issues that come up from time to time and they drive me crazy. They are like the ? of eating in theatres/ anaesthetists wearing masks/ OT staff changing attire etc. Why IC professionals continually have to fight these causes is exhausting and sad but back to the science.whilst Michael provides a meta-analysis it is a few years old and it is based on very few reports probably because the issue hasnt been well studied not that the issue isnt important.

I would also draw attention to the increasing use of air-purifying systems in the US and other countries. Some of the data related to validation studies are very compelling and show how CFU counts of bacteria rise (sometimes to extremes) when speaking (behind masks) happens. Obviously showing causation between high counts/ speaking and actual wound infection is difficult given to the many confounders (# of people in the room/ traffic/ movement/ +/- measures like laminar flow/ skin prep etc etc) but surely it just makes sense for people in the OR to wear masks for everyones sake.

Off track..but I recall being asked this exact question by a group of anaesthetists at a scientific meeting in the late 1990s and after responding seriously and scientifically I then added mask wearing depends on how good looking you are and in your case I wouldas you can imagine it went down like a lead balloon but it silenced the question asker.

I seriously wish you good luck in fighting these battles and I wish the people we served relaised the very serious and very real issues we fight daily and perhaps then they would stop creating distractions like this.

With respect
Cath

Cathryn Murphy RN B. Photog MPH PhD CIC
Chief Executive Officer & Creative Director
Infection Control Plus Pty Ltd
QLD, Australia

E: Cath@infectioncontrolplus.com.au
M: +61 428 154154
W:http://www.infectioncontrolplus.com.au

From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Michael Wishart
Sent: Wednesday, 9 August 2017 15:29
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Wearing of Surgical masks in the Operating room

Hi Fran

This topic has received a fair bit of attention over the years, and yes, your doctors are correct: there is no compelling evidence to suggest surgical face masks reduce surgical site infection rates. See this meta-analysis conclusion: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0064347/

Having said that, my own rationale for staff wearing surgical face masks during procedures is for protection of their mucous membranes from splashing of potentially infectious material. In my view, the strike resistance for surgical face masks is of high importance, and has little to do with preventing contamination of the surgical wound.

To suggest staff in a room during a procedure dont wear masks would in my opinion be asking for trouble. From a occupational health and safety perspective, I would always recommend everyone in a room during a surgical procedure should be wearing a surgical face mask, and eye protection as well.

In my view, anyway.

Cheers
Michael

Michael Wishart
Infection Control Coordinator

A 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
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From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Franciska Ferreira
Sent: Wednesday, 9 August 2017 3:03 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: Wearing of Surgical masks in the Operating room

Afternoon All,

I require some assistance please.

Weve had interesting discussions amongst some of Visiting Medical Officers regarding the effectiveness of wearing surgical masks in the operating room to decrease the likelihood of postoperative surgical site infections. The practice of wearing masks is believed to minimize the transmission of oro-and nasopharyngeal bacteria from Theatre Operating staff to patients wounds. However a couple of individuals believe there is not enough evidence to support this and therefore dont think it is necessary to wear surgical masks while operating.

Im aware of the requirements as per the ACORN Standards and the National Infection Control Guidelines (2016 Draft version), which our Staff complies by, however I cannot find current best practice or evidence to provide to those two individuals.

Any suggestions please? And if youre willing to share, what is the Policy in regards this matter at your facilities?

Kind Regards

Franciska Ferreira
Infection Prevention & Control/Wound Management Consultant
Burnside War Memorial Hospital
120 Kensington Road, Toorak Gardens, SA 5056
t: 08 8202 7231 f: 08 8407 8573 e: fferreira@burnsidehospital.asn.au
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