A Comparison of Face Masks and Visors for the Scrub Team A Study in Theatres Anita Norman RGN RM Face masks, theoretically could have two functions, firstly to protect the patient from the health care worker or, secondly, to protect the health care worker from the patient. Until about a hundred years ago face masks were never worn during the treatment of patients, either in the ‘operating theatre or in the ward, nor were masks worn if the patient had an infectious disease which could be passed on to the medical or nursing staff, In 1897, following its introduction by a German Doctor Von Mikulicz!, the face mask became an integral part of the surgical team’ apparel. For the last hundred years medical and nursing staff world-wide have continued to don masks before commencing any “sterile” procedure on a patient. Over the hundred years, the material used for masks has changed from lint to cotton and now to disposable materials.” ‘That change has not always been beneficial as, when fibreglass was the chief component of masks, the resultant irritation and discomfort to the wearer became all too apparent in the rashes and lesions suffered by them." It is only recently that people have asked if the masks do actually protect the patient from infection in the operating theatres. §:5 7 Some have shown no differences in infection rate whether masks are worn or not, although a study from Colchester in 1981 actually showed a 50% reduction in infections when masks were not worn.’ In the 1990's the necessity for masks has turned full cirele, but this time to protect the staff. The present “Guidance for Clinical Health Care; For protection against infection with HIV and Hepatitis Viruses”, recommends that for all major operations eye and mouth protection should be worn. This can be achieved with a mask and goggles but alternatively, a full-face visor could be worn, Deseription of the Visor The visor consists af a spectacle frame which is held in place with a ski-type head band, The visor part is a clear moulded shield which is placed near to the face. This shield is coated with an anti-fog agent which stops droplet formation. If this fails the shield must be discarded. The cost of the entire unit is £25.00 and a replacement shield is £7.00. The firm advise that the anti-fog should last up to 2 years. The shield is washed with soap and water at the end of each list, or more frequently if required. Should the mask need to be disinfected, it can be wiped with hypochlorite solution. ‘The author was awarded a hospital research grant and a half day per week to carry out a study comparing ‘asks and the visor. "The aim of tho study.was to assees the following 3 factors: 1, The acceptability of the visor to the staff. 2. The degree of protection afforded by the visor. 3, Tho comparability of infection rates between the toro patients groups, Methods The clinical trial consisted of three months when a thoracic team and © general team wore visors in the operating theatre for all cases. This included the scrub team, the circulating team and the anaesthetic team. On a daily basis, stait wore requested to complete a simple questionnaire to assess the degree of visor contamination and acceptability ‘The same teams then reverted to wearing conventional theatre masks for a further period of three months, At the end of each month the numbers and types of operations were collected from the medical staff end details of any post-operative infection.moracic — | Total Cases | 37 Infected Cascs | 4 | Bronchoploural fistula, large subphrenic abscess from ‘ruptured duodonsl ulcer. Pationt died. ‘Right pneumonectomy. Staph, Aureus pneumonia, recovered with antibioties, Left thoracotomy, chest infection, green sputum, Patient died. Right pneumonectomy. Sight pyrexia, microbiology fom sputum and pleural aspirate nogativo, Patient sent home. GENERAL, ‘otal Cases | 41 Infected Cases | 0 THORACIC — | Total Cases | 33 Infected Cases | “3 | Wedge excision right upper lobe. Abseoss around drain sto. Potient made good recovery. eft pneumonectomy, pleural space infeetion Space invigated with antibiotic, Patient made good recovery. Right pneumonectomy, patient developed a broacho-pleural fetula. Antibiotics, but the pationt died. Bowel resection raquired wound irrigation. GENERAL Total Cases | 57 Infected Cases | 1 an |] THORACIC ‘Total Cases: 33 . 2 Infested Cases | 8 | Individual deta not given. 2501) cenenat, ‘wal Cason | 57 Pe Infected Cases | 0 i i i Jace mask wearing period ‘Total Cases Infected Cases ‘Total Cases Tnfected Cases Right lobe rasostion developed persistent sir laak ‘Responded to tale and sent home, Hernia repair. No wound breakdown, no pus, responded to antibioties and sent home, ‘Total Cases Infected Cases, Total Cases Infected Cases Anterior resection, Wound discharge. Did not prolong. hospital stay but required District Nurse attention. ‘THORACIC ‘Total Cases Infected Cases GENERAL ‘Total Cases Infected Cases ‘Emergency laparotomy for small bowel obstruction. Wound infection. Wound opened in theatre and pus drained 31/8/93, Wound opened on ward auperficially and antibiotics, orally 2/4/98. Discharged home 9/4/93,Good visibility 4 Fog resistant HW Ansesthetist | DO opa 41 Surgeon B Assistant Comfortable TD Scrub Nurse | | Eeeeeeee 1s CO Runners Hee Glare resistant a i ; i 4 | 20 No 0 Yes 20 40 60 eee co ae ete Figure 3. Questionnaire Responses | 45 aed ae Hee | 40 Hee 35 | } 30 1 Hear a a eet i 3 Light s None { 3 2 39 o |4 | 3 15 Zu 10 Er fee 1 \ 5 0 3 [ene f | Runner Scrub Assistant Surgeon ODA Anaesthestist Nurse ‘ Figure 4 Visor contamination at ond of case(NB. The numbers of questionnaire results vary due to the small number of returns from groups other than nurses). Results In goneral, the acceptability ofthe visor was very high. ‘The only adverse comment related to comfort: amongst scrub nurses, Contamination of the visor occured most frequently to the assistant, followed by the surgeon and then the serub nurse. Overall, the infeetion rates were comparable. Discussion The literature indicates that there is no need for masks to be worn to prevent infection of the patient. Indood the rubbing of the mask against the skin may even increase shedding of skin squames and adversely affect infection rates In this country some hospitals stopped wearing masks, butit is now apparent that the health care worker must, be protected from the risk of blood-bome viruses coming into contact with mucosal surfaces. In terms of wearability, the surgeons were the most enthusiastic and it was with great difficulty that: the author got them to return to masks. The scrub nurses and the circulators were not happy with the comfort of the visors and the firm has said it will look again at the design of the bridge pieco, The author thinks this may bbe because this group wore the visors for much longer periods and most: in this group were female and had more delicate bridges to their noses, In all other aspects the visors were more favourable, No wearer of a visor reported facial splashing. In this study it has been shown that the assistent has ‘the most persistent contamination, Could this be because the surgeon can anticipate the sitnation better than the assistant and move out ofthe line of fire? Even 0, it must he pointed out that the surgeon and the serub nurse take the brunt of the gross contamination such as a full face-splash of blood when a clamp comes off vessel. In respect to the infection rate, overall there was no difference between masks and visors. As far as, minor splashing is concerned, it is possible to sce minute splashes on a visor but not on a mask ‘The cost of masks for one year in the Northern General operating theatres is £5475. If 150 visors at £25 each ‘were purchased and 10 placed in each operating theatre the cost would be £3750. This would be a one-off purchase to cover all staff, including visitors and medical students. The visors would become part of the theatre equipment and it would be the responsibility of the G Grade Sister to maintain them and monitor standards. Only the scrub team would be required to ‘wear them, The circulating staff would only wear them from choiee. The recurring costs will depend on the durability of the visor and the care given to them by the users, References 1 Mikulicz, J. 1897. Das Operiren in Sterkisirten Zwirnhandschuhon und mit Mundbinde. Centriblatt far Chirurgie.26: 714 2 Rogers, K-B. 1980. An Investigation into the Bifficacy of Disposable Face Masks. J Clin Path 33: 1086-1091 8 Rogers, K.B. 1981, Face Masks, Which, When, Where, and Why. J Hosp Infect 2: 1-4 4. Mitchell, NJ,, Hunt, 8. 1991. Surgical Face Masks in Modern Operating Rooms - a Costly and Unnecessary Ritual? J Hosp Infect 18: 289-242 6 Taylor, LJ, 1980. Are Faco Masks Necessary in Operating Theatros and Wards? J Hosp Infect 1: 173 D 14 6 Schweizer, R-T, 1977. Mask Wiggling as a Potential Cause of Wound Contamination, Lancet 2; 1129D 1130 7 Shah, M., Crompton, P, Viekers, M.D.A. 1983. The Efficacy of Face Masks. Ann Roy Coll Surg Engl 65: $80.81 8 Ory, N. 1981. Is a Mask Necossary in the Operating ‘Theatre? Ann Roy Coll Surg Engl 63: 390-392 9 Recommendations of the Expert Advisory Group on AIDS. 1990. Guidance for Clinieal Health Care Workers: Protection Against Infection with HIV and Hepatitis, Virueos, Acknowledgements ‘Mr, A. Mackay of Pauldrach and Mackay Endoscopy Products Ltd, Mrs. C. Caroline, Director of Nursing Service, Theatres, Northern General Hospital Trust Sheffield. Anita Norman is a theatre sister at Sheffield Northern General Hospital,