Use of face masks by non-scrubbed operating room staff: a randomized controlled trial

Unexpected Benefits of Coronavirus Disease 2019: Impact of Coronavirus Disease 2019 Pandemic on Surgical Site Infection: A Systematic Review and Meta-Analysis

Background: We aimed to summarize and synthesize the current evidence regarding the indirect impact of the coronavirus disease 2019 (COVID-19) pandemic and its associated measures on the surgical site infection (SSI) rate compared with the pre-pandemic period. Methods: A computerized search was conducted on MEDLINE via PubMed, Web of Science, and Scopus using the relevant keywords. Two-stage screening and data extraction were done. The National Institutes of Health (NIH) tools were used for the quality assessment. The Review Manager 5.4.1 program was used for the analysis. Results: Sixteen articles (n = 157,426 patients) were included. The COVID-19 pandemic and lockdown were associated with reduced risk of SSIs after surgery (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.56-0.75; p < 0.00001) and (OR, 0.49; 95% CI, 0.29-0.84; p = 0.009), respectively. There was no significant reduction in the SSIs rate after applying the extended use of masks (OR, 0.73; 95% CI, 0.30-1.73; p = 0.47). A reduction in the superficial SSI rate during the COVID-19 pandemic compared with the pre-COVID-19 pandemic period was observed (OR, 0.58; 95% CI, 0.45-0.75; p < 0.0001). Conclusions: The current evidence suggests that the COVID-19 pandemic may have some unexpected benefits, including improved infection control protocols, which resulted in reduced SSI rates, especially superficial SSIs. In contrast to extended mask use, the lockdown was associated with reduced rates of SSIs.

Impact of COVID-19 Protocols on Primary and Revision Total Hip Arthroplasty

BACKGROUND

Surgical site infection (SSI) after total hip arthroplasty (THA) is associated with increased morbidity, mortality, and healthcare expenditures. Our institution intensified hygiene standards during the COVID-19 pandemic; hospital staff exercised greater hand hygiene, glove use, and mask compliance. We examined the effect of these factors on SSI rates for primary THA (pTHA) and revision THA (rTHA).

METHODS

A retrospective review was performed identifying THA from January 2019 to June 2021 at a single institution. Baseline characteristics and outcomes were compared before (January 2019 to February 2020) and during (May 2020 to June 2021) the COVID-19 pandemic and during the first (May 2020 to November 2020) and second (December 2020 to June 2021) periods of the pandemic. Cohorts were compared using the Chi-squared test and independent samples t-test.

RESULTS

A total of 2,682 pTHA (prepandemic: 1,549 [57.8%]; pandemic: 1,133 [42.2%]) and 402 rTHA (prepandemic: 216 [53.7%]; Pandemic: 186 [46.2%]) were included. For primary and revision cases, superficial and deep SSI rates were similar before and during COVID-19. During COVID-19, the incidence of all (-0.43%, P = .029) and deep (-0.36%, P = .049) SSIs decreased between the first and second periods for rTHA. pTHA patients had longer operative times (P < .001) and shorter length of stay (P = .006) during COVID-19. Revision cases had longer operative times (P = .004) and length of stay (P = .046). Both pTHA and rTHA were discharged to skilled nursing facilities less frequently during COVID-19.

CONCLUSION

During COVID-19, operative times were longer in both pTHA and rTHA and patients were less likely to be discharged to a skilled nursing facility. Although intensified hygienic standards may lower SSI rates, infection rates did not significantly differ after our hospital implemented personal protective guidelines and a mask mandate.

Incidence and risk factors for surgical wound complications in women with body mass index >30 kg/m2 following cesarean delivery: a secondary analysis

BACKGROUND

OBJECTIVE

STUDY DESIGN

RESULTS

CONCLUSION

Guidelines for clothing in the operating theatre, 2021

OBJECTIVE

To provide guidelines for the choice of items of clothing (except sterile surgical gown) for staff working in the operating theatre.

DESIGN

A committee of nine experts from SFAR and the SF2H learned societies was convened. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. Likewise, it did not benefit from any funding from a company marketing a health product (drug or medical device). The authors were required to follow the rules of the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based.

METHODS

We aimed to formulate recommendations according to the GRADE® methodology for four different fields: operating theatre suits, operating theatre hats, masks, and shoes/over-shoes. Each question was formulated according to the PICO format (Patient, Intervention, Comparison, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology.

RESULTS

The experts' synthesis work and their application of the GRADE® method resulted in 13 recommendations. As the GRADE® method could not be integrally applied to all questions, some recommendations were formulated as expert opinions.

CONCLUSION

Based on strong agreement between experts, we produced 13 recommendations to guide the choice of operating theatre attire.

Surgical Masks Affect the Peripheral Oxygen Saturation and Respiratory Rate of Anesthesiologists

Background

Surgical masks (SMs) protect medical staff and reduce surgical site infections. Extended SM use may reduce oxygen concentrations in circulation, causing hypoxia, headache, and fatigue. However, no research has examined the effects of wearing SMs on oxygenation and physical discomfort of anesthesiologists.

Methods

An electronic questionnaire was established and administered through WeChat, and a cross-sectional survey was conducted to determine SM use duration and related discomfort of operating room medical staff. Then, operating room anesthesiologists were enrolled in a single-arm study. Peripheral blood oxygen saturation (SpO2), heart rate, and respiratory rate were determined at different times before and after SM use. Shortness of breath, dizziness, and headache were subjectively assessed based on the visual analog scale (VAS) scores.

Results

In total, 485 operating room medical staff completed the electronic questionnaire; 70.5% of them did not change SMs until after work, and 63.9% wore SMs continuously for more than 4 h. The proportion of anesthesiologists was the highest. After wearing masks for 4 h, the shortness of breath, fatigue, and dizziness/headache rates were 42.1, 34.6, and 30.9%, respectively. Compared with other medical staff, the proportion of subjective discomfort of anesthesiologists increased significantly with prolonged SM use from 1 to 4 h. Thirty-five anesthesiologists completed the study. There was no difference in anesthesiologist SpO2, heart rate, or respiratory rate within 2 h of wearing SMs. After more than 2 h, the variation appears to be statistically rather than clinically significant—SpO2 decreased (98.0 [1.0] vs. 97.0 [1.0], p &lt; 0.05), respiratory rate increased (16.0 [3.0] vs. 17.0 [2.0], p &lt; 0.01), and heart rate remained unchanged. As mask use duration increased, the VAS scores of shortness of breath, dizziness, and headache gradually increased.

Conclusion

In healthy anesthesiologists, wearing SMs for more than 2 h can significantly decrease SpO2 and increase respiratory rates without affecting heart rates.

Peter SD, Oyetunji TA. Behind the mask: extended use of surgical masks is not associated with increased risk of surgical site infection

PURPOSE

COVID-19 has prompted significant policy change, with critical attention to the conservation of personal protective equipment (PPE). An extended surgical mask use policy was implemented at our institution, allowing use of one disposable mask per each individual, per day, for all the cases. We investigate the clinical impact of this policy change and its effect on the rate of 30-day surgical site infection (SSI).

METHODS

A single-institution retrospective review was performed for all the elective pediatric general surgery cases performed pre-COVID from August 2019 to October 2019 and under the extended mask use policy from August 2020 to October 2020. Procedure type, SSI within 30 days, and postoperative interventions were recorded.

RESULTS

Four hundred and eighty-eight cases were reviewed: 240 in the pre-COVID-19 cohort and 248 in the extended surgical mask use cohort. Three SSIs were identified in the 2019 cohort, and two in the 2020 cohort. All postoperative infections were superficial and resolved within 1 month of diagnosis with oral antibiotics. There were no deep space infections, readmissions, or infections requiring re-operation.

CONCLUSION

Extended surgical mask use was not associated with increased SSI in this series of pediatric general surgery cases and may be considered an effective and safe strategy for resource conservation with minimal clinical impact.

Are facemasks a priority for all staff in theatre to prevent surgical site infections during shortages of supply? A systematic review and meta-analysis

BACKGROUND

The provision of facemasks must be prioritised when supplies are interrupted. These include supplies to operating rooms. The aim of this review is to evaluate the available evidence to determine the relative priority for the provision of facemasks in operating rooms to prevent surgical site infection.

METHODS

A systematic search of OVID Medline, Embase & Cochrane Central was completed. Candidate full-text articles were identified and analysed by two reviewers who also assessed risk of bias.

FINDINGS

Six studies were identified that described infections with and without facemask usage. The pooled effect of not wearing facemasks was a risk ratio for infection of 0.77 (0.62-0.97) in favour of not wearing masks. Only one case-controlled study evaluated facemask usage in implant surgery and demonstrated an odds ratio for developing infection of 3.34 (95% CI 1.94-5.74) if facemasks were not worn by the operating surgeon. Four studies collected microbiological cultures during periods in surgery with or without facemasks. Two demonstrated an increase in colony forming units in surgery where the wound was directly below the surgeon. One study showed equivocal results when masks were worn, and one was terminated early limiting interpretation.

CONCLUSION

The use of facemasks by scrubbed staff during implant surgery should be mandatory to prevent infection. We recommend the use of facemasks by all scrubbed staff during other forms of surgery to protect the patient and staff, but the supporting evidence is weak. There is insufficient evidence to show that non-scrubbed staff must wear masks during surgery.

Moving towards green anaesthesia: Are patient safety and environmentally friendly practices compatible? A focus on single-use devices

OBJECTIVE

Discuss if the use of disposable or reusable medical devices leads to a difference in terms of hospital-acquired infection or bacterial contamination. Determine which solution is less expensive and has less environmental impact in terms of carbon footprint, energy and water consumption and amount of waste.

METHODS

We carried out a narrative review. Articles published in English and French from January 2000 to April 2020 were identified from PubMed.

RESULTS

We retrieved 81 articles, including 12 randomised controlled trial, 21 literature reviews, 13 descriptive studies, 6 experimental studies, 9 life-cycle studies, 6 cohort studies, 2 meta-analysis, 4 case reports and 8 other studies. It appears that pathogen transmission in the anaesthesia work area is mainly due to the lack of hand hygiene among the anaesthesia team. The benefit of single-use devices on infectious risk is based on weak scientific arguments, while reusable devices have benefits in terms of costs, water consumption, energy consumption, waste, and reducing greenhouse gas emissions.

CONCLUSION

Disposable medical devices and attire in the operating theatre do not mitigate the infectious risk to the patients but have a greater environmental, financial and social impact than the reusable ones. This study is the first step towards recommendations for more environmental-friendly practices in the operating theatre.

Closed incision negative pressure wound therapy versus standard dressings in obese women undergoing caesarean section: multicentre parallel group randomised controlled trial

OBJECTIVE

To determine the effectiveness of closed incision negative pressure wound therapy (NPWT) compared with standard dressings in preventing surgical site infection (SSI) in obese women undergoing caesarean section.

DESIGN

Multicentre, pragmatic, randomised, controlled, parallel group, superiority trial.

SETTING

Four Australian tertiary hospitals between October 2015 and November 2019.

PARTICIPANTS

Eligible women had a pre-pregnancy body mass index of 30 or greater and gave birth by elective or semi-urgent caesarean section.

INTERVENTION

2035 consenting women were randomised before the caesarean procedure to closed incision NPWT (n=1017) or standard dressing (n=1018). Allocation was concealed until skin closure.

MAIN OUTCOME MEASURES

The primary outcome was cumulative incidence of SSI. Secondary outcomes included depth of SSI (superficial, deep, or organ/body space), rates of wound complications (dehiscence, haematoma, seroma, bleeding, bruising), length of stay in hospital, and rates of dressing related adverse events. Women and clinicians were not masked, but the outcome assessors and statistician were blinded to treatment allocation. The pre-specified primary intention to treat analysis was based on a conservative assumption of no SSI for a minority of women (n=28) with missing outcome data. Post hoc sensitivity analyses included best case analysis and complete case analysis.

RESULTS

In the primary intention to treat analysis, SSI occurred in 75 (7.4%) women treated with closed incision NPWT and in 99 (9.7%) women with a standard dressing (risk ratio 0.76, 95% confidence interval 0.57 to 1.01; P=0.06). Post hoc sensitivity analyses to explore the effect of missing data found the same direction of effect (closed incision NPWT reducing SSI), with statistical significance. Blistering occurred in 40/996 (4.0%) women who received closed incision NPWT and in 23/983 (2.3%) who received the standard dressing (risk ratio 1.72, 1.04 to 2.85; P=0.03).

CONCLUSION

Prophylactic closed incision NPWT for obese women after caesarean section resulted in a 24% reduction in the risk of SSI (3% reduction in absolute risk) compared with standard dressings. This difference was close to statistical significance, but it likely underestimates the effectiveness of closed incision NPWT in this population. The results of the conservative primary analysis, multivariable adjusted model, and post hoc sensitivity analysis need to be considered alongside the growing body of evidence of the benefit of closed incision NPWT and given the number of obese women undergoing caesarean section globally. The decision to use closed incision NPWT must also be weighed against the increases in skin blistering and economic considerations and should be based on shared decision making with patients.

TRIAL REGISTRATION

ANZCTR identifier 12615000286549.

A Survey among Plastic Surgeons Wearing a Mask in Operating Room

BACKGROUND

Face mask is considered to be an integral part of a surgeon's dress in operating room. The following study was carried out among the plastic surgeons to know their views about the wearing the face masks in operating room (OR).

METHODS

A questionnaire was developed and was sent to the 2 groups of plastic surgeons which included 8 questions. Group A consisted of 100 plastic surgeons from the subcontinent. Group B consisted of 100 plastic surgeons of USA and European origins. The questionnaires were sent by emails and the data was analyzed. The questionnaire was consisted of 8 questions.

RESULTS

About 93% of the plastic surgeons in group A wore the mask and 86% in group B. About 96% of plastic surgeon in group A and 99% in group B used disposable masks and only 4% in group A and 1% in group B used re-usable/washable face masks. About 59% in group A and 63% in group B covered the nose. Botox and filler injections were the commonest procedures in which the surgeons opted to perform without face mask (74% in group A and 68% in group B), followed by liposuction (41% in group A and 34% in group B). The majority in both groups believed that face mask decreases the surgical site infection.

CONCLUSION

Most of the plastic surgeons wore the face masks in the OR. Care must be taken to ensure that properly designed studies that determine if surgical masks prevent post-operative wound infection.

Disposable surgical face masks for preventing surgical wound infection in clean surgery

BACKGROUND

Surgical face masks were originally developed to contain and filter droplets containing microorganisms expelled from the mouth and nasopharynx of healthcare workers during surgery, thereby providing protection for the patient. However, there are several ways in which surgical face masks could potentially contribute to contamination of the surgical wound, e.g. by incorrect wear or by leaking air from the side of the mask due to poor string tension.

OBJECTIVES

To determine whether the wearing of disposable surgical face masks by the surgical team during clean surgery reduces postoperative surgical wound infection.

SEARCH METHODS

In December 2015, for this seventh update, we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials; Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We also searched the bibliographies of all retrieved and relevant publications. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-randomised controlled trials comparing the use of disposable surgical masks with the use of no mask.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently.

MAIN RESULTS

We included three trials, involving a total of 2106 participants. There was no statistically significant difference in infection rates between the masked and unmasked group in any of the trials. We identified no new trials for this latest update.

AUTHORS' CONCLUSIONS

From the limited results it is unclear whether the wearing of surgical face masks by members of the surgical team has any impact on surgical wound infection rates for patients undergoing clean surgery.

ADding negative pRESSure to improve healING (the DRESSING trial): a RCT protocol

INTRODUCTION

Obese women are more likely to develop a surgical site infection (SSI) following caesarean section (CS) than non-obese women. Negative pressure wound therapy (NPWT) is increasingly being used to reduce SSI with limited evidence for its effectiveness.

OBJECTIVES

To determine the clinical and cost-effectiveness of using NPWT in obese women having elective and semiurgent CS.

METHODS AND ANALYSIS

A multisite, superiority parallel pragmatic randomised controlled trial with an economic evaluation. Women with a body mass index (BMI) of ≥ 30, booked for elective and semiurgent CS at 4 Australian acute care hospitals will be targeted. A total of 2090 women will be enrolled. A centralised randomisation service will be used with participants block randomised to either NPWT or standard surgical dressings in a 1:1 ratio, stratified by hospital. The primary outcome is SSI; secondary outcomes include type of SSI, length of stay, readmission, wound complications and health-related quality of life. Economic outcomes include direct healthcare costs and cost-effectiveness, which will be evaluated using incremental cost per quality-adjusted life year gained. Data will be collected at baseline, and participants followed up on the second postoperative day and weekly from the day of surgery for 4 weeks. Outcome assessors will be masked to allocation. The primary statistical analysis will be based on intention-to-treat.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the ethics committees of the participating hospitals and universities. The findings of the trial will be disseminated through peer-reviewed journals, national and international conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12615000286549; Pre-results.

Reducing the risk of surgical site infection using a multidisciplinary approach: an integrative review

PURPOSE

To identify and describe the strategies and processes used by multidisciplinary teams of health care professionals to reduce surgical site infections (SSIs).

MATERIALS AND METHODS

An integrative review of the research literature was undertaken. Searches were conducted in April 2015. Following review of the included studies, data were abstracted using summary tables and the methodological quality of each study assessed using the Standards for Quality Improvement Reporting Excellence guidelines by two reviewers. Discrepancies were dealt with through consensus. Inductive content analysis was used to identify and describe the strategies/processes used by multidisciplinary health care teams to prevent SSI.

RESULTS AND DISCUSSION

In total, 13 studies met the inclusion criteria. Of these, 12 studies used quantitative methods, while a single study used qualitative interviews. The majority of the studies were conducted in North America. All quantitative studies evaluated multifaceted quality-improvement interventions aimed at preventing SSI in patients undergoing surgery. Across the 13 studies reviewed, the following multidisciplinary team-based approaches were enacted: using a bundled approach, sharing responsibility, and, adhering to best practice. The majority of studies described team collaborations that were circumscribed by role. None of the reviewed studies used strategies that included the input of allied health professionals or patient participation in SSI prevention.

CONCLUSION

Patient-centered interventions aimed at increasing patient participation in SSI prevention and evaluating the contributions of allied health professionals in team-based SSI prevention requires future research.

Endophthalmitis following intravitreal anti-vascular endothelial growth factor (VEGF) injection: a comprehensive review

The purpose of this review is to report and summarize previously reported studies and assess many of the individual steps of the intravitreal injection procedure's possible effect on the prevention of endophthalmitis. The pooled endophthalmitis rate from 20 large retrospective case series of anti-VEGF injections was 144/510,396 (0.028%; 1/3,544). Injections may be performed in an office-based location or in an operating room (OR) and low rates of endophthalmitis can be achieved in either location with careful attention to asepsis. Pre- or post-injection topical antibiotics have not been shown to be effective, and could select for more virulent microorganisms. Povidone-iodine prior to injection is accepted as the gold-standard antiseptic agent, but aqueous chlorhexidine may be an alternative. Antisepsis before and after gel or subconjunctival anesthetic is suggested. The preponderance of Streptococcal infections after intravitreal injection is discussed, including the possible role of aerosolization, which can be minimized by using face masks or maintaining silence. As with other invasive procedures in medicine, the use of sterile gloves, following adequate hand antisepsis, may be considered. Control of the eyelashes and lid margin is required to avoid contamination of the needle, but this can be achieved with or without a speculum. Techniques to minimize vitreous reflux have not been shown to reduce the risk of endophthalmitis. Same day bilateral injections should be performed as two separate procedures, preferably using drug from different lots, especially when using compounded drugs.

Unmasking the surgeons: the evidence base behind the use of facemasks in surgery

The use of surgical facemasks is ubiquitous in surgical practice. Facemasks have long been thought to confer protection to the patient from wound infection and contamination from the operating surgeon and other members of the surgical staff. More recently, protection of the theatre staff from patient-derived blood/bodily fluid splashes has also been offered as a reason for their continued use. In light of current NHS budget constraints and cost-cutting strategies, we examined the evidence base behind the use of surgical facemasks. Examination of the literature revealed much of the published work on the matter to be quite dated and often studies had poorly elucidated methodologies. As a result, we recommend caution in extrapolating their findings to contemporary surgical practice. However, overall there is a lack of substantial evidence to support claims that facemasks protect either patient or surgeon from infectious contamination. More rigorous contemporary research is needed to make a definitive comment on the effectiveness of surgical facemasks.

Surgical attire and the operating room: role in infection prevention

➤ Although there is some evidence that scrubs, masks, and head coverings reduce bacterial counts in the operating room, there is no evidence that these measures reduce the prevalence of surgical site infection.➤ The use of gloves and impervious surgical gowns in the operating room reduces the prevalence of surgical site infection.➤ Operating-room ventilation plays an unclear role in the prevention of surgical site infection.➤ Exposure of fluids and surgical instruments to the operating-room environment can lead to contamination. Room traffic increases levels of bacteria in the operating room, although the role of this contamination in surgical site infection is unclear.

Disposable surgical face masks for preventing surgical wound infection in clean surgery

BACKGROUND

Surgical face masks were originally developed to contain and filter droplets containing microorganisms expelled from the mouth and nasopharynx of healthcare workers during surgery, thereby providing protection for the patient. However, there are several ways in which surgical face masks could potentially contribute to contamination of the surgical wound, e.g. by incorrect wear or by leaking air from the side of the mask due to poor string tension.

OBJECTIVES

To determine whether disposable surgical face masks worn by the surgical team during clean surgery prevent postoperative surgical wound infection.

SEARCH METHODS

We searched The Cochrane Wounds Group Specialised Register on 23 October 2013; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-randomised controlled trials comparing the use of disposable surgical masks with the use of no mask.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently.

MAIN RESULTS

Three trials were included, involving a total of 2113 participants. There was no statistically significant difference in infection rates between the masked and unmasked group in any of the trials.

AUTHORS' CONCLUSIONS

From the limited results it is unclear whether the wearing of surgical face masks by members of the surgical team has any impact on surgical wound infection rates for patients undergoing clean surgery.

Disposable surgical face masks for preventing surgical wound infection in clean surgery

BACKGROUND

Surgical face masks were originally developed to contain and filter droplets of microorganisms expelled from the mouth and nasopharynx of healthcare workers during surgery, thereby providing protection for the patient. However there are several ways in which surgical face masks could potentially contribute to contamination of the surgical wound.

OBJECTIVES

To identify and review all randomised controlled trials evaluating disposable surgical face masks worn by the surgical team during clean surgery to prevent post-operative surgical wound infection.

SEARCH STRATEGY

All relevant publications about disposable surgical face masks were sought through the Specialised Trials Register of the Cochrane Wounds Group (March 2001). Manufacturers and distributors of disposable surgical masks as well as professional organisations including the National Association of Theatre Nurses and the American Operating Room Nurses Association were contacted for details of unpublished and ongoing studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-randomised controlled trials comparing the use of disposable surgical masks with the use of no mask were included.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by AL and PE.

MAIN RESULTS

Two randomised controlled trials were included involving a total of 1453 patients. In a small trial there was a trend towards masks being associated with fewer infections, whereas in a large trial there was no difference in infection rates between the masked and unmasked group. Neither trial accounted for cluster randomisation in the analysis.

REVIEWER'S CONCLUSIONS

From the limited results it is unclear whether wearing surgical face masks results in any harm or benefit to the patient undergoing clean surgery.