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Surgical face masks in the operating theatre
234
Letters to the Editor
doi:10.1053/jhin.2001.1167, available online at http://www.idealibrary.com on
Surgical face masks in the operating theatre Sir, I was very disappointed in Romney's review `Surgical Face Masks in the operating theatre re-examining the evidence'.1 Romney proposed to re-examine the evidence for and against the routine wearing of surgical face masks in the operating theatres. He then proceeded to make recommendations on the basis of his review. Romney reviews no new evidence, as similar recent reviews quote the same supporting data. It is, however, difficult to see why the recommendations were able to pass the editorial review.* Romney quotes two clinical reports examining the question.2,3 Both reports found a decreased rate in wound infection in `non-masked' procedures (one was non-significant).3 He quotes four additional clinical papers and three papers on `filtering efficiency' all of which he notes are unsatisfactory for various technical reasons. He then quotes two nursing organizations' and the CDC guidelines (which use consensus techniques referencing similar data). He then concludes that circulating personnel `should continue to wear surgical face masks' to protect `open sterile items and equipment'. This conclusion is not consistent with the two satisfactory clinical studies which he has presented, and is not consistent with a consensus statement on a similar topic recently published Journal of Hospital Infection.4 There are certainly no additional data presented beyond that quoted in the CDC guidelines whose recommendations are at considerable variance with the discussion, and one cannot be surprised to learn that clinicians, even locally, have not found reason to support these recommendations. Readers may wish to refer to another, more recent paper, which may be viewed as more balanced5 as it is written by clinicians and demonstrates understanding of the operating room environment. R. N. Merchant
Department of Anaesthesia, Royal Columbian Hospital, New Westminster, Canada
*Editorial note: It should be pointed out that the editorial process of the Journal of Hospital Infection leaves the interpretation of the content of a review to the authors.
References 1. Romney MG. Surgical face masks in the operating theater: re-examining the evidence. J Hosp Infect 2001; 47: 251±256. 2. Orr NW. Is a mask necessary in the operating theatre? Ann R Con Surg Eng 1981; 63: 390±392. 3. Tunevall TG. Postoperative wound infections and surgical face masks: a controlled study. World J Surg 1991; 15: 383±388. 4. Guidelines for preventing infections associated with the insertion and maintenance of central venous catheters. J Hosp Infect 2001; 47: S47±67. 5. Skinner MW, Sutton BA. Do anaesthetists need to wear surgical face masks in the operating theater? A literature review with evidence-based recommendations. Anaesth Intens Care 2001; 29: 331±338.
doi:10.1053/jhin.2001.1168, available online at http://www.idealibrary.com on
These letters were shown to Dr. Romney and his reply follows Sir, As a clinician and researcher with considerable experience inside and outside the operating room, I would like to take this opportunity to rebut the inaccurate statements made by Dr. Merchant in his letter, as well as to respond to the comments made by Dr. Belkin. Prior to the publication of my review `Surgical face masks in the operating theatre: re-examining the evidence',1 no systematic review of the topic had been published in the medical literature in over a decade, nor had any of the more recent evidence been critically evaluated. Dr. Merchant seems to be against the use of surgical masks by circulating staff in the operating theatre and has chosen to ignore two very important points made in the review. First, apart from Tunevall's 1991 study,2 much of the recent evidence favouring the discontinuation of masks is based upon studies that were poorly controlled, nonrandomized and lacked blinding. For example, the study by Orr3 is not `satisfactory', as Dr. Merchant claims, nor does it fail to meet the grade for just `technical' reasons. Based upon the criteria for quality evidence explicitly described in the review, the design of Orr's study is fundamentally flawed. Implementing the conclusions drawn from such a study into clinical practice would result in unsound infection control policies.
Letters to the Editor
doi:10.1053/jhin.2001.1167, available online at http://www.idealibrary.com on
Surgical face masks in the operating theatre Sir, I was very disappointed in Romney's review `Surgical Face Masks in the operating theatre re-examining the evidence'.1 Romney proposed to re-examine the evidence for and against the routine wearing of surgical face masks in the operating theatres. He then proceeded to make recommendations on the basis of his review. Romney reviews no new evidence, as similar recent reviews quote the same supporting data. It is, however, difficult to see why the recommendations were able to pass the editorial review.* Romney quotes two clinical reports examining the question.2,3 Both reports found a decreased rate in wound infection in `non-masked' procedures (one was non-significant).3 He quotes four additional clinical papers and three papers on `filtering efficiency' all of which he notes are unsatisfactory for various technical reasons. He then quotes two nursing organizations' and the CDC guidelines (which use consensus techniques referencing similar data). He then concludes that circulating personnel `should continue to wear surgical face masks' to protect `open sterile items and equipment'. This conclusion is not consistent with the two satisfactory clinical studies which he has presented, and is not consistent with a consensus statement on a similar topic recently published Journal of Hospital Infection.4 There are certainly no additional data presented beyond that quoted in the CDC guidelines whose recommendations are at considerable variance with the discussion, and one cannot be surprised to learn that clinicians, even locally, have not found reason to support these recommendations. Readers may wish to refer to another, more recent paper, which may be viewed as more balanced5 as it is written by clinicians and demonstrates understanding of the operating room environment. R. N. Merchant
Department of Anaesthesia, Royal Columbian Hospital, New Westminster, Canada
*Editorial note: It should be pointed out that the editorial process of the Journal of Hospital Infection leaves the interpretation of the content of a review to the authors.
References 1. Romney MG. Surgical face masks in the operating theater: re-examining the evidence. J Hosp Infect 2001; 47: 251±256. 2. Orr NW. Is a mask necessary in the operating theatre? Ann R Con Surg Eng 1981; 63: 390±392. 3. Tunevall TG. Postoperative wound infections and surgical face masks: a controlled study. World J Surg 1991; 15: 383±388. 4. Guidelines for preventing infections associated with the insertion and maintenance of central venous catheters. J Hosp Infect 2001; 47: S47±67. 5. Skinner MW, Sutton BA. Do anaesthetists need to wear surgical face masks in the operating theater? A literature review with evidence-based recommendations. Anaesth Intens Care 2001; 29: 331±338.
doi:10.1053/jhin.2001.1168, available online at http://www.idealibrary.com on
These letters were shown to Dr. Romney and his reply follows Sir, As a clinician and researcher with considerable experience inside and outside the operating room, I would like to take this opportunity to rebut the inaccurate statements made by Dr. Merchant in his letter, as well as to respond to the comments made by Dr. Belkin. Prior to the publication of my review `Surgical face masks in the operating theatre: re-examining the evidence',1 no systematic review of the topic had been published in the medical literature in over a decade, nor had any of the more recent evidence been critically evaluated. Dr. Merchant seems to be against the use of surgical masks by circulating staff in the operating theatre and has chosen to ignore two very important points made in the review. First, apart from Tunevall's 1991 study,2 much of the recent evidence favouring the discontinuation of masks is based upon studies that were poorly controlled, nonrandomized and lacked blinding. For example, the study by Orr3 is not `satisfactory', as Dr. Merchant claims, nor does it fail to meet the grade for just `technical' reasons. Based upon the criteria for quality evidence explicitly described in the review, the design of Orr's study is fundamentally flawed. Implementing the conclusions drawn from such a study into clinical practice would result in unsound infection control policies.