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Surgical face masks in the operating theatre: are they still necessary?
Journal of Hospital Infection (2002) 50: 233±239
Letters to the Editor doi:10.1053/jhin.2001.1166, available online at http://www.idealibrary.com on
Surgical face masks in the operating theatre: are they still necessary? Sir, In his recent article on this subject, Romney failed to include several vitally important points.1 Firstly, he cited Meleny's study of 19262 in which the use of the surgical mask was credited for contributing to the reduction of the high and unacceptable rate of surgical site infections. However, he failed to mention Meleny's subsequent study some nine years later (1935) in which he refuted the earlier data and reported that the rate of infection had actually been closer to the original rate of 15% rather than the 2±5% range that had been anticipated.3 For all practical purposes, therefore, the influence of the use of the surgical mask on surgical site infections has yet to be conclusively demonstrated. Secondly, in citing the results of the recent but rather limited study in which `visors' were worn rather than the mask,4 Romney states that `female operating theatre personnel found the visors uncomfortable'. However, the original text states that `In general, the acceptability of the visor was very high. The only adverse comment related to comfort amongst scrub nurses'. Under those circumstances, it is quite possible that a change or modification in the visor's design could overcome that problem. On the basis of Tunevall's comprehensive, prospective in vivo study,5 Beck suggested that the mask could be replaced by what he called a `splashshield'.6 As concluded by Shooter et al. in 19597 and later by Ritter et al. in 1975,8 an item of this nature would protect the patient by deflecting the projectile of air expelled by the surgeon, behind the surgeon's head. This has been confirmed in a study by Cruse (personal communication, P. Cruse, Calgary, Alberta, Canada, November 1996). The use of surgical masks was adopted a century ago because it seemed a reasonable thing to
0195-6701/02/030233 1 07 $35.00/0
do at the time, and the practice has been continued on that basis. In some instances, there have been those who assumed that there were studies that demonstrated its need even though they never sought confirmation to that effect. In the process, its effectiveness has managed to escape criticism and has simply survived the ages by being perpetuated by the `that's the way we've always done it' syndrome. The current literature indicates that in those settings in which a HEPA filtered air circulating system with 17±20 air changes per hour is used, the frequently abused surgical mask could be replaced by a `splash-shield' without compromising the quality of care rendered to the patient. Not to be overlooked is the element of comfort, let alone the savings, to be derived from abandoning its universal use. The real question that remains is whether the surgical community and society in general are prepared to reconsider and reassess the importance of a theoretical, but unproven, age-old practice. N. L. Belkin
1906 Sandpiper Drive, Clearwater, FL 33764, USA
References 1. Romney MG. Surgical face masks in the operating theatre: re-examining the evidence. J Hosp Infect 2001; 47: 251±256. 2. Meleny FL, Stevens, FA. Postoperative haemolytic streptococcus wound infections and their relation to haemolytic streptococcus carriers among the operating personnel. SG&O 1926; 43: 338±342. 3. Meleny FL. Infection in clean operative wounds: a nine year study. SG&O 1935; 60: 264±275. 4. Norman A. A comparison of face masks and visors for the scrub Team. Br J Theatre Nurs 1995; 5: 10±13. 5. Tunevall TG. Postoperative wound infections and surgical face masks: a controlled study. World J Surg 1991; 15: 383±387. 6. Beck WC. The surgical mask. Guthrie J 1993; 62: 97±98. 7. Shooter RA, Smith MA, Hunter CJN. A study of surgical masks. Br J Surg 1959; 203: 246±249. 8. Ritter RA, Eitzen H, French MNL, Hart JB. The operating room environment as affected by people and the surgical face mask. Clin Orthop 1975; 111: 147±150.
& 2002 The Hospital Infection Society
Letters to the Editor doi:10.1053/jhin.2001.1166, available online at http://www.idealibrary.com on
Surgical face masks in the operating theatre: are they still necessary? Sir, In his recent article on this subject, Romney failed to include several vitally important points.1 Firstly, he cited Meleny's study of 19262 in which the use of the surgical mask was credited for contributing to the reduction of the high and unacceptable rate of surgical site infections. However, he failed to mention Meleny's subsequent study some nine years later (1935) in which he refuted the earlier data and reported that the rate of infection had actually been closer to the original rate of 15% rather than the 2±5% range that had been anticipated.3 For all practical purposes, therefore, the influence of the use of the surgical mask on surgical site infections has yet to be conclusively demonstrated. Secondly, in citing the results of the recent but rather limited study in which `visors' were worn rather than the mask,4 Romney states that `female operating theatre personnel found the visors uncomfortable'. However, the original text states that `In general, the acceptability of the visor was very high. The only adverse comment related to comfort amongst scrub nurses'. Under those circumstances, it is quite possible that a change or modification in the visor's design could overcome that problem. On the basis of Tunevall's comprehensive, prospective in vivo study,5 Beck suggested that the mask could be replaced by what he called a `splashshield'.6 As concluded by Shooter et al. in 19597 and later by Ritter et al. in 1975,8 an item of this nature would protect the patient by deflecting the projectile of air expelled by the surgeon, behind the surgeon's head. This has been confirmed in a study by Cruse (personal communication, P. Cruse, Calgary, Alberta, Canada, November 1996). The use of surgical masks was adopted a century ago because it seemed a reasonable thing to
0195-6701/02/030233 1 07 $35.00/0
do at the time, and the practice has been continued on that basis. In some instances, there have been those who assumed that there were studies that demonstrated its need even though they never sought confirmation to that effect. In the process, its effectiveness has managed to escape criticism and has simply survived the ages by being perpetuated by the `that's the way we've always done it' syndrome. The current literature indicates that in those settings in which a HEPA filtered air circulating system with 17±20 air changes per hour is used, the frequently abused surgical mask could be replaced by a `splash-shield' without compromising the quality of care rendered to the patient. Not to be overlooked is the element of comfort, let alone the savings, to be derived from abandoning its universal use. The real question that remains is whether the surgical community and society in general are prepared to reconsider and reassess the importance of a theoretical, but unproven, age-old practice. N. L. Belkin
1906 Sandpiper Drive, Clearwater, FL 33764, USA
References 1. Romney MG. Surgical face masks in the operating theatre: re-examining the evidence. J Hosp Infect 2001; 47: 251±256. 2. Meleny FL, Stevens, FA. Postoperative haemolytic streptococcus wound infections and their relation to haemolytic streptococcus carriers among the operating personnel. SG&O 1926; 43: 338±342. 3. Meleny FL. Infection in clean operative wounds: a nine year study. SG&O 1935; 60: 264±275. 4. Norman A. A comparison of face masks and visors for the scrub Team. Br J Theatre Nurs 1995; 5: 10±13. 5. Tunevall TG. Postoperative wound infections and surgical face masks: a controlled study. World J Surg 1991; 15: 383±387. 6. Beck WC. The surgical mask. Guthrie J 1993; 62: 97±98. 7. Shooter RA, Smith MA, Hunter CJN. A study of surgical masks. Br J Surg 1959; 203: 246±249. 8. Ritter RA, Eitzen H, French MNL, Hart JB. The operating room environment as affected by people and the surgical face mask. Clin Orthop 1975; 111: 147±150.
& 2002 The Hospital Infection Society