PPE Best Practice

Level of Barrier Protection for Surgical Face Masks

Surgical masks and N95 respirators are used to protect the wearer from airborne particles and droplets contaminating the face and are regulated by the Therapeutic Goods Administration (TGA), Centres for Disease Control and Prevention (CDC) and the US Food and Drug Administration (FDA). It is important to recognise that the optimal way to prevent airborne transmission is to use a combination of interventions from across the hierarchy of controls, not just personal protective equipment (PPE) alone.

Surgical Face Masks

Surgical, or procedure face masks are single-use disposable masks mainly used by health care professionals to protect themselves and others from the spread of airborne infectious diseases, bodily fluids and particulate matter (FDA, 2020) During a disease outbreak, health departments may recommend that members of the public wear surgical masks to protect themselves as well (FDA, 2020). Surgical masks prevent large droplets of bodily fluids that may contain viruses or germs from escaping from the nose and mouth such as from someone sneezing and coughing (Healthline, 2020). A study by Milton et al., (2013) looked at how masks could help people with the seasonal flu limit spreading it when they exhale small droplets containing the virus. The study found that masks led to over threefold reduction in the number of virus people transmitted in the air.

Surgical masks can vary in design, but the mask itself is often flat and rectangular in shape with pleats or folds. The top of the mask contains a metal strip that can be formed to your nose. Elastic bands or long, straight ties help hold a surgical mask in place while you are wearing it. These can either be looped behind your ears or tied behind your head. These masks are generally designed to completely cover both the mouth and nose.

Infection Control Practices: ​

  • Procedure masks are single patient, single-use PPE ​
  • Masks should be removed once the patient interaction is complete and outside the clinical space​
  • Handle masks for disposal via the loops or ties only and perform hand hygiene.
  • Best practice dictates immediate disposal and replacement of exam gloves following exposure to blood or bodily fluid

Note: Wearing a surgical mask in public settings can benefit you tremendously. You must also wear a surgical mask if you have COVID-19 and need to be around others or if you are caring for someone at home who can’t wear one (CDC, 2020). The edges of the mask are not designed to form a seal around the nose and mouth (FDA.gov, 2020).

N95 Respirators

An N95 respirator is an important piece of PPE for health practitioners as it can block 95% of microscopic particles (down to 0.3 microns) and protect them against airborne infectious diseases, such as tuberculosis and anthrax (FDA, 2020They must form a perfect seal around the mouth and nose so there is no way for airborne viruses to enter, hence why N95 respirators fit more securely on your face compared to surgical masks (CEC, 2020). N95 respirators are not designed for use by children or by people who have facial hair as a tight seal cannot be achieved (CDC, 2020

Some N95 respirators come with an exhalation valve that is designed to reduce condensation build-up inside the mask and allow the wearer to breathe easier (NPPTL, 2020). These respirators, however, should not be used in a situation where a sterile field is required as the exhalation valve allows unfiltered (and possibly contaminated) air to leave the mask (NPPTL, 2020).  In general, each type of N95 respirator should come with detailed instructions from the manufacturer explaining how to put on and take off the respirator. The Occupational Safety & Health Administration (OSHA) also requires users to be trained on how to fit and use N95 respirators (NPPTL, 2020).

Note: It is important to note that not all N95 respirators are tested for fluid resistance to be used as surgical N95s in the perioperative setting.

Cloth Face Masks

A cloth face mask can be used in public settings when it is difficult to maintain physical distance between others by providing an extra layer to help prevent respiratory droplets from travelling in the air and onto other people (CDC,2020). These masks are made from household items or common materials at low cost and can be used as an additional, voluntary public health measure (CDC, 2020). However, they do not offer the same level of protection as surgical face masks or respirators with a recent study indicating homemade face masks maybe half as effective as surgical masks and up to 50 times less effective than N95 respirators (Davies et al (2013).  Despite this, the CDC is now recommending that everyone wear cloth face masks out in public as they can help reduce the community spread of viruses (Healthline, 2020). This includes helping prevent people who do not exhibit symptoms (asymptomatic or pre-symptomatic) of COVID-19 from transmitting the virus via respiratory droplets (CDC,2020).

Wearing Cloth Face mask does not replace or reduce the need for other protective measures. Proper hygiene practices and physical distancing are still the best methods of keeping yourself safe (Xiao J et al., 2020). A study examining non-pharmaceutical interventions to reduce flu rates found that influenza viruses were lowered when masks were paired with proper hand hygiene (Smith et al., 2016). Regularly washing your hands remains an essential method to prevent the spread of infectious viruses.

NOTE: Wash homemade cloth masks after every use. Do not put cloth face masks on children under 2 years old, people who have trouble breathing, people who are unconscious, or people who are unable to remove the mask on their own (CDC, 2020).

Face Mask Safety Tips

  • Always wash your hands before and after mask use. Proper hand hygiene is essential to prevent contamination.
  • Put on and take off mask by holding it by the ear loops or ties, do not touch the front of the mask.
  • Make sure face mask fits snugly and straps fit securely over your ears or behind your head.
  • Avoid touching the mask while it is on your face as most contamination is present on the outer side of the face mask.
  • If using cloth mask: Run mask through washer and dryer after each use. Use laundry detergent or bleach solution when washing your mask.  Place the face mask in a paper bag and store it in a warm, dry place for 2 or more days before wearing it again (CEC, 2020).
  • If you must reuse respirator or surgical mask, isolate it in a breathable container such as a paper bag for at least 7 days (CEC, 2020). This helps ensure the virus is inactive and no longer infectious.

The 5 Fs of selecting the risk mask (Maxwell and Boring, 2018)

The aim is to always keep safety top of mind for both the wearer and others around you. For both safety and comfort, follow these four best practices for mask selection:

Filtration

  • When smoke is present or interacting with a patient with a known or suspected aerosol transmittable disease, use a high filtration mask (N95 respirator).

Fluid Resistance

  • Wear a fluid-resistant mask if there is any chance of blood and/or bodily fluid splatter.ASTM Level 3 surgical masks are recommended.

Feature

  • Earloops work better for everyday situations, while masks with ties can be securely fastened the mask with two points, works better for surgical procedures.
  • To reduce distractions from fogging issues, consider anti-fog film or foam material masks.

Fit

  • Ensure the correct mask has also the correct fit when worn.
  • Be sure it covers your nose and mouth completely, which creates a barrier around the face to prevent the risk of contamination exposure.

Feel

  • Lastly, a fifth consideration is the ‘Feel’ of the mask.

The right mask should also be comfortable and breathable to the wearer.

Reference List:

  1. Maxwell, A and Boring, T. L., 2018. American Society For Testing And Materials Medical Mask Protection Standards And How To Select The Right Mask.. [podcast] Available at: <https://www.beckersasc.com/webinars/cardinalhealth_webinar_june.pdf> [Accessed 18 June 2020].
  2. CDC. 2020. Ancillary Respirator Information, Healthcare Faqs | NPPTL | NIOSH | CDC. [online] Available at: <https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource3healthcare.html> [Accessed 18 June 2020].
  3. Clinical Excellence Commission (2020). Infection Prevention And Control – Clinical Excellence Commission. [online] Available at: <http://www.cec.health.nsw.gov.au/keep-patients-safe/infection-prevention-and-control> [Accessed 18 June 2020].
  4. Davies, A., Thompson, K., Giri, K., Kafatos, G., Walker, J. and Bennett, A., 2013. Testing the Efficacy of Homemade Masks: Would They Protect in an Influenza Pandemic?. Disaster Medicine and Public Health Preparedness, 7(4), pp.413-418.Food Administration and Drug (2020) https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/face-masks-and-surgical-masks-covid-19-manufacturing-purchasing-importing-and-donating-masks-during
  5. Healthline. 2020. Best Face Mask Options For Coronavirus Protection. [online] Available at: <https://www.healthline.com/health/best-face-mask-2> [Accessed 18 June 2020].
  6. Lim, S., 2020. What Are The Main Types Of Face Masks & Who Should Use Them?. [ebook] SYDNEY: Safe Work Australia. Available at: <https://www.safeworkaustralia.gov.au/doc/types-and-uses-face-masks#picModal> [Accessed 18 June 2020].
  7. Radonovich, L., Simberkoff, M., Bessesen, M., Brown, A., Cummings, D., Gaydos, C., Los, J., Krosche, A., Gibert, C., Gorse, G., Nyquist, A., Reich, N., Rodriguez-Barradas, M., Price, C. and Perl, T., 2019. N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel. JAMA, 322(9), p.824.Recommendation regarding the use of cloth face coverings, especially in areas of significant community-based transmission. (2020).cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover.html
  8. Smith, S., Sonego, S., Wallen, G., Waterer, G., Cheng, A. and Thompson, P., 2015. Use of non-pharmaceutical interventions to reduce the transmission of influenza in adults: A systematic review. Respirology, 20(6), pp.896-903.
  9. Szarpak, L., Smereka, J., Filipiak, K., Ladny, J. and Jaguszewski, M., 2020. Cloth masks versus medical masks for COVID-19 protection. Cardiology Journal, 27(2), pp.218-219.Uchida M, et al. (2016). Effectiveness of vaccination and wearing masks on seasonal influenza in Matsumoto City, Japan, in the 2014/2015 season: An observational study among all elementary schoolchildren. DOI:10.1016/j.pmedr.2016.12.002
  10. Xiao J, et al. (2020). Nonpharmaceutical measures for pandemic influenza in nonhealthcare settings—personal protective and environmental measures.wwwnc.cdc.gov/eid/article/26/5/19-0994_article

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