Practice Of Wearing Masks To Prevent Infection In Clinical Practice:Myth Or Fact?

Objective:To determine if wearing masks by nurses impacts bacteriological counts of puncture sites and prevents the incidence of phlebitis.Methods:A cross-sectional two group, with three measures survey was conducted to determine the relationship between the bacteriological counts of puncture sites and the incidence of phlebitis in patients with venipuncture as a result of mask wearing practices by nurses (group1wearing masks) and (group2not wearing masks). Three major research tools were used:observation of the nurses’ practice of wearing masks evaluated by a checklist based on the standard procedure; two questionnaires-a demographic questionnaire and the "Mask usage, attitudes and knowledge questionnaire" and the bacteriological counts of venipuncture sites.Results:The results and findings of this study are presented in3parts respectively.Part1:Usage of masks among clinical nurses.95.29%of participants wore masks when doing every nursing procedure. Suspicious contaminated masks were replaced by67.98%(n=361) immediately."Violations of regulations for the proper wearing of masks were:mask not fully cover nose and mouth (38.23%), masks dangling around the neck or on the ears (26.18%), contact with the outside of masks (64.03%), did not wash hands immediately after mask removal (56.12%), surgical masks not discarded into the yellow waste receptacles (25.61%).Attitude towards masks. The rank order from most frequent to least frequent for reasons of being unwilling to wear masks identified by clinical nurses were: uncomfortable, inconvenient, not enough masks for use or replacement, no side effect on patients, no side effect on nurses themselves, worrying about waste of resources. The reasons of not replacing masks timely were ranked as follows:shortage of masks, feel trouble, worry about waste, no side effect on nurses themselves, no side effect on patients. The percentage of wearing masks when nurses meet general clinical situations was as follows:replace injecting drugs (97.9%), pulling out injection needle (94.2%), venipuncture (87.6%), prepare injection drugs in the treatment room (86.8), measure vital signs (73.3%), enter the treatment room without doing any procedure (54.0%), wards round (32.4%), communicate with patients (19.6%), stay in the health care offices (12.4%).Knowledge of correct mask use. The top three highest correct rate of masks related knowledge were as following:both nose and mouth should be covered by masks (97.76%), the disposable mask should be thrown into the yellow waste receptacles after wearing (96.03%), change the mask immediately when it becomes moist (95.78%). The correct rate lower than50%were two aspects related mask removal:touched the outside of masks when removing and whether pull off the under or upper belt first when removing mask. In addition, as for the knowledge about N95masks,84.29%(338/401) of respondents unfamiliar or did not know about the N95and69.75%and (279/400) of respondents never used the N95. Only8%of respondents who had used the N95mask did a fit test before use.Part2:The standard behavior of mask use among clinical nurses.284clinical nurses in four clinical units (medical,surgical, intensive care and infectious disease) unit were observed and1323violations of mask use s were recorded. The highest frequency of occurrence was as follows:touch the outside of masks, not cover both mouth and nose, not wash hands after taking off mask removal, fold masks into their pockets after use and, not hand washing before taking off masks.Bacterial count of masks based on units and types of masks.. The results revealed:significant statistical difference among different clinical departments (p=0.000); statistically significant between medicine department and surgical department; difference were also statistically significant between intensive care unit and medicine department or surgical department or infective disease department, by pair-comparison. The average of bacterial count numbers of284sampled masks was2.06±4.129, there were no statistically significant differences between cotton masks and surgical masks (p=0.141).Bacterial counts on inside and outside of masks and time variance. The masks’ contamination difference between inner and outer of masks and different duration of use. Significant differences between two groups below2hours and over8hours were detected..No differences between inner and outer surfaces of worn cotton masks and no difference between different duration of use for surgical masks. There were no statistical differences in the totally group related to varying duration of use of cotton masks.Correlation between behavior of mask uses and contamination. There were positive correlations between bacterial counts and noncompliance of standards for mask use:touch the outside of masks, no hand washing before mask removal, masks folded into pockets after use, hanging masks on the ear, and not fully covering both mouth and nose when in use.The regression analysis of influencing factors on mask’bacterial count numbers. Correlation between bacterial counts, department units and5noncompliant behaviors were determined by one-way ANOVA and Pearson correlation. To determine which factor(s) influence the bacterial count, multiple stepwise regression analysis was conducted and4factors were found:contact with the outside of masks, no hand washing after mask removal, duration of use of cotton masks and no hand washing before,mask removal (R=0.578, R2=0.335, F=22.002, P=0.000).Part3:Patients with a venipuncture who participated in the study to determine development of phlebitis based on the use or misuse of masks included199inpatients selected from the research hospital. The sample included120men and79women, aged18-93years (52.35±19.07years). These inpatients were in the following departments:33(cardiology department),28(gastroenterology department),70(orthopedics department),37(general surgery department), and31(urology department). The general information of patients and nurses in the masked group and the non-masked group showed no significant differences. There was no significant differences found in the bacterial colonies after disinfection between two groups (χ2=0.024, P=0.594). There was also no significant difference in the incidence of phlebitis observed between the two groups (χ2=0.403, P=0.630).Conclusion:The conclusion can be found from the study of Part1as following:Clinical nurses do not follow the recommend procedure for mask use. Clinical nurses’ attitudes toward wearing masks were related to inadequate mask supply, mask material uncomfortable and nurses’ lack of awareness of standards. Mask-related knowledge among clinical nurses was low and the compliance to correct mask use should be improved.The following conclusion can be drawn from Part2:There were serious abuses of mask use among clinical nurses. The bacterial counts of masks among clinical nurses was higher with unequal distribution based on clinical unit. Correlations between bacterial contamination of masks and5nonstandard or incorrect behaviors of mask use among clinical nurses such as touching the outside of masks, no hand washing before and after mask removal, placing folded masks into pockets after use, hanging masks on the ears and not fully cover both mouth and nose. Predictive factors on mask bacterial count found in this study were:contact with the outside of masks, no hand washing after mask removal, long duration of use of cotton masks, no hand washing before mask removal.The conclusion can be drawn from the study of Part3:When healthy nurses perform venipuncture for patients without respiratory tract infections, mask wearing does not affect the incidence of phlebitis or the quality of disinfection, i.e., the number of bacterial colonies on the surface of the disinfected puncture site.In summary, problems exist in the requirement to wear masks among clinical nurses in China; there is serious non-compliance with standard procedure for wearing masks; wearing masks do not affect the incidence of phlebitis or the quality of disinfection, i.e., the number of bacterial colonies on the surface of the disinfected puncture site, when healthy nurses perform venipuncture for patients without respiratory tract infections. Further studies should be conducted to conclusively ascertain whether masks should be worn for every healthcare procedures.