Skill List > Use of Masks
Clinical Alert
The order of removal of personal protective equipment (PPE) must be adhered to.

Please note: The information below is for general use of masks. Additional precautions are required if looking after a patient with suspected or confirmed COVID-19. In particular, hand hygiene should be performed at specific stages of equipment removal. The order for PPE removal is gloves, hand hygiene, apron or gown, eye protection, hand hygiene, surgical face mask or FFP3 respirator, hand hygiene (Public Health England 2020).

New recommendations from 6th April 2020 state that gloves and aprons remain single use only, as per existing Standard Infection Control protocols, with disposal after each patient or resident contact. However, fluid repellent surgical mask and eye protection can be used for a session of work rather than a single patient or resident contact. Similarly, gowns can be worn for a session of work in higher risk areas. Hand hygiene should be practised and extended to exposed forearms, after removing any element of PPE (Public Health England, DHSC et al. 2020). As these are rapidly developing recommendations, the reader is advised to check Public Health England and NICE websites for updates.

Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:
Based on Nicol: Essential Nursing Skills 4E
Adapted by: Professor Maggie Nicol BSc(Hons) MSc(Nursing) PGDipEd RN
Updated by: Janet Hunter MA BSc(Hons) PGCE; Karen Rawlings-Anderson BA(Hons) MSc DipNEd; Marsh Gelbart BA(Hons) MA PGCert RN 
Last updated: April 2020
 
Learning Objective
After reading the skill overview, watching the video, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of using masks to prevent infection.

Introduction

Masks form part of personal protective equipment (PPE) that is used to protect you and your patients from the risks of cross-infection. It includes aprons, gloves, masks, goggles, and visors, and, in areas such as the operating theatre, may also involve the use of gowns and hats (Loveday et al. 2014). The advent of SARS in 2003 was a timely reminder that the correct usage of PPE is essential to protect healthcare staff as well as patients. Some 20% of those infected were healthcare providers (Brown et al 2019). 

There are two types of mask available: surgical face masks and respirator masks. Surgical masks are designed to minimise the risk of large respiratory droplets being expelled from the mouth and nose during invasive procedures such as surgical procedures. They are also used to protect mucous membranes of healthcare staff from contamination with body fluids in situations where splashing may occur.

Respirator masks are designed to protect against inhalation of airborne droplets that may transmit tuberculosis and some respiratory viruses. They will only provide protection if they fit closely around the nose and mouth so that air is not drawn in at the sides (Bunyan et al. 2013, Health Protection Scotland 2015). Respirator masks are categorised according to the efficiency of the filtration provided. FFP means filtration face piece. FFP2 masks filter with 95% efficiency; FFP3 masks achieve 98% efficiency (Health Protection Scotland 2015).

Until recently, masks were not routinely worn to protect patients from micro-organisms from the respiratory tract of the staff caring for them or to protect staff caring for patients with infectious diseases. Their use was only recommended in situations where there was a high risk of splashing of blood or other body fluids, and for patients with active pulmonary tuberculosis when they left their single room (Bunyan et al. 2013). However, pandemics of H1N1 influenza (swine flu) and Ebola have meant that masks are now recommended. When caring for patients with H1N1 influenza, especially when performing aerosol-producing procedures such as chest physiotherapy, administering a nebuliser, or caring for patients receiving continuous positive airway pressure (CPAP), masks should be worn. Staff within two metres of a patient with COVID-19 should wear a fluid-resistant surgical mask. In the case of suspected or diagnosed COVID-19, a FFP3 mask (a filtering facepiece respirator) and visor must be worn if any aerosol-producing procedures are being performed (Public Health England 2020; Public Health England, DHSC et al. 2020).

Preparation and safety


  • Although evidence is limited, patients with pulmonary tuberculosis usually wear surgical masks whenever they leave their single room (Bunyan et al. 2013).
  • Staff should wear FFP2 or FFP3 masks when caring for a patient with pandemic flu or COVID-19.
  • FFP3 masks must not be worn by patients. They are designed to allow expired air to escape via the valve in the mask and therefore will not prevent droplet or aerosol spread. FFP3 respirators should be placed on before entering the patient’s room or prior to performing aerosol generating procedure (Health Protection Scotland 2014).
  • Surgical masks are recommended for use in the operating theatre and if in contact with patients with pandemic flu. Healthcare staff and patients wear them to prevent droplets being expelled from the mouth and nose into the environment. They protect the wearer from splashing or spraying of blood, body fluids, secretions and excretions. Eye protection (goggles or a visor) is added when there is a risk of splashing of blood or body fluids into the mouth, nose, or eyes (Health Protection Scotland 2014).
  • Respirator masks are worn to protect healthcare workers from inhaling harmful airborne infectious aerosols either directly from the patient or from aerosol-generating procedures such as open suctioning. These masks are categorised according to their filtration efficiency and your institution’s infection control policy will determine when each should be used (Coia et al. 2014):
    • FFP2 (filtration face piece) masks, which offer 95% efficiency, may be required when caring for patients with active pulmonary tuberculosis
    • FFP3 masks, which offer 98% efficiency, will be required when performing aerosol producing procedures (Health Protection Scotland 2015).
  • The apron or gown should be put on before the mask. Check carefully that you have the right type of mask.
  • The mask ties should be secured above the ears in the middle of the head and below the ears at the neck.
  • The flexible band at the nose should be adjusted to ensure a close fit.
  • The mask should fit snugly on the face and below the chin. The FFP3 can only provide effective protection if the wearer is clean shaven. A different type of appropriate protection, such as a powered hood, should be considered if a good fit cannot be achieved (Health Protection Scotland 2015).
  • The mask should not be touched when it is being worn or being removed.

Additional PPE such as gloves, apron/gowns and goggles should be removed (in stated order) prior to removal of the mask or respirator. This reduces the risk of cross/self-contamination (Loveday et al. 2014).

Procedure

Surgical mask with elastic loops

  • Place the loops over the ears and adjust the flexible nose section to ensure a close fit.
  • Pull the lower part of the mask under the chin. Rationale – To ensure air is breathed through the mask rather than around it.
  • Remove any gloves, then apron/gowns, followed by goggles and mask. Rationale – In order to minimise cross/self-contamination.
  • To remove the mask, use the loops to remove the mask from the ears and take it away from your face.
  • Holding just the loops, discard it into the clinical waste. Rationale – To prevent contamination of your hands by touching the mask, which will have become moist due to respiration.
  • Perform hand hygiene following disposal.

Surgical mask with ties

  • Place the mask over the nose and tie the top tape above the ears at the middle of the head.
  • Adjust the flexible nose section and pull under the chin to ensure a close fit.
  • Tie the second tape below the ears at the neck.
  • Check you have a close fit over the nose and under the chin. Rationale – To ensure air is breathed through the mask rather than around it.
  • Remove any gloves, then apron/gowns, followed by goggles and mask. Rationale – In order to minimise cross/self-contamination.
  • To remove the mask, untie or break the lower tie and then the upper one. Rationale – Untie/break the lower tie first so that the mask stays in place as you unfasten the second tie.
  • Holding the ties only, discard the mask in the clinical waste. Rationale – To prevent contamination of your hands by touching the mask, which will have become moist due to respiration.
  • Perform hand hygiene following disposal.

Surgical mask with visor attached

This should be worn when there is a risk of splashing of blood or body fluids, for example, during tracheal suctioning.
  • This is put on in the same way: first the top tie, then adjust the nose section, pull under the chin, and then the second tie.
  • Check you have a close fit over the nose and under the chin. Rationale – To ensure air is breathed through the mask rather than around it.
  • Remove any gloves, then apron/gowns, followed by goggles and mask. Rationale – In order to minimise cross/self-contamination.
  • It is removed in the same way by untying or breaking the ties and handling only the ties. Do not touch the mask. Rationale – Untie/break the lower tie first so that the mask stays in place as you unfasten the second tie.   Prevent contamination of your hands by only touching the ties as the mask will have become moist due to respiration.
  • Perform hand hygiene following disposal.


Duck-billed FFP2 mask

  • Open the mask, stretch out the straps, and place it under your chin. Adjust the elastic straps so that one is above the ears in the middle of the head and one is below.
  • Check you have a close fit over the nose and under the chin. Rationale – To ensure air is breathed through the mask rather than around it.
  • Remove any gloves, then apron/gowns, followed by goggles and mask. Rationale – In order to minimise cross/self-contamination.
  • Break or remove the ties and discard the mask in the clinical waste without touching the mask. Rationale – Untie/break the lower tie first so that the mask stays in place as you unfasten the second tie. Prevent contamination of your hands by only touching the ties as the mask will have become moist due to respiration.
  • Perform hand hygiene following disposal.

Cone-shaped FFP2 mask

  • This is put on in the same way, but has an additional piece to ensure a close fit at the nose. Rationale – To ensure air is breathed through the mask rather than around it.
  • It is removed in the usual way by breaking the straps or removing them. Rationale – Untie/break the lower tie first so that the mask stays in place as you unfasten the second tie. 
  • Remove any gloves, then apron/gowns, followed by goggles and mask. Rationale – In order to minimise cross/self-contamination.
  • Discard the mask in the clinical waste without touching the mask. Rationale –  Prevent contamination of your hands by only touching the ties as the mask will have become moist due to respiration.
  • Perform hand hygiene following disposal.


Duck-billed FFP3 mask

  • Because this mask is worn for aerosol-generating procedures such as tracheal suctioning, a gown, goggles or visor are also worn. Rationale – These afford additional PPE.
  • Open the mask, stretch out the straps, and place it under your chin.
  • Adjust the elastic straps so that one is above the ears in the middle of the head and one is below. Check you have a close fit over the nose and under the chin. Rationale – To ensure air is breathed through the mask rather than around it.
  • Remove any gloves, then apron/gowns, followed by goggles and mask. Rationale – In order to minimise cross/self-contamination.
  • Perform hand hygiene following disposal.

FFP3 mask with a valve to allow expired air to escape

  • FFP3 masks must only be worn by staff, not patients. Rationale – These masks are designed to allow expired air to escape via the valve in the mask and therefore will not prevent droplet or aerosol spread from patients.
  • Stretch out the straps and place the mask under your chin. Adjust the elastic straps so that one is above the ears in the middle of the head and one is below. Check you have a close fit over the nose and under the chin. Rationale – To ensure air is breathed through the mask rather than around it.
  • Goggles and a disposable gown should be worn when involved in aerosol generating procedures.
  • Remove any gloves, then apron/gowns, followed by goggles and mask. Rationale – In order to minimise cross/self-contamination.
  • Perform hand hygiene following disposal.

Ongoing care, monitoring and support

  • All masks are single use only and cannot be reused once removed.
  • Surgical masks can be used until they feel moist or humid.
  • FFP2 and FFP3 masks can be worn for up to 8 hours if necessary, but once removed cannot be reused.
  • If the goggles are reusable, they should be washed in hot, soapy water and dried thoroughly.

Documentation and reporting

  • Signs may be required to explain the need for masks to patients, healthcare professionals, and visitors.
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