National Patient Safety Alert: Infection risk when using FFP3 respirators with valves or Powered Air Purifying Respirators (PAPRs) during surgical and invasive procedures

Summary

The purpose of wearing a type II fluid resistant surgical mask (FRSM) during surgical and invasive procedures is to minimise the transmission of pathogens in the nose, mouth and throat of staff to patients. They also protect staff from splash or spray of blood/body fluids onto their respiratory mucosa (nose and mouth).

A wide range of FFP3 respirators have been used as protection by staff across healthcare settings during the COVID-19 pandemic, including FFP3 respirators with and without exhalation valves. The exhalation valves do not filter exhaled breath, even when of a ‘shrouded’ type. Current infection control guidance states that: “Valved respirators should not be worn by a healthcare worker/operator when sterility directly over the surgical field is required, eg in theatres/surgical settings or when undertaking a sterile procedure”.

Powered hoods (also known as powered air purifying respirators or PAPRs) have been provided as respiratory protective equipment (RPE) for staff unable to achieve a tight fit with an FFP3 respirator(s). The air exiting PAPR hoods is not filtered.

Incident reports received since March 2020 identified five incidents describing dripping of condensation from the exhalation valve of an FFP3 respirator, potentially compromising the sterile field; one cerebral abscess involving an oral bacterium linked to the use of a valved FFP3 respirator during brain surgery; and three cases of endocarditis linked to PAPR use during cardiac surgery. These incident reports and feedback from services suggest that the risks of valved respirators and PAPRs for surgical and invasive procedures is not well recognised, and that their use may have become routine in some theatre environments.

Actions

Actions to be completed by 25 Nov 2021:

Revise procedures, purchasing processes, stock supply, checklists, and stock labelling to ensure:

1. Type II FRSMs and non-valved FFP3 respirators are available for departments undertaking surgical or invasive procedures.

2. Valved FFP3 respirators/PAPR are removed from any areas that do not need them.

3. Staff whose only respiratory protection equipment option is a PAPR or valved FFP3 respirator are informed that these should not be worn when undertaking a sterile procedure or directly over the surgical field,  except when Note A applies (see full alert).

4. In areas where valved and non-valved FFP3 respirators need to be stocked, clear point of use warnings are attached that the valved FFP3 respirators should not be worn when undertaking a sterile procedure or directly over the surgical field, 1 except when Note A applies (see full alert).