Facing Facts: Protective Masks Needed to Combat Endoscopy's High Risk for Contamination

David A. Johnson, MD


February 13, 2019

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

As gastroenterologists, we're acutely aware of infection risks. There's been a tremendous focus on disinfection of endoscopes and transmissibility to patients, but what about protection for the physician and staff in the operating room performing the procedures?

In 2014, the American Society for Gastrointestinal Endoscopy put out guidelines[1] on this topic, suggesting that we understand that there are both low- and high-risk exposure scenarios to consider. At low risk would be those in the room who may not be in direct contact with the patient, endoscope, or secretions, whereas at high risk would be those in direct contact or performing the procedure. However, is that system of differentiation really enough? The guidelines also recommended defaulting to local Occupational Safety and Health Administration guidelines and state regulations. However, the guidelines on facial protection devices have been fairly weak, and although their use may be recommended, the evidence to support doing so has really been lacking. I'll be the first to note that I've never routinely worn these devices unless I have to and have been informed by the nurses that it's an infection-control risk.

A New Study's Concerning Findings

A recent study on this topic was published in Gastrointestinal Endoscopy,[2] in which the authors looked at 1100 procedures performed by four gastroenterologists over 239 morning endoscopy sessions, or approximately five procedures per session. A very meticulous swabbing of the facial shield was conducted before and at the end of the session. The endoscopist was not allowed to touch the face shield in any way, other than lifting it up from with inside if they needed to communicate with the patient. The nurses and the endoscopy staff were attuned to warn the endoscopist if they accidentally touched the mask; if so, that procedural morning was dismissed and not included in the study.

Researchers identified four events where the endoscopist recognized that something had splashed up on their facial shield. The data were pretty strong and very concerning, because they observed a rate of definite facial contamination (measured as > 15 colony-forming units) of 5.6 per 100 half-days of endoscopy. More concerning was the fact that the staff in the room had a facial contamination rate of 3.4 per 100 half-days of endoscopy, despite not being in direct contact; they imposed this by hanging another shield on a wall within 6 feet away from the patient. This means that approximately 60% of those not in direct contact but in the same proximity would actually have had a contamination.

Time to Change Practice

These results tell us that a lot of the physicians and staff have contact with the patient secretions that we don't recognize. This is incredibly alarming to me, having done this for over 35 years without routinely wearing facial protection, but also to the staff who needs to be aware of this well.

The authors also conducted a very interesting survey that included 12 fellows and 19 staff, asking them if they would change their protection efforts if they were aware of this information regarding facial contamination rates. The rate of those saying they absolutely would do so was 58% for fellows versus 17% for the staff; those willing to consider it was 42% for fellows versus 67% for the staff; and those who said absolutely not was 0% for the fellows versus 17% for the staff. This shows that there remains incredible reticence among the staff gastroenterologists to change what they do.

Let's think about what we do when, with the lack of a protective shield, our face is contaminated. We don't necessarily have data that there is contact with the mucous membranes and how that may pose a risk to the staff in the room performing the procedure. But consider the colonization on the face—the endoscopist potentially taking his or her hands and touching the face and then touching a patient. This carries a risk for nosocomial infection, polymicrobial infection, and infection with some high-resistant organisms, Clostridium difficile being one in particular. This face-hand contact during the morning procedure that is followed by touching another patient (or anyone else) may cause exposure. How many of you wash your face between procedures? I certainly don't. This study raises the alarm that we need to be better and more receptive at addressing this risk.

This information to me is incredibly provocative, and although it needs to be confirmed, it is nonetheless a game-changer for me. I'm changing my recommendations for my staff, ensuring that we have adequate protection with the facial plastic shields, and raising awareness of this in a very proactive way. I think you should as well. Give it strong consideration. It's a no-brainer for me; I'm changing now.

This is Dr David Johnson. I look forward to chatting with you again soon, and thanks for listening.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: