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Neutropenic precautions and paper masks

  • 1.  Neutropenic precautions and paper masks

    Posted 08-06-2019 10:37
    ​​Typically at our practice when we discuss neutropenic precautions with patients we give them a few paper masks to use if they have to be out in a crowd or travel etc.  We recently hired a new nurse with many years of pediatric oncology experience and she said at her former practice they didn't recommend the paper masks because they were almost completely ineffective after something like 4 minutes.  This is related to the moisture on the mask surface from normal exhalation.  My question is what do other practices recommend doing for their neutropenic patients?  All the articles I found online discussed the need for more studies and that basically, the researchers were not sure about effectiveness.  Thanks for any input you guys have.  If there is a particularly good article would you forward that on to me please?

    Melissa Suttles
    Oncology Clinical Services Manager
    Arden NC

  • 2.  RE: Neutropenic precautions and paper masks

    Posted 08-06-2019 12:42
    We only require masks for patients who have respiratory symptoms--and it's to protect the rest of us, not the patients. Our Infection Prevention and Infectious Disease teams have said that masks have a 30 minute wear time--due to moisture.

    As an aside, we've been treating profoundly neutropenic BMT patients for 5 decades, and de-masked our staff some 30 years ago due to lack of any proven efficacy. Best prevention techniques continue to be having patients avoid anyone who is sick (and young children), and proper hand-washing for patients and staff.


    Seth Eisenberg RN ASN OCN BMTCN
    Seattle Cancer Care Alliance
    Federal Way WA

  • 3.  RE: Neutropenic precautions and paper masks

    Posted 08-07-2019 08:40

    I was part of a group that did an EBP project on mask wearing in neutropenic patients and then presented a poster at APHON a few years ago. At that time, the literature did not support surgical masks providing any real benefit for the neutropenic patient. They were not designed to keep things away from the person wearing the mask, they were designed to keep things inside the mask (droplets from healthcare providers) away from surgical sites. We found some small in vivo studies, and a lab based study that tested the different masks and protection from controlled particle concentrations in the enviornment.

    The only possible benefit mentioned in any of the studies was, a mask indicates to other people the individual is sick, and that may make other people keep their distance. The mask may indirectly provide benefit by keeping sick people further away from immune compromised patients.

    They did find some benefit in patients wearing N95 masks, especially in areas where construction was happening within the hospital. But then there are problems with ensuring the correct fit. And since I also work in pedatrics and have been unable to locate pediatric sized N95 masks (and highly doubt most pediatric patients would tolerate them), that hasn't been implemented most places I have worked.

    Though even with the EBP project complete, not every where I have worked has changed their practice. Partly because people think it can't hurt to have patients wear the masks (although struggling with a screaming toddler who does not want anything on their face is the reason we started the EBP project in the first place). And partly beacuse some patients expect it because they've seen movies and such with cancer patients. And partly because the evidence isn't super strong in vitro (though does seem pretty strong in vivo.)

    RIght now where I work, we don't have a firm guideline, but most patients do not wear masks.

    Amanda Lulloff PhD RN PCNS CPHON
    Clinical Nurse Specialist
    Blank Children's Hospital

  • 4.  RE: Neutropenic precautions and paper masks

    Posted 08-07-2019 09:46
    Great replies from Seth and Amanda. Here is some literature that goes with what they wrote:

    The 2018 "Prevention of Infection: A Systematic Review of Evidence-Based Practice Interventions for Management in Patients With Cancer" -- it includes the following statement/reference about masks:

    There is no evidence that protective gear (gowns, gloves, and masks) are effective in preventing infection when caring for neutropenic patients (Freifeld et al., 2011).

    Freifeld, A.G., Bow, E.J., Sepkowitz, K.A., Boeckh, M.J., Ito, J.I., Mullen, C.A., . . . Wingard, J.R. (2011). Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 52, 427–431.

    The CDC guideline at references the following article on masking of neutropenic patients but in the context of during periods of construction:

    During periods of construction, to prevent inhalation of respirable particles that could contain infectious spores, provide respiratory protection (e.g., N95 respirator) to patients who are medically fit to tolerate a respirator when they are required to leave the Protective Environment945, 158. Category II

    945. Raad I, Hanna H, Osting C, et al. Masking of neutropenic patients on transport from hospital rooms is associated with a decrease in nosocomial aspergillosis during construction. Infect Control Hosp Epidemiol 2002;23(1):41-3.

    The following was presented at MASCC but it's the health care provider (not patient) wearing the mask:

    From – "Low Evidence: wearing mask by the health care provider"

    P. Combrez
    Department of Hematology and Hematopoietic Stem Cell Transplantation, Jules Bordet Institute, Brussels, Belgium
    Neutropenia is the most common dose-limiting toxicity of cancer chemotherapy, and complications from chemotherapy-induced neutropenia
    (CIN) can cause significant morbidity and mortality. In fact, Given and
    Shewood (2005) identified CIN as a nursing-sensitive patient outcome
    symptom. Expert nursing assessmant, intervention, education and evaluation facilitate patient management of CIN.
    To identify and highlighted evidence-based management of CIN and
    related complications, and to provide effective nursing interventions
    which should be implemented in daily practice.
    Extensive review and summary of published neutropenia litterature, clinical practice guidelines and meta-analyses.
    Prevention of infection should be the primary focus of oncology nurses'
    practice rather than management of neutropenia.
    Based on a review of the litterature following classification of costeffective nursing interventions for the prevention and management of
    febrile neutropenia (FN), according to the level of evidence, can be
    Low Evidence: wearing mask by the health care provider, low bacterial
    food and dressing of tunneled central catheters.
    Moderate Evidence:systematic use of HEPA-filtered air for prevention of
    Aspergillus infection and Laminar Air Flow rooms.
    High Evidence: frequent oral care, venous access devices not
    placed during neutropenia, antimicrobial prophylaxis if neutropenia ≤ 500/mm3 is expected during more than 7 days, construction
    barriers, avoiding fresh flowers and plants and prompt action
    when neutropenic fever (administration of antibiotics in 2 h after
    first fever).
    Oncology nurses play critical roles in the areas of clinical practice, research and education as related to the prevention and management of CIN
    and are charged with maintaining their knowledge of the evidence and
    guidelines. In doing so, oncology nurses can be confident that clinical
    evidence is driving their decision-making processes to ensure quality
    cancer care and provide patients with the best opportunity for favorable
    long-term outcomes.

    Mark Vrabel
    Oncology Nursing Society
    Pittsburgh PA