Infectious disease/Brief research report
Use of Adhesive Tape to Facilitate Optimal Mask Positioning and Use in the Emergency Department: A Randomized Controlled Trial

https://doi.org/10.1016/j.annemergmed.2021.06.004Get rights and content

Study Hypothesis

We hypothesize that placing a piece of surgical tape at the bridge of the nose over the mask will improve proper mask use among emergency department patients by creating a physical deterrent to mask removal.

Methods

This study was an open-label single-center randomized controlled trial of a simple intervention to improve mask use performed at Eskenazi Hospital between April 2020 and October 2020. We permitted participants to either use their own mask or the surgical/cloth mask that we provided. We then randomized the participants to either the control group (no tape over the mask/nose) or to the intervention group (tape placed over the face mask at the bridge of the nose). The primary outcome of this study was the frequency at which participants correctly wore their masks upon reevaluation at 60 minutes. A subgroup analysis based on the mask type compared adherence in those with a hospital-provided mask versus in those with a patient-supplied mask.

Results

We enrolled 123 participants in this trial. At 60 minutes, 100% of the intervention group participants were correctly wearing their masks versus 69% of control participants (absolute risk reduction, 31%; 95% CI, 19% to 43%; number needed to treat=3.2 patients). Subjects who were observed wearing their masks incorrectly exhibited some combination of either their mask removed or their nose and/or mouth exposed. Hospital-provided masks were not more likely to be worn correctly (odds ratio, 3.4; 95% CI, 0.9 to 12.3).

Conclusion

Applying a piece of tape to a mask on the bridge of the nose affords a simple, low-cost, and low-risk solution that resulted in 100% of patients wearing their masks correctly at a 60-minute reevaluation.

Introduction

COVID-19 is caused by SARS-CoV-2, and the World Health Organization (WHO) declared COVID-19 a pandemic on March 11, 2020 after the identification of more than 118,000 cases in 114 countries.1 Multiple studies have demonstrated that the predominant route of human-to-human transmission of SARS-CoV-2 is through respiratory droplets and contact routes.2

Editor’s Capsule Summary

What is already known on this topic

Universal mask use is an important strategy to reduce COVID-19 transmission, but improper mask use is common.

What question this study addressed

Does applying adhesive tape to the nasal bridge of a mask worn by emergency department (ED) patients improve adherence with universal mask wearing in the ED?

What this study adds to our knowledge

In this randomized trial of 123 adults, proper mask use at 60 minutes was higher in participants randomized to adhesive tape versus those without (100% versus 69%, respectively).

How this is relevant to clinical practice

Adhesive tape improves patient adherence with universal mask use.

With limited efficacious pharmacologic interventions currently available for treating COVID-19, reducing the transmission is critically important. Containing the spread of infection depends on nonpharmacologic interventions, such as social distancing, the use of personal protective equipment (personal protective equipment [PPE]; eg, masks, gowns, eyewear, gloves), and hand hygiene practices. Universal masking of staff and patients is effective at reducing hospital transmission of the virus, even in the absence of being able to physically distance.3 In one hospital system with more than 9,000 admitted patients, no documented cases of inhospital transmission of SARS-CoV-2 were observed after the implementation of a universal masking policy.4 Reported outbreaks or known cases of hospital-acquired SARS-CoV-2 usually occur in unmasked situations (eg, improper mask use, staff unmasked while eating) or during high-risk procedures (eg, aerosol-generating procedures like endotracheal intubation).3 Additionally, health care workers are among those at high risk of nosocomial infection with COVID-19. According to Centers for Disease Control and Prevention (CDC) data as of April 1, 2021, approximately 11.5% of cases of COVID-19 infection were among health care workers.5 However, this may underestimate the true rate, given that health care personnel status was available for only 18% of total US cases.5 Ensuring adequate access to PPE, improved donning and doffing, improved hand hygiene, and proper mask use are critical strategies for protecting health care workers from infection.

Universal masking of patients and staff is crucial to maintaining low rates of transmission of SARS-CoV-2.6 To our knowledge, no study has examined the multiple factors through which patients incorrectly use face masks, such as mask fatigue or misinformation, nor has work been done at attempting to increase the rate at which patients properly wear face coverings. This is despite moderate-to-poor levels of knowledge and practice regarding facemask usage among health care workers.7

This study aimed to test the hypothesis that applying tape to an emergency department patient’s mask over the bridge of the nose improves adherence of proper mask usage at a 60-minute reevaluation during their ED visit.

Section snippets

Study Design and Setting

This study was an open-label randomized controlled trial at the Eskenazi Hospital ED from April 2020 to October 2020. Eskenazi Hospital is a busy, urban, academic, level 1 trauma center in downtown Indianapolis serving a racially diverse, underserved population with more than 100,000 annual ED visits. This study was approved by the Indiana University institutional review board (protocol #2004425945) and registered on ClinicalTrials.gov (NCT04812184).

Selection of Participants

Patients presenting to the ED were screened

Participants

We screened a total of 130 ED patients, and 123 met the eligibility criteria and agreed to participate in the study (Figure). After randomization, 60 patients were allocated to the intervention group, and 63 were allocated to the control group. After enrollment, 4 patients, specifically 2 from each arm, were discharged before reevaluation.

Characteristics of Study Subjects

Table 1 shows the baseline characteristics of the participants. Participants were well balanced on age, race, disposition, and comorbidities, but more

Limitations

One limitation is that study participants were a convenience sample of adults in a single urban county hospital. We asked participants to enroll “in a clinical research study regarding personal protective gear, which is equipment we all wear to protect each other.” Although they were not informed why we placed a piece of tape on their mask, the cue of physically taping the mask may have contributed to the increased proper use at 60 minutes among the intervention group. However, proper mask use

Discussion

In this study, the application of tape on the bridge of the nose of a face mask resulted in 100% proper mask use at 60 minutes in ED patients. Conversely, participants equipped with masks alone without tape were found to be far less adherent to appropriate mask use during the same time interval. These findings provide evidence that not only is proper mask use among patients in the ED during the COVID-19 pandemic a significant issue, but that ED personnel may positively influence proper mask use

References (10)

There are more references available in the full text version of this article.

Cited by (2)

Please see page 59 for the Editor’s Capsule Summary of this article.

Supervising editor: Nicholas M. Mohr, MD, MS. Specific detailed information about possible conflict of interest for individual editors is available at https://www.annemergmed.com/editors.

Author contributions: NP conceived the study, designed the trial, and obtained institutional review board approval. NP, AZ, BO, MD conducted the trial and data collection, undertook the recruitment of patients, managed the data, assisted in drafting the manuscript, and contributed substantially to its revision. NP performed statistical analysis. NP takes responsibility for the paper as a whole.

All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

Trial registration number: NCT04812184.

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© 2021 by the American College of Emergency Physicians.