Surgical Attire: Professional Accountability Notes
October 27, 2010
Speaker: Joan Blanchard, RN, BSN, MSS, CNOR, CIC
Compare surgical attire that should be worn in the semirestricted and restricted
areas of the perioperative suite
Identify components of surgical attire that may introduce safety issues for patient’s,
healthcare personnel, their families and the community
Discuss the advantages of using an accredited laundry facility
PURPOSE OF SURGICAL ATTIRE FOR NONSCRUBBED PERSONNEL
Surgical attire is worn to promote healthcare personnel safety and a high level of cleanliness
Handwashing Prior to Donning Clean Surgical Attire
Hands may become contaminated with debris from the home or any place stopped along the
way to work
Wash hands with:
_ soap and water
_ antiseptic and water, or
_ a hand rub if no visible soil is present RP Hand Hygiene
Surgical Attire in the Semirestricted Area
Surgical attire should be
_ Low-linting material
_ Contain skin squames
_ Provide comfort and safety
_ Have a professional appearance
Head coverings include
Disposable bouffant caps and hoods
1. Disposable bouffant caps and hoods are single use and disposed of daily and when
contaminated or soiled
2. Disposable hoods should cover side burns and hair at nape of neck
Reusable fabric caps
- Cover all hair
- Reusable fabric caps should be washed daily
- Tuck scrub top into pants to decrease shedding Scaltriti et al
- No evidence to show scrub tops and pants are preferable to dresses
Jewelry should be contained and confined within the surgical
Earrings are contained within the caps – no dangles Field et al
Necklaces are contained within the scrub top
Watches are removed for hand washing and scrubbing Field et al Jeans et al Graves
Rings are removed for hand washing and scrubbing Boyce & Pittet Salisbury et al
Kelsall et all Trick et al
Bracelets should not be worn in the perioperative setting as they move up and down
the arms Field et al Bartlett et al Graves et al
Warm-up jackets are part of the surgical attire
Worn snapped-up with cuffs down to the wrists
Photo identification badges should be worn by all personnel so that they are visible
Badges assist in identifying personnel who are authorized
Badges support security measures
In emergency operations badges are worn
AORN Position Statement Industry Representatives, RP Environment of Care, The Joint
Wearing badges may assist in preventing violence in the workplace Violence in the
Protective shoes in the perioperative setting
OSHA requires the use of protective footwear that prevents injuries from falling
objects or objects that may pierce the sole
Study of 15 pairs of shoes were tested for scalpel penetration
SIX materials prevented complete penetration
o Sneaker suede
o Suede with inner mesh lining
o Leather with inner canvas lining
o Non pliable leather
o Rubber with leather lining and
o Hard rubber Barr and Siegel, Amber et al
Example of Protective Footwear: Shoe Covers
Worn to protect the feet during cases that have a large amount
of irrigation and resultant blood or body fluids
Fluid-resistant shoe covers must be worn when the risk of exposure to and
transmission of potentially infectious microorganisms are anticipated such as
Orthopedic cases, CSections and trauma cases OSHA
Masks if needed in the Semirestricted Area
Protects both the patient and the surgical team from transfer of microorganisms Mangram
• Surgical masks protects from droplets greater than 5 micrometers in size such as
group A Streptococcus, adenovirus, and Neisseria meningitides CDC Isolation
• Masks should cover the mouth and nose and be secured to prevent venting OSHA
• Ties are secured behind the back of the head and behind the neck. OSHA
• Masks should be worn for all surgical and invasive Procedures
The identical surgical attire is worn in the restricted area
Attire and practices that may place HCP patient, families, and the community at risk
Surgical attire studies
Study of polyester fabric and cotton scrub suits found
• 100% polypropylene decreased bacterial load in the air by 50% compared to
cotton Andersen& Solheim, Tammelin et al
• 100% cotton versus cotton/polyester blend Whyte et al, Barrie D
1. Head coverings should contain hair and cover the scalp
2. Skull caps that do not cover the hair in front of the ears and at the nape of the neck
should not be worn
• A head cover or hood should minimize microbial dispersal
• Human hair can be the site of pathogenic bacteria such as MRSA. Neutral
shampoos (e.g. baby) do not remove staphylococcus Mastro et al
• S aureus and S epidermidis can colonize hair, skin, and the nasopharynx Mase et al
Tops that are loose may:
Allow skin squames to disperse from the axilla and chest a major source of bacteria
comes from healthcare personnel’s Skin Mitchell et al Woodhead et al
Individuals lose a complete layer of skin every four days with the movement of
walking Noble WC, Noble WC et al
Jewelry that cannot be contained should not be worn
1. Wearing jewelry can cause an increase in bacterial counts both when they are in
place and after they are removed
2. Earrings were found to have bacterial counts 21 times higher
underneath the earring than on the surface.
3. Nose rings had 9 times the bacterial count beneath them than on the
surface. Bartlett et al
1. A warm-up jacket with sleeves pushed up to the elbow or no warm-up jacket worn at
2. Surgical attire prevents skin shedding and promotes environmental control
• Individuals shed millions of skin squames daily Scaltriti et al
• 5% of skin squames have bacteria
• Carriers of methicillin-resistant S epidermidis are possible sources of air
contamination Scaltriti et al Tammelin et al
1. 100% cotton fabrics made of fleece collect and shed lint
2. Cotton fibers are one of the most flammable materials
3. 100% cotton fleece does not meet federal flammability
standards. 16 CFR 1610, Yang and Qui
4. Blending cotton and polyester does not always reduce flammability Yang and Qui
5. Fleece is made up of napped material with low density which makes it more
flammable. Even fleece linings catch lint and bacteria Wu and Yang
6. Lint may harbor microbial-laden dust, skin squames, and respiratory droplets
Mangram et al
1. Badges should be cleaned routinely and when soiled – check with the manufacturer
2. Badges studied for bacterial loads had 0.3 CFU/cm² isolated Kotsansas et al
1. Lanyards, beads or chains pose a risk for contamination and can also pose a hazard
by getting caught on equipment or being grabbed by a patient
2. Lanyards studied showed a 10-fold greater bacterial load than badges Kotsansas et
Fanny packs, backpacks and brief cases
1. Fanny packs, backpacks and brief cases made of porous materials which cannot be
cleaned and disinfected should not be worn or taken into the perioperative suite
RP Environmental Cleaning
2. Settings that are moist and soiled may support gram-negative bacilli (eg, floors)
3. Gram-positive cocci may persist in dry settings (eg, coagulasenegative
staphylococcus species) Sehulster et al
Shoes with perforations, cloth, open toes or elevated heels and soles that lack
1. Shoes with holes or perforations on the top or sides do not offer protection
2. Shoes made of cloth or are open-toed do not offer protection
3. Elevated heels or soles that lack non-skid soles may place the wearer at risk of injury
4. Shoes should be cleaned regularly and be free of soil
5. Shoes which are only worn in the perioperative area may reduce contamination of
the environment – change shoes
6. 98% of outdoor shoes studied had coagulase-negative staphylococcus, coliform and
bacillus species Amirfeyz et al
1. Removing masks by the filter portion which harbors bacteria collected from the
nasopharyngeal airway should not be done
2. Contaminated masks should not be worn around the neck with the strings hanging
3. Removing masks by the strings prevents contamination of the hands
4. Wearing double masks makes breathing through them more difficult and does
not increase filtration. Romney
Cover Apparel (lab coat cover coat)
Facilities determine the use of cover apparel- by job category or for protection purposes
1. Studies have found cover apparel may be contaminating garments worn under them
2. Research testing of cover apparel found apparel may not have been laundered daily
or on a frequent basis
3. Laundering should occur daily due to exposure to microorganisms, especially
multidrug resistant microorganisms Kaplan et al, Wong et al, Loh et al, Treakle et al
1. Researchers found cover apparel contaminated with Staphylococcus including
susceptible and resistant isolates Treakle et al
2. Study showed that the cuffs and pockets of cover apparel were the most
contaminated area. Wong D et al
1. Stethoscopes should be cleaned between patients
2. Stethoscopes can be vectors for transmission to patients. Stethoscope
diaphragm cultures studied found:
• 79.8% of cultures grew gram-positive bacilli,
• 74.8% had staphylococcus species non-aureus, methicillin-sensitive
Staphylococcus aureus was isolated on 2.5% of baseline cultures, and
group A streptococcus was found in 1% of cultures Bernard et al
3. Gram-positive and gram negative bacteria, anaerobes and yeast have been isolated
on fabric covers on stethoscopes Milam et al
Cleaning stethoscopes helps to reduce colony counts which avoids increasing
emergent strains Sood et al
Wet or visibly soiled contaminated clothing
1. Remove as soon as possible
2. A shower may need to be taken before donning fresh surgical attire
3. Contaminated surgical attire must remain at the facility laundry or be sent to a
commercial laundry OSHA Final Rule, Mangram et al, CDC Guideline for Isolation, RP
Controlled laundering reduces the risk of transferring pathogenic organisms from facility to
the home or general public NIOSH Protecting Workers & Families
AORN does not recommend home laundering
Studies on survival of microbes on textiles – this includes homemade hats, cover ups and
• One study found textiles inoculated with staphylococci survived from 1 to 56 days.
The shortest survival time for enterococci tested in the same manner was 11 days.
Neely & Maley, Neely & Orloff
Another study tested fungal survival on textiles and found that candida,
aspergillus, mucor, and fusarium survived from 1 day to several weeks on plastic
and textiles. Neely & Maley
Home laundries are not monitored for quality, consistency, or safety
Potential for blood or other infectious materials in attire may result in improper
handling and decontamination Blood borne pathogen occupational exposure-OSHA.
Final rule. 1991
Home washers may have lower temperatures which may not be able to be
adjusted, and may have limited capacity for chemical additives used in industrial
washer cycles AAMI ST 65
Home washing machines may not meet necessary measures to decrease
antimicrobial levels in soiled surgical attire which are:
1. diluting and agitating water to remove microorganisms and soil;
2. selecting chemicals suitable if low-temperature cycle is used;
3. using proper chemical concentrations if low-temperature cycle is used;
4. using water temperature >160° for more than 25 minutes;
5. using chlorine bleach which adds microbial benefit; and
6. adding sour to water to neutralize alkalinity in the water, soap
or detergent. Sehulster et al, Association for Linen Management
Twomey et al assessed the bioburden associated with surgical scrubs in prior
(“Clean”) and after (“Worn”) use
Eight laundering methods were studied in 20 geographical
areas. Results were:
Bioburden on home-laundered attire greater than facility, third party or single-use
Data suggested scrubs ―enter‖ health care facilities already contaminated when worn
to and from work, despite home laundering.
Home laundering mechanism is potentially failing to achieve uniform
decontamination. Twomey et al.
Home laundering is NOT as effective as facility or third party laundering in
decontaminating of surgical scrub attire
Implication: MDRO cross contamination is likely since no official
procedure for home laundering of scrubs has been established as safe and effective.
No reliable and valid means to monitor home laundering procedures if such a
standardized procedure exists.
Emphasis on newer energy saving domestic washing (and drying) machines
contributes to microbial survival with lower temperatures, shorter cycles, milder
Home laundered scrubs are not as effectively ―clean‖ as single use scrubs prior to
In a study by Hedin surveillance cultures taken from 5 patients found 3 patients colonized
with the same strain of microorganisms cultured from the healthcare personnel's
The uniforms were home-laundered and were found to be contaminated at the beginning of
Home laundering process may not be cleaning uniforms sufficiently. Hedin
Gerba and Kennedy conducted a study done with inoculations of enteric viruses on
fabric strips and found enteric viruses survived a home-laundering process. To
improve the process the addition of sodium hypochlorite was found to reduce the
number of enteric viruses.
Soiled laundry has a potential for being route of disease transmission
Laundry has been associated with outbreaks of salmonellosis, bacterial viral
meningitis, Q fever, and ringworm.
Change surgical attire when leaving the health care facility or going between buildings -
smoke breaks too since outside increases exposure
Health care approved and accredited laundry include but not limited to:
Soiled and contaminated laundry separated by physical barrier
Ventilation controlled in each area
Storage shelves 1-2‖ from wall, bottom shelf 6-8‖ from floor, top shelf 12-18‖ below
Working surfaces are clean and are disinfected if they become contaminated with
blood or other potentially infectious materials
Water quality is tested on a regular basis for hardness, alkalinity, iron content, and
Soiled health care textiles are handled, collected, and transported according to local,
state, and federal regulations
Each wash load is monitored and applicable data recorded including cycle, pre-wash,
wash, rinse, and final rinse times; water levels and usage; temperatures; and
Water extraction and drying is performed using methods that preserve the integrity
of the textiles, minimize bacterial growth
Clean textiles stored in area free of vermin, dust and lint, temperature 68° to 78° F
(20° to 25.6° C)
Cleaned textiles are packaged and stored in fluid-resistant bundles or fluid-resistant
carts or hampers and are handled as little as possible
Clean textiles are stored and transported separate from soiled textiles
Carts used for transport or storage are kept clean and wellmaintained
Vehicles used to transport textiles provide separation of clean and soiled textiles, and
the vehicle interiors are cleaned on a regular basis
Personnel training is provided and documented
Quality control monitoring and processes are in place Healthcare Laundry
*** Approved laundries do have the capability of washing attire for those with noted
allergies or sensitivities.
Residual Contamination with Clostridium difficile
Carbone et al focused on risk of C diff cross contamination in laundering comparing
cleaning contaminated surfaces with reusable wipers saturated with either sporicidal
or nonsporicidal hard surface disinfectants
Results illustrated that cross contamination occurs with use of non-sporicidal
disinfectants and water by too numerous to count colony forming units (cfu) while
use of sporicidal disinfectant wipe showed significantly reduced cfu
Conclusion: cleaning C diff contaminated surfaces with nonsporicidal disinfectants creates
a vector for cross contamination to other textiles via the laundry process. Cleaning
contaminated surfaces with sporicidal disinfectant may not completely eliminate this vector,
but does significantly reduce associated risk
IMPLICATION: Emphasis on environmental cleaning and disinfectant remains a hallmark
adjunct to hand hygiene as fundamental infection prevention and control practices
Carbone et al. Poster 160, Fifth Decennial 2010
Emphasis on newer energy saving domestic washing (and drying) machines
contributes to microbial survival with lower temperatures, shorter cycles, milder
chemical agents. Thus, scrubs are just as contaminated/dirty prior to wear as after
wear, meaning home laundering of scrubs cannot be supported.
Home laundered scrubs are not as effectively ―clean‖ as single use scrubs prior to
RARE BUT REAL OUTBREAK
Duffy et al from CDC investigated an outbreak of Zygomycosis
caused by Rhizopus species among patients in Hospital A associated with hospital
linen in June 2009
Following the standard outbreak investigation protocols, results identify 5 patients
who died in the Aug 08-Jul 09 outbreak associated with hospital linen as the common
source. The link narrowed to Rhizopus oryzoe from Patient 5’s isolate, which
was closely genetically related to an isolate from a clean linen bin.
Rhizopus oryzoe was isolated from 4 of 5 case patients in this rare but real outbreak
and 1 sample was genetically related to Rhizopus oryzoe from a clean linen bin
Hospital linens are the most likely the vehicle common to all 5 patients susceptible to
infection due to underlying medical conditions
Length of time and intervals over which cases occurred indicates that contamination
of clean linens with Rhizopus happened repeatedly, but might have been intermittent
Linens could have become contaminated at the laundry facility, in route, or during
delivery at the hospital. The point at which contamination occurred could not be
determined. Negative cultures do not prove the absence of Rhizopus oryzoe at
Hospital linens should be laundered, shipped, and stored in a manner that minimizes
exposure to environmental contaminants.
Standardized, consistent, proven laundering protocols and infection prevention and
control practices are paramount to hygienically clean reusable health care textiles.
Laundry facilities accredited to stringent, evidenced based standards
provide the better option over home laundering of health care textiles
including the operating rooms. Duffy et al. Poster 227 Fifth Decennial 2010
Following the updated Recommended Practice for Surgical Attire could prevent surgical site
infections or disease transmission for patients and healthcare personnel as well as
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