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					Surgical Attire: Professional Accountability Notes

October 27, 2010

Speaker: Joan Blanchard, RN, BSN, MSS, CNOR, CIC
AORN Employee

      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

Surgical attire is worn to promote healthcare personnel safety and a high level of cleanliness
and hygiene

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
       et al
      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

Head Coverings
  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

Surgical Attire
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

Warm-up Jacket
  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
      for cleaning
   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
non-skid soles
   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
Cover Apparel

   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 laundering
      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
        laundered attire
    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
      chemical agents.
    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
the shift.

   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
       chemical usage
    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
       Accreditation Council

    *** 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

   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.

Outbreak Conclusions
    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
      or persistent
    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
      specific locations
    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
the community

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