-
201-3 Edition~-
Perioperative Standards
and Recommended Practices
For Inpatient and Ambulatory Settings
Recommended Practices for
Surgical Attire
he following Recommended Practi ces for Surgical Attire were developed by the AORN Recomme nd ed Practices Com mitt ee a nd hav e
been approved by th e AORN Board of Directors. T h ey
were prese nte d as proposed reco mme nd ati ons for
comments by members and others. They arc effec ti ve
November 1, 2010. These recommended practices are
inteuded as achi evable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in
practice settings a nd/or clinical situations tha t dctcrmiue the degree to w hich the rec01 nmended practices
l:an be impleme nted. AORN recognizes th e various
se t t ings in whi c h pe riop era ti ve nurses p rac ti ce.
T hese recommended prac tices are in tended as guid elines a daptabl e to various practice se ttings. These
practice sett ings include traditional ope rating rooms
(ORs). amb u latory s urge ry ce nt ers, p h ys i c ian s'
offices, ca rd iac catheterization laboratories, endoscopy
suites, rad iology departm ents, and all oth er a reas
where surgery a nd other invasive procedures may be
performed.
T
design of the surgical a tt ire was not as important as
th e mate rial of whic h it was mad c.a
I.a.
Surgical att ire fabrics shou ld be tight ly wove n ,
stai n res ist a nt , a nd dura bl e. Surgica l att ire
should provide comfort in terms of des ign , fi t,
breathability, and the we ight of th e fab ri c.
Co tton fab r ics with pores grea te r tha n 80
mi crons may allow mi croorga ni sms attac hed
to skin squames to pass th rough the interstices
of the material's weave.M Tight ly woven surgical atti re (cotton and polyes te r [50/50) with
560 x 395 threads/1 0 em) reduced th e amount
of bacte ria shed into the a ir by two to five
t imes , with the exce p ti on o f m e thi ci ll inresistant Sta phylococcus epiderm idis (MRSE)
from MRSE carriers . ~
Lb.
Surgical attire m ade of 100% cotto n fle ece
should not be worn .
Scme fabrics mad e of cott on fleece material
collect and shed lint. Lint may ha rbor microbiallade n dust, s ki n squam es , an d res pi ratory
drop lets . In add itio n, fleece is made up of a
napped surface w ith low de nsity, which renders it more flammabl e . ~
Cotton fiber is one of th e mos t fl am mab le
fibers, and 100% cotton fl eece with out fireretardant chemical treatment docs not meet the
federal flammability standard. z.t Cotton blended
with 10 % to 20% polyester may redu ce the
fla mmability,u bu t th is is not a lway:; successful. Application of a fire- retarda nt c hemical
still may be required. a
Purpose
T h ese recommended practices provide guidelin es for
s urgical a ttire in cluding jewelry, c lothing , s h oes,
head coverings, masks, jackets, and other accessories
worn in the semirestricted and restricted areas of the
surgical or invas ive procedure sett ing. T he huma n
body a nd inanimate surfac es in he rent to the surgical
environment are major sources of microbial contami na tion and tra ns mission of microbes; there fore, su rgic al att ire and app ropriate persona l protecti ve eq uipme nt (PPE) are worn to p romote worker safety and a
high leve l of cleanliness a nd hygiene wi thin the periopera ti v e tmv iro nment. These reco mm ended p racti ces arc not inte nded to address steril e surgical attire
worn a t th e surgical field or all PPE.
Recommendation II
Recommendation I
Clean surgical attire, including shoes, head covering, masks,
jackets, and identification badges should be worn in the
semirestricted and restricted areas of the surgical or invasive
procedure setting.
Surgical attire should be made of low-linting material, contain
shed skin squames, provide comfort, and promote a professional appearance.
l.lean a tt ire minimizes the introd uction of microorganisms ami lint from health care perso nuel to clean
items and the envi ron men t. II
In a prospective interventional study of surgical att ire
tha t was motivated by an increase in e ndop htha lmitis
a fter cataract s urgery, researchers compared severa l
types of polyester scrub att ire and cotton scrub a ttire.
They found tha t surgical attire made o f 100% spunbond polypropylene decreased the bacterial load in
th e air by 50% co mpa red to cotton surgical attire.
Research ers also fo und tha t surgical a ttire helps co ntai n bacterial sh edd ing and promotes e nvironme nta l
co ntroJ.l In another study research ers found tha t th e
Il.a.
Faci lity -appro ved, cle an, a nd freshl y lau n dered or disposable surgical a ttire should be
don n ed daily in a d esignat ed d ressi ng a rea
before entry or reentry into the semirestricted
a nd restricted a reas.
Changing from street ap pare l in to facilityapproved , clean , and freshly laund ered or disposable surgical att ire in a de signate d area
d ecreases the possib ili ty of cross-contam ination
a nd assists with tra ffic control.
2013 Perioperative Standards and Recommended Practices
Last revised: October 2010. Copyright © 2013 AORN, Inc. All rights reserved.
51
_
RP: Surgical Attire
Il.a.1.
When donning surgi cal attire, ca re should
be taken to avoid contact of the clean attire
with the floor or other p ossi bly co nta minated surfaces.
II.a.2 .
Whe n wearing a two-pie ce scrub suit, th e
top of the scrub suit should be sec ured at
th e waist, tu cked into the pants, or lit close
to th e body to prevent skin squ am es from
being dispersed into the environment.
Loos e scr ub tops may a llo w sk in
squames to disperse into the en vironment
from the axilla and chest. The major source
of b acte ri a dispersed into th e air comes
from health care providers' skin ..IJW. When
s kin squ ames com o off the body surface,
they carry any mi croorganism that is found
on the surface of th e indi vidua l's skin.
Every indi vid u al loses a complete layer of
s kin every four da ys (about 10 ' s kin
squam es every d ay). With just the movement of wa lki ng, this may cause a loss of
10' squames per minute.u.u
II.a.3.
II.b.
care providers' hands with gram-negative
and gram-positive pathogens .ll.JJ!ill Finger
rings have been found to increase skin surface bacterial counts. Although hand washing r edu ces th ese counts, the re are more
bacteria und er rings than on th e adjacent
skin or th e opposite hand. The pathogens
identified in one stud y were coagulasenegative stap hy l ococci, other skin flora ,
gram-negative cocci, Pseudomonas spp , and
Staphylococcus aureus.:u
Re moving rings before hand washing
may decrease th e potential for p athogens to
rem a in on hands after hand was hing.u
Remov ing rings before hand h yg iene may
e nha n ce the effectiv eness of th e hand
hygiene procoss.ll
II.c.
Persons entering the semirestricted or restricted
areas of the surgical Sllite for a brief time for a
specific purpose (eg, law enforcement officers,
parents, b iomedical engineers) should cover all
head and facial hair and should don either freshly
laundered surgical attire; single-use attire; or a
single-use jumpsuit (eg, coveralls, bunny suit)
designed to completely cover outside app3rel.
Clean and fre shly laundered surgical attire,
single-use attire, or single-use jumpsuits donned
before entry into the semirestricted and restricted
areas may minimize the potential for contamination of the environment and cross-contamination
of the attire (eg, animal hair, cross-contamination
from other uncontrolled environments, spores in
soil).
ll.d.
Shoes worn within the p erioperative en vironment should be clean Y·
Soiled shoes have been found to contribute
to en v ironmental co nt am ina tion within th e
periopera tive environment. A study of shoes
worn outdoors and shoes worn only in the surgical suite sh ow ed 98% of th e outdoor s hoes
were contaminated wi th co ag ulase-n egati ve
staphy lococci, coliform, and bacillus s pecies
compared to 56% of the shoes worn only in the
s urgical suite. Bacteria on the periop era ti ve
floor ma y contribute up to 15 % of colon yforming units (CFUs) , which are di spersed into
th e air by walking. Shoes tha t are worn oniy in
th e perioperative area may h elp to redu ce co ntaminat io n of the perioperative e nvironm e nt. ~
Health care p ersonnel shou ld change into
s tr ee t clothes w h e n ever the y leave th e
health car e facilit y or when traveling
between buildings located on separate
campuses. a
Surgical attire may become contam inated
by direct or indirect contact with the extern al environment.
Jewelry including earrings, necklaces, watches,
and bracelets that cannot be contained or confin ed within the surgical attire should not be
worn. u Jewelry that cannot be confined within
the surgical attire s hould be re moved before
e ntry into th e se mires tricted and restricted
areas.
Necklaces on the skin may con tamina te the
front of the steril e gown if they are not confined
w ithin the surgical attire.
Wearing fin ger rin gs, nose ring s, a nd ear
p iercings increases bacteri al counts on skin surfaces both when the jewelry is in place and after
re mov al. One study showed that earrings had
bacterial counts more tha n 21 times hi gher
beneath the earrings than on the surface of the
earrings. Bacterial count s w er e nine time s
greater on the skin beneath finger and nose rings
than on the rings thems elves. 11
The removal of watches and bracelets allows
for more thorough hand washing. llll Researchers sa mpled 100 wristwatch wearers in the
health care environment and found that immediately after they removed their watches, 25%
of th e wristwatch wearers' wrists had positive
cultures for Staphylococcus aureus.a
II.b.1.
52
Rings should be removed before hand washing or using hand rubs.
Several studies have sh own that wearing
rings may result in colonization of health
II.d.l.
Shoes worn w ithin tho periop erative environment should have closed toes and backs,
low h eels, non-skid soles, and must meet
Occupational Safety & Health Administration (OSHA) and the h ealth care organization's safety requirements ..u
Shoes that enclose the foot with backs,
low h eels, and non-skid soles may red u ce
the risk of injury from slips and falls and
from dropped items. The OSHA regulations
r equire th e use of protective footwear in
areas where there is a danger of foot injuries
RP: Surgical Attire
from falli ng or ro lli ng obj ects or objec ts
pierci ng the sole. The empl oyer is resp onsible for d etermining if foot injury h azard s
exist and what, if any, protecti ve footwear is
required .an The OSHA regulations mandate
that e mpl oyers perform a w orkp lace h azard
risk assess ment and ensure that e mpl oyees
wear protective footwear to provide p rotection from identi fied po tential hazard s (eg ,
n eedles ticks, scalpel cuts, splas hing from
bl ood or o th er p oss ibl y in fec tiou s
materials).=
Sh oes th a t have h ol es or pe rfora tions
may not p rotect the fee t from ex posure to
blood, body flu ids, or other liquids that may
contain potentiall y infecti ous agents. Shoes
made of cloth, tha t are o p en-toed , or th at
have holes on th e top or sides d o not o ffer
protection against spilled liquids or sh arp
items tha t may bP. dropped or kicked . In one
study, 1 5 diffe re nt types of sh oes we re
tes te d with an ap p ara tu s th a t m eas ured
resista n ce to pe n etrati on by scalpels. Th e
ma teria ls o f th e sho es inclu de d l ea th er ,
su ede, rubber, and ca nvas. Sixty percent of
th e sho es sus tain ed scalp el p en etra ti on
through the sh oe into a simuia ted foot. Only
six materi als prevented complete pe netra ti o n . Th ese ma teri als in clud ed s n ea ke r
s u ed e , s u ed e w ith inn e r m es h lining,
leath e r with inn e r can vas lining, n on pliable leath er, rubber w ith inner leath er
lining, and rubber.=
!I.e.
II.f.1 .
Ide ntifi cati on badges should be worn by all personnel authorized to enter th e perioperative settin g.;tU,l Health ca re p e r sonne l as w ell as
pati ents sh ould b e able to identify caregivers .
Identification badges assist in ide ntifying persons authorized to be in the perioperative setting
and support security measures.:u.u
II.e. 1.
ll.f.
requ irements an d th e culture of the h ealth ca re
organizati on.
Wearing cover appa rel over surgica l attire
outs id e of th e p e ri opera ti ve suite may b e
required for some health care p erso nne l in some
health care organi zati ons for a va rie ty of reaso ns , which may include professional ap pearance . This may be based on th e belief tha t cover
a pparel decreases th e risk of infection. The use
of cover apparel has been fo un d to have little or
no effec t on redu cing contamination of surgical
attire.;!§
Ide ntificati on badges sh ould b e secured on
th e su rgical attire top, b e visible, an d be
cleaned if they become soiled.
Badge holders suc.;h as la n yard s, chains,
or beads pose a risk for conta mination and
may be very difficult to clean. One study of
identification badges and lanyards sh owed
that the median bacterial load isolated was
10-fold greater for la nyards (3.1 CFU/cm' )
than for identification badges (0.3 CFU/cm' ).
Th e microorganisms recovered from lanyards
and identification badges were methicillinsensitive S taphy lococcus aureus (MSSA),
me thi cillin-resistant Staphy lococcus aureus
(MRSA), Enterococcus spp, and enterobacteriaceae.n As with other personal attire, such
as stethoscop es, identification badges become
contaminated over time.
The use of cover a ppar el (eg, lab coa t, cover
gown) may b e d etermined a t each indi vidual
prac ti ce settin g b ase d o n s ta te reg ul a to ry
Il.g.
Cover apparel shoul d be la und ered d aily in
a health care-a pproved or -accredited laundry facility. (Sec Recommendation V. )
Health care personnel may carry sta phylococci a nd enterococci on their clothing,
which may include surgical attire a nd cover
app ar e t. u Studi es o f cove r a p pa rel ha v e
sh own that rath er than protecting the clothing und e rn ea th th e cover gow n, cove r
apparel may conta minate th e cloth es worn
und er th e cover a ppare l. Research ers h ave
found that cover ap parel is not always di scarded daily after use or la und ered on a frequent bas is.llll
In one study of cover coats worn by 100
physicians, Staphy lococcus aureus was isolated from 25 of the cover coats . The cu ffs
a nd p ockets of th e coa ts were th e mo st
contaminated. aD
In another study of 100 medical students,
mi c roorganisms were fo und on the cuffs
a nd si de pocke ts o f th e s tu de nts' cover
apparel. Conta mination was found un their
domin ant hand sleeve cuffs a nd th e backs
of the cover ap parel 10 em down from th e
collar. These areas were contaminated with
Staphy lococcu s s p o n all cover apparel ,
Acinetobac ter sp on seven stud ents' cover
appa rel, an d dip hth eroids on 12 stud ents'
cover appareJ. ll
In a st udy of h ealth care prac titione rs'
cover apparel, researchers fo und that cover
a ppa rel in inpatie nt a nd outpatie nt a reas,
intensive care units, admin is tration areas,
a nd th e OR wa s co nt a minat e d with
S taphylococcus aure us, whi c h in clu d ed
sus ceptible a nd resista nt isola tes . Health
care personnel with colonizati on were more
likely to have home-laundered their cover
ap parel. Two-thirds o f the health care practition ers perceived their cover appa rel to b e
di rty beca use it h ad not been wash ed in
more than a week. JI
Ste th osco p es sh ould b e cl ean a nd not worn
around the neck.
Ina ni mate objects, su c h as conta mina ted
stethoscope tubing and diaphragms, may transmit pa thogens su ch as MRSA b y indirec t contact (eg, by wearing the s tethoscope around the
53
R~
Surgical Attire
nec k a nd co ntaminating th e s kin a nd surgical
a ttire ).ill Clea ning ste thoscopes in combination
with h ealth care personnel washing their hands
between caring for patients decreases the possibility of transmission of pathogens to patients
and environ men tal surfaces.
Steth oscop es may be th e most widely used
medi cai d ev ice in a hea lth ca re fac ilit y. 11
Although stethoscopes are not cons idered part
of the surgica l a ttire, h ealth cam providers often
wear th em around th eir n eck s as th ough they
were pa rt of s urgical attire. Steth oscopes come
in direct con tact with patients' skin and could
provide an opportunity for transm ission of
mi crobes from patien t to patient, to health care
p erso nn e l, o r from hea lth ca re personnel to
patient s. O ne study verified tha t ste thosco pes
could be a vector for tra nsmission to patients.n
Anothe r study co ndu cted on ste thoscope diaphrag m s noted that , w h en c ultured befo re
cleaning,
o 79.8 % of th e cultures grew gram-pos itive
baci lli ,
o 74.8 % h ad S t aphy l ococcus spec i es
non-aureus,
o 2.5% of baseline cultures showed MSSA , and
o group A stre ptococcus was fo und in 1% of
cultures.u
A study showe d reco ntamin ation of stethoscopes cun occ ur by th e fifth tim e the stethoscope is used on different patients. The number
of bacteria on a stethoscope increases with each
u se.u
Cleaning th e steth oscope da il y may not be
adequa t e; clea ning s t e th oscopes may be
requir e d betw een eac h pati e nt u sc . Several
studi es on contamination of st ethosco p e diaphragms a nd earpi eces h ave heen condur;ted
and sh ow that 66% to 100% of the diaphragms
are conta min a te d. 11 One stud y not ed tha t to
avoid inc reasing e me rge nt s trai n s, routin e
cl eaning of stethoscopes may help reduce bacterial colony counts. 11
II. g.1.
II.h.
Fabric stethoscope tubing covers should not
be used.
Adding fabric covers to stethoscope tubing may result in the covers acting as fomites. One study of stethoscope fa bric covers
isolated gram-positive aerob i c bacteria ,
gram-negati ve aerobic bacteria, a naerobes,
a nd yeas t. The average l e n gt h of tim e
between stethoscope cover laundering was
3.7 months, with some fabri c covers that
were never laundered.!§
Fanny packs, backpacks, and briefcases should
not be taken into the semirestricted or restricted
areas of the perioperati ve suite.
Ite m s brought into the OR, su c h as fann y
packs, backpacks, briefcases, a nd other personal
items that are constructe d of porou s materials,
may be difficult to clean or di sinfect adequately
54
and may harbor pathogens, dust, and bacteria.iZAII
Pathogens have been shown to smvive on fabrics
and p last ics. i\l.lll Dust is made up of skin particles,
h a ir, fabric fib ers, pollens, mold, fu ngi, insect
p arts, glove powd er, and paper fi bers, amo ng
other things . Bacteria may be transported from
one location to another by carriers such as dust
or liquids, and may contaminate fan ny packs,
backpacks, a nd briefcases.iJ!.m i
The type o f envi ron me nt al surface an d its
ab ility to support m icrobia l growth wi ll influence microbial ca rriage. Gram-positive cocci (eg,
coagulase-negative staphylococci) may persist in
dry sett ings. Settings that are moist and soiled
may support gram-negative bacilli (eg, fl oors).
Fungi favors moist, fibrous material and are a lso
found in dust.!l
Recommendation Ill
All Individuals who enter the semirestricted and restricted
areas should wear freshly laundered surgical attire that is laundered at a health care-accredited laundry facility or disposable
surgical attire provided by the facility and intended for use
within the perioperative setting.
Surgical a ttire he lps con ta in bacterial shedd ing a nd
promotes e nvironmenta l clean liness. 1 An in d ivid ual
sheds millions o f skin squames daily. Five perce nt to
10% of skin squames carry bacteria. a In a study on dispersal of MRSE, carriers of MRSE were seen as possible sources of air contam ination in ORs.}
Ill.a.
Surgical a ttire should be cha nged dai ly or at the
e nd of th e shi ft. u
It has bee n report ed that surgical att ire may
h ave bacteria l colon y co unts tha t are hi gh e r
when scrub clothing is re moved, s tor ed in a
locker, and usud agai n. Microbes have been
shown to survive for long periods of tim e on
fabrics such as surgical attire.ilUll.}}
III.a. 1.
Reusable or si ngle-use con tam ina ted attire
shou ld b e placed in appropria tely designated containers after use. u Worn reusable
surgical att ire should be left at the health
care facility for laundering.
III. <J.2.
Surgical attire t hat has been penetra ted by
blood or ot her potentially infectious materials s hou ld be removed immediate ly or as
soon as possible a nd replaced with freshly
iaun de r ed, c lean s urgica l a tti re. When
extensive contamina tion of th e body occms,
a sh ower or bath should be ta ke n b e fore
donning fresh att ire.=
Changing con tam inated, soiled, or wet
attire reduces th e potential for contamination and protects personnel from prolonged
exposure to potentia lly harmful bacteria.I!i.u
III.a.3.
Wet or contaminated surgical att ire should
not be rinsed or sorted in the loca tion of
u se. ~
RP: Surgical Attire
Rinsi ng or sorting contaminated reu sable
a ttire m ay expose th e h ealth ca re worker
to blood , bo dy fluids, or other liquid s that
m ay co ntain pote ntiall y in fec ti ou s agents
a n d m ay co nt a minate th e pa t ie nt care
environment.lli
lll. a.4.
lll.b.
Surg ica l a ttire contamina ted w ith visi ble
blood o r b od y fluid s mus t remain a t th e
health ca re facility for launde ring or be sent
to a n accredited la undry facility co ntracted
by th e health care org ani zati o n. 1li.!A.li-~
Controlled la undering of a ttire contaminated by blood or body flui ds red uces th e
risk of tra ns fe rring pathoge ni c mi croorganisms from the facility to the home or ge neral
public.~ (Sec Recommendation V.)
When in the semirestricted or restric ted areas,
all n o n sc rubb cd personn e l s h o u lrl wear a
fres hl y la und e red or s ingle-u se lon g-s leeved
warm-u p jacke t snapped closed w ith t he c uffs
down to the wri sts.
Wearing the warm-up jacket snap ped closed
prevents th e edges of the front of the jacket from
conta mina tin g a skin pre p a rea or the ste ril e
surgical fi eld. Long-sleeved attire he lps contain
skin squames s hed from bare arms.1
lll. b.l.
All personal clothing sh ou ld be completely
cover ed by the s urgical a tt ire. Unde rgarme nts such as T-shirts w ith a V-neck, w hich
can be contai ned underneath the scrub top,
m ay b e wo rn ; p e rso n a l c lo thin g t h at
ex tends ab ove th e scrub top n ec kline or
b e low th e s leeve of th e surgi ca l a ttire
should not be worn.
Per sonal clothing is not laund ered by a
h ealth care-accredited la undry facility. (See
Recommendation V.)
Recommendation IV
All personnel should cover head and facial hair, including sideburns and the nape of the neck, when in the semirestricted and
restricted areas.
Head coverings contain skin squames an d hair shed
fro m th e scalp. It is important to prevent sh ed skin
squ ames from fa lling onto the sterile fi P.IrJ.u.» Although
group A s treptococcus is isolated in less tha n 1% of
surgical site infec ti ons (SSis) (ie, 1 per 10,000), it is a
serious cause of SSis a nd can be carried on th e sca lp. ~
An outbreak of SS i s was attribut ed t o g roup A
~-hemoly tic Strept ococcus carried on the scalp of periop era ti ve p e rson ne l. The rep ort identifi ed group A
~-hemolytic Strep tococcu s in 20 pa tients with an SSI.
In th e outbreak in vestigation , 88 periopcrative personn e l were c ultu red . One was found to have erythema
a nd scaling o n the scalp and ears and under the breast.
The individual was treated with medication and re located to a non-pa tient work area, and the outbreak was
resolve d. ~
Huma n hair ca n be a site o f pa thogenic bacteria
su ch as MRSA. Routin e shampooing of hair with neutral d eterge nts docs not remove MRSA or have a bacteri cidal effect.lill
IV.a.
A clea n , low-lin t surgical head cover or hood
t h a t co n fi nes all h a ir and covers scalp skin
should he worn. The head cover or hood should
be designed to min imize microbial dispersa l.
Hair acts as a fil ter when it is u ncovered a nd
co llects bact eria in proporti on to its le ngt h ,
wa vin ess, and oili ness. Stud ies have shown that
S tap hy locuccus aureus and S taphylococcu~>
epidermidis h ave a tendency to colonize h air,
s kin , a n d the nasop hary nx .lill Head cove ri ngs
designed to contai n hair a n d scalp skin w ill
minimize mic robial dispe rsaJ. ll Skull caps may
fa il to co ntain the side hair above and in fron t o f
the cars and h air at the nape of the neck.
IV.a. l.
Used single-usc head cover ings sh ould be
re m oved an d discar ded in a d es ignate d
receptacle dai ly or when contam ina ted.
Placing con taminated head coverings in
a designa ted recep tacle assists in mainta ining a clea n a nd orderly area and decreases
the p ossib ili ty of cross-contaminati on.
lV.a.2.
Reu sable head coverings shou ld be launde red in a h ea lth care-accred ited lau nd ry
facility after each da ily use.ll (See Re commendation V.)
Recommendation V
Surgical attire should be laundered in a health care-accredited
laundry facility.
Surgical a ttire; street clothing; PPE; a nd other hos pital
textiles (eg, bed li nens, towels, pri vacy curtains, washcloth s ) may become contami nated by bact e ria a n d
fu ng i during wear or use. In one st udy, researchers
fo und that mi crobes can survive on hosp ital textiles for
extended p eriods of time. These textiles included
• 100% cotton cloth ing;
• 60 % cotton an d 40% polyeste r ble nd (eg, scrub
suits, lab coats);
• 100% polyester cloth ing; a nd
• polyethylP.n e plas tic aprons.
Researc hers inoculated these textiles with staphylococci u n der laboratory cond itions. The textiles were
allowed to re main in ambient air w ithout any laundering for vari ous periods of time. Resu lts showed that th e
staphy lococci survived one to 56 d ays on polyeste r
and up to 90 days on p olyet hylene plasti c. The la rger
th e mi crobial inoculum of sta phylococci on p olyester
a nd p olye thyle n e, the longe r th e staph ylococci su rvived. Even if only a few hundred staphylococci survived , they were viable for clays on most textiles. Th e
shortest time fo r enterococci survival on textiles was
11 days.Wll
Researchers in another study tested funga l survival
under laboratory conditions on
• 100% cotton clothing;
55
RP: Surgical Attire
• 60% cotton a nd 40% pol yes ter blend (eg, scrub
suits, lab coats, clothes);
• 100% polyester clothing; a nd
• polyethyle ne p lastic aprons.
The microorganisms used as the inoculum were
Candida albicans, Candida tropicalis, Candida krusei,
Candida parapsilosis, Aspergillu s flavu s, Aspergillus
fumigatu s, Aspergiilus niger, Asp ergillu s terreus,
Fusarium sp , Mucor sp, and Paecilomyces s p. These
pathogens were isolated in the researchers ' health care
facility. The da ta co llect ed showed th a t ca ndid a,
aspergi llus, mucor, and fu sarium, which are known to
be health care-associa ted infec tious agents, survived
on fabrics an d plasti cs for at least one d ay a nd often for
weeks. The survi val of these microorganisms on these
textiles and plastics shows that they may serve as reservo irs or vectors for fungi. ~ Another study showed that
Staphy lococcus aureus a nd Pseudomonas aeruginosa
bind to polyester a nd acry lic fibers. tl
Hea lth care-accredited laundry faciliti es are prefe rred beca u se th ey foll ow indus try st;mdards. The
Hea lthcare La und ry Accreditation Co un r.i l (HLAl.)
offers voluntary accreditation for those laundry fac ilities that process reusable h ea lth care tex ti les and
which incorporate OSHA and th e Centers for Disease
Control and Preven ti on (CDC) guid eli nes and profess ional association recommended practices. The HLAC
sta nd ard s for accreditation include, but are not limited
to,
• Tex tile quality control procedures are defin ed
a nd implemented.
• The in vsntory system is ad equ a t e t o e n sure
supply.
• Soil ed a nd contam inated tex tile areas are separated by a physical barrier.
• The ventilation is controlled with negative pressure in the soiled area, positive pressure from th e
clean textile area through thfl soiled textil e area, 6
to 10 air exch anges per hour, and air vented to
the outside.
• Clean textiles are stored in an area free of verm in,
dust, and lint and at room temperatures of 68° F to
78° F (20° C to 25.6° C).
• Storage shel ves are 1 inc h to 2 inc hes from th e
wa ll, the bottom shelf is 6 inc hes to 8 inches from
the floor, and th e top sh e lf is 12 inches to 18
inch es below the ceiling.
• Hanel washing faci lities arc located in all areas w ith
soiled textile~; !Jand washing or antiseptic dispensers are in the clean textile area; and emp loyees perform hand washing after glove removal and restroo m u se, before eating, a nd when hand s are
contaminated with blood or other potentially infectious materials.
• Working surfaces are clean and are disinfected if
th ey become conta mina ted with b lood or other
potentially infectious materials.
• The OSHA Exposure Control Plan is in place and
PPE is supplied and available.
• Personnel training is provided and docum ented.
• Quality control monitoring a nd processes arc in
p lace.
56
• Material Safety Data Sheets are avai lable for each
chemical used .
• Water quality is tested on a regular basis for hardness, alkalinity, iron conte nt, and pH.
• Soiled health care textiles are hand led, collected,
and transported according to local , state, and federal regulations.
• Each wash load is monitored and a pplicable data
for each wash are recorded, inclu ding cycle, prewas h , wash , rinse, and final rin se times; wate r
levels and usage; t em pe ratures; a nd c h e mi cal
u sage.
• Water extraction and drying are performed using
methods that preserve the integrity of the texti les
and minimize bacterial growth.
• Clea ned texti les are packaged and stored in fluidresistant bundles or fluid-resistant carts or hampers and are hand led as little as possible.
• Carts used for transport or storage a re kept clean
a nd arc well maintained.
• Clean textiles nre stored and trnn s ported se pnra tely from soiled textil es.
• Ve hicles used to transport textil es provide separation of clea n and soiled textiles, and the ve hicle
interiors are cleaned on a regular basis.n
Rou tine monitoring of laundry processes, including
clea ning of work areas, equi pmen t, a n d good hand
hygie n e practi ces, is imp or ta nt to minimi ze c rosscontamina tion of clean textiles. An accredited health
care facility lau nd ering process includes monito ring
correct measureme nt of chemicals, sufficient water,
correct te mp erature, mechani cal acti on, a nd the dura·
tion o f the washing cycle. Cleaning a nd d isinfecting
the work area incl udes, but is not limited to, the wash ers, extractors, d ryers, and co nveyor be lts. The presence of skin bacteria on processed texti les and e nvironmental surfaces in one study direc ted a ttenti on to
hand h ygiene of th e lnu ndry facility workers, air con tamina tion, inadequate separation of soiled and clean
work areas, a nd the cleaning a nd disinfecting of all o t
the equi pm ent and work s urfaces. !li Wa ter can be a
source of bacterial tra ns mission , which makes th orough drying of textil es vitaJ. u Stap hylococci , Salmonella, and Mycobacteri um a re fairl y res istan t to h eat
and may survive dry ing. ~m
Home laundering is not monitored for quality, consistency, or safety. Exposure of health care personnel and
th eir family members to blood and other pote nti ally
infectious matcrh1ls may rosult fro m improper h anrlling
and d econtamination of surgical attire. Home washers
may have a lower temperature (ie, < 160° F [71.1 o C]) or
washing parameters and temperatures may not be adjustable. Home washers may have limited capacity for chemical add itives and may not h ave direc ti ons for using
alkalis and acids.
Home laund ering may not meet the specifi ed meas ures necessary to achieve a red uct ion in mi crobial
levels in soiled surgical attire. These measures involve
mechanical, thermal , and c h e mi ca l com p o n e nt s,
including
• diluting and agitating the water to remove mic roorga nisms and bioburdcn;
_ RP: Surgical Attire
• selecting suitable che micals. if low-temperature
cycles(< 160° F [< 71.1° C)) are used ;
• using prope r chemical concentrati ons if low temperature cycles are used ;
• using water temperatures > 160° F (> 71.1 o C) for
more than 25 minutes for hot-water cycles;
• u sing chlorine bleach, which gives added mi crobicidal benefit: and
• adding chemicals known as "sour" to the water to
n e utralize alkali n it y in th e water, soa p , or
detergent.
These measures cause a shift in pH from 12 to 5,
inactivating so m e mi croorganism s. Low temperatures
(ie, < 160° F [< 71.1° C]) may be used so long as the
dry ing temperatures and ironing temperatures provide
th e additi on al mi crobicidal benefits to ensure surgi cal
att ire is clean.ll-lil
A stud y on b ac terial co ntamination of h omelaundered uniforms began by culturing uniforms worn
a t the beginning of th e shift. Thirty-nine percent of the
uniforms identified as "clean" had one or more microorganisms (eg, va ncomyc in- resis tant en terococc i ,
MRSA, Clostridium diffici/e) identified. Uni forms were
tes ted again at the end of the shift and 54% had one or
more microorganisms; so me tha t were positive at the
beginning of the shift were negative at the end of th e
shift. ln one demonstration, bacillus spores were transferred from h ea lth care pro vid ers' aprons and cotton
uniforms to a mock pati ent.lill
A study of home-laundered uniforms involved taking surv e illa nce cultures from five pa ti ents . Results
showed that three of the patients were colonized with
the same strain of mi croorganism as th at cultured from
th e h ealth care proviclers' uniforms . With uniforms
contaminated with microorganisms a t the beginning of
a shift, the researchers suggested that inappropriate
laundering practices may b e the cause.lli!
Home la undering has been shown to be less effectiv e for cleaning surgical attire than laund ering by
health care facilities or commerciallaundries.lll
A quantita tive stu dy was perform ed in 20 different
geographi cal areas.lll Eight lau ndering me thods were
studied:
• reusable clean scrubs laundered at the facility in
which they were used;
• reusable worn scrubs la undered at the facility in
w hich they were usP.d;
• re usable clean scrubs that w ore homo laundered;
• reusable w orn scrubs that were home laundered;
• reusable clean scrubs laundered by an outsi de
laundry facility;
• reusable worn scrubs la un dered b y an ou tside
laundry facility;
• p ackaged , clean, single-use, non-woven scrub s;
and
• packaged , worn, single-use, non-woven scrubs.
Results of the study showed that the bioburden on
home-laundered surgical attire was significantly greater
than on surgical attire that was faci lity-laundered; laundered by a third-party; or single-use, disposable. Homelaundered clean scrubs at the beginning of the day had
the same amount of organisms as did worn scrubs at the
end of the work day.lll
A quantitati ve study was performed on cotton strips
of fabric that were inoculated with 10 mL of a viral suspension to discover if enteric viruses (ie, adenovirus,
rotavirus, hep atitis A virus) survive d a home-laundering
process . Th e inoculated fabric strips were was h ed,
rin sed, a nd dried on a 28- minute permanent p ress
cycle in home wash ers. lt was found th at enteric
viruses remained on th e fabric str ips after they were
washed. n
V.a.
V.a.l.
V.b.
V.b.1.
La undered surgical attire should be pro tected
during transport to the practi ce setting to prevent contamination. :m
PropP.r tmnsfer an d storage of surgical attire
protects surgical attire from contamination by
o preventing any physical dam age to la undry,
o minimi zing mi c robial contamination from
environmental surfaces. and
o preventing any deposits from airborne sources
such as dust to settle on laundry.Jtu
Surgical attire should be tran sported in a
cl ea n vehicle a nd e n c l osed car ts or
containers.JMu
Laundry vehicles can be a source of contamination. Cleaniug and di sinfection on a
regular basis are required.
Clean surgical attire should be stored in a clean,
enclosed cart or cabine t. 2-M
Storing clean surgical attire in a locker with
pe rsonal items from outside of the hospi tal may
conta min ate th e clean surgical a ttire. Enteric
viruses h ave been detected in lock ers w h ere
contaminated attire ca n ac t as reservoirs for
viral transmission J Lll
Surgical attire may be stored in a d ispensing machin e. Dispe nsing machines should
be routinely emptied and cleaned according
to the ma nufacturer's d irections.
Attire-dispensing machin es m3y be used
to increase individual acco untability, prom ot e cos t containment , facilitate an ad equate supp ly, and provide clean storage for
surgical attire. il.Zf
Recommendation VI
All individuals entering the restricted areas should wear a surgical mask when open sterile supplies and equipment are
present.
A surgical mask protects both the surgical team and the
patient from transfer of microorganisms.H The surgical
mask protects h ealth care providers from droplets
greater than 5 mi c ro m e ters in size. Examples o f
di seases th a t produce dropl e ts include group A
streptococcus, adenovirus, and Neisseria meningitides.Z->
A single surgical mask is worn to protect the h ealth care
provider from contact with infectious material from the
p atient (eg, respiratory secreti ons, sprays of blood or
body fluids) and to protect the patient from exposure to
57
RP: Surgical Attire
infectious age nts ca rri ed in the provider's mouth or
nose. Surgi cal masks protect surgical team memb ers'
noses and mouths from inadve rtent splash es or splatters of blood and other body fluids.lli A study involving
8,500 surgi cal procedures s howed tha t 26% of exposures to blood were to the heads and n ecks of scrubbed
personn el, a nd that 1 7% of blood expos ures we re to
circul ating p ersonnel outside the steril e field .lli
Vl.a.
VI.b.
The mask should cover the mouth and nose and
be secured in a manner to prevent venting.
A mask th at is securely tied at the back of the
head a nd behind th e neck decreases the risk of
health care pe rsonnel transmitting nasopha ryngeal and respiratory microorga nisms to patients
or th e sterile fie ld. Infec tious particles can reach
the wea rer's nose and mouth by passing through
leaks at the mask-face seal.
A fresh, clean surgical mask should be worn for
every procedure. The mask should be replaced
and di scard ed when e ver it becom es w e t or
soiled .
The filtering capacity of a mas k is compromis ed when it becomes wet. In a study to determin e microbi al barri er e ffi ca cy of s urgi cal
masks with 95% b ac te ri a l filt ra tion a t on e-,
two-, three-, a nd four-hour inte rval s showed
that after four hours, the masks h ad decreased
effi cacy. Avoiding unnecessa ry sp P-aking a nd
keeping in mind the patient's possible immunological status are important. This research study
showed that all counts of CFUs were lower than
4 x 10 2 , which could cause an SSI in p ati ents
with poor immunity, those with surgical wound
compli ca tions (eg, isch e mia , h e matoma ), or
those undergoing surgery with an implant. u
VLb.l.
VLc.
Masks s hould n ot be worn hanging down
from the neck.
The fi lte r portion of a surgical mask harbors bacteria collected from the nasopharyngea l airway. The contam inat ed mas k may
cross-contaminate the surgical att ire top.
Surgi cal masks should b e disca rd ed after each
procedu re. Masks should be re moved carefull y
by handling only th e mas k ties. Hand hygiene
should be performed after removal of masks. ll
Re moving masks by the ties prevents possible
contamination of the hands. The filter portion of
the mask harbors bacteria collected from th e
nasopharyngeal airway.
VI.d. Onl y one s urgi cal ma sk s hould b e w orn a t
a time.
Mas ks a re inte nde d to contain and filt er
dro plets of mic roorganisms exp e lled from th e
mouth and nasopharynx during talking , sneezing, and coughing.LI! Use of a double mask crea tes an impedim ent to breathing and does not
increase filtra tion ; th e r e fo r e, thi s is not
recomm ended .Zll
58
Recommendation VII
Health care personnel should receive initial and ongoing education and demonstrate competency on appropriate surgical
attire.
Compe te ncy assessment verifies that h ea lth care personnel h ave an understanding of the arti cles and purpose of surg ical a ttire. This knowledge is essential for
reducing the risk of health care-associat ed infections.
VILa. Health ca re perso nnel should receive education
and guida nce on appropriate a rticles of surgical
attire worn in the periopera ti ve en vironme nt at
ori e nt ati on a nd a ft e r ch a nges a re mad e. ull.
Health ca re perso nn el shou ld be informed o f
a nd be complia nt with the health care organi zation 's surgical a ttire policy, including launde ring policies.
Ongoing education of perioperati ve p erso nne l facilita tes the d evelopme nt of know ledge,
s kills , and attitud es th a t a ffec t pa ti e nt a nd
worker safety.
VII.a.1.
Health care p ersonnel should understa nd
the ri sk of becoming colonized or infec ted
with microorganis ms from pati ents or th e
environment wh en surgical attire is clean ed
imprope rly.
RecommendationVIII
Policies and procedures for surgical attire should be developed,
reviewed periodically, and be readily available within the practice setting.
Policies a nd procedures serve as ope rational guidelines a nd es tabli s h a uthorit y, res pons ibility, a nd
accountability within th e organi zation . Policies a n d
procedures also ass ist in the developme nt of pati ent
safety, quality assessment , a nd im provement activiti es.
VIlLa. Surgical a ttire polices and procedures sh ould
include, b ut n ot be limited to , requirem e nts
rela ted to
o fac ili ty-a pproved a nd sta nda rdi zed surgical
attire,
o areas where s urgical attire is worn ,
o infection preve ntion and control,
o use of PPE,
o launde ring,
o tra nsport and storage of clea n attire, and
o complia nce monitoring.
An unde rstanding of su rgical attire policies
a nd procedures assists health care personne l in
prot ecting the pa ti e nt, th em se lves, a nd th e ir
family members.
VIII.b. Policies and procedures should be introduced
a nd revi ew ed in th e initial orientation, wh en
now surgical attire is intro duced , a nd during
ongoing edu cation of health care personnel.
Re vi ew o f policies a nd procedures ass ists
health care p ersonnel in being kn owl edgeab le
- - - - RP: Surgi.cal Attire
about and compliant with the health care organization's policies and procedures.
Recommendation IX
The health care organization's quality management program
should evaluate compliance with surgical attire policies and
identify and respond to opportunities for improvement.
Quality management programs that enhance personal
performance and monitor surgical attire practices are
established to promote patient and health care personnel
safety. Health care laundry processing requires specialized equip ment , adequate space, qualified personnel
with ongoi ng training, and continuous monitoring for
quality assurance.~
IX.a.
Stru cture, process, and performance measures
should be identified.
Structure, process, and performance measures can be used to improve surgical att ire
quality and monitor compliance with facility
policies and procedures, national s tandards,
and regulatory requirements.
IX.a.1 .
IX.b.
Quality indicators for surgical attire may
include, but are not limited to,
• head coverings completely cover the hair
and scalp ;
• warm-up jackets wi th wrist- l ength
sleeves are worn and are snapped;
• identification badges are worn, visible,
and clean;
• sh oes are clean and protect heal th care
personnel's feet;
• visibly soil ed or wet surgica l att ire is
removed and cleaned a t an accredited
health care laundry facility;
• masks, when worn, are tied securely and
are discarded after each procedure; and
• cover apparel, if worn, is laundered dail y
at th e organization or an accredited laundry facility.
Quality assurance monitoring of laundry processes should be ongoing.
A study of the risk of Clostridium diffici!e
cross-contaminati on in the laundry process
illnstrates that cross-contamination occurs with
the use of nonsporicidal disinfectants, but that
the use of sporicidal disinfectant cloths showed
significantly reduced CFUs. The researcher concluded that cleaning Clostridium difficilecontaminated surfaces with nonsporicidal disinfectants crea t es a vector for cross contamination to ot h er textiles via the
laundering process. Cleaning contaminated surfaces with sporicidal disinfectant may not completely e liminate this vector, but does significantly reduce associated risk.lll
A rare outbreak of zygomycosis in a hospital
was investigated by the CDC using standard outbreak protocols. Zygomycosis is an invasive
fungal infection caused by mucormycetes,
which includes a Rhizopus species (ie, a group
of molds that is commonly found in the environment) . Infections with this microorganism
are rare and usually occur in people who h ave
underlying medical conditions. A cluster of six
cases occurred from August 2008 to July 2009.
Of the six cases, five patients died (ie, premature children up to age 13). All five children
h ad risk factors for zygomycos i s, which
included acidosis (ie, four children) and bone
marrow transplant (ie, one child). Hospital linens were the only items common to these cases.
Environmental cultures taken at the hospita l
revea l ed Rhizopus species on 26 out of 65
swabs (40%) of clean linens and areas in contact with clean linens, and on 1 out of 25 samples (4%) of items not in contact with linens.
Clean linen closets were cultured, including
those in the OR, where two items were found to
be Rhizopus-positive. Researchers determined
the hospital linens to be the most likely vehicle
of transmission to patients' skin. Contamination
of linens may have occurred during laundering,
en route to the hospital, or during delivery to
the hospital. The hospital c hanged commercial
laundry facilities, replaced all of its linens, disinfected all linen storage closets, and u sed a different delivery area for its linens in an effort to
prevent reoccurrence of this type of outbreak. ~
Glossary
Restricted area: Incl ud es the OR and procedure
room, the clean core, and scrub sink areas. People in
this area are required to wear full surgical atti re and
cover all head a nd facial hair, including sideburns,
beards, a nd necklines.
Semirestricted area: Includes the peripheral support
areas of the surgical suite and has storage a reas for sterile and clean supplies, work areas for storage and processing ins trum en ts, and corridors l eading to the
restricted areas of the surgical suite.
Surgical attire: Nonsterile appare l designated for the
OR practice setting that includes two-piece pantsuits,
cover jackets, head coverings, sh oes, masks, protective
eyewear, and other protective barriers.
REFERENCES
1. Andersen BM, Solheim N. Occlusive scrub suits
in operati ng theaters during cataract surgery: effect on
airborne contamination. Infect Control Hasp Epidemiol.
2002;23(4):218-220.
2. Tammelin A, Hambraeus A, Stahle E. Source and
route of methicillin-resistant Staphylococcus epidermidis
transmitted to the surgical wound during cardia-thoracic
surgery. Possibility of preventing wound contamination by use of special scrub suits. f Hasp Infect. 2001;47
(4):266-276.
3. Whyte W, Hamblen DL, Kelly IG, Hambraeus A,
Laurel! G. An investigation of occlusive polyester surgical
clothing. J Hasp Infect. 1990;15(4):363-374.
4. Barrie D. How hospital linen and laundry services
are provided. f Hasp Infect. 1994;27(3):21 9-235.
59
RP: Surgical Attire
5. Tamm e li n A, Domicel P, Hambraeus A, Sta hle E.
Dis persal of methicillin-resista nt Staphy lococcus e pidermidis by s taff in an operating suite for thoracic a nd ca rdiovascu lar surgery: relation to skin carriage and clothing.
J Hasp Infect. 2000;44(2):119-126.
6. Wu X, Yang CQ. Flame re ta rdant fin ishing of cotton
fleece fabric: part III- the combination of ma leic acid a nd
sodium hypophosphite. J Fire Sci. 2008; 26(4):351-368.
7. US De pa rtm e nt o f Health a nd Human Serv ices.
Standard for the flammability of clothing tex tiles. 16 CFR
§1610.
8. Yang CQ, Qiu X. Flame-retardan t finishin g of cotton fl eece fabric: Part I. The usc of a hydroxy-functional
orga n op hosp horu s ol igo me r a n cl d i me t h y lo lei i h ydroxylethyle neurea. Fire and Materials. 2007;31(1):67-81.
9. AAMI. S T79: Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities.
2009.
10. Mi tche ll NJ, Evans DS, Kerr A. Reduc tion of skin
bacter ia in theatre air with co111fortable, non-wove n disposabl e cluthing fo r operating-t h eatre s taff. Br Med f.
1978;1 (6114):696-698.
11 . Woodhead K, Taylor EW, Bannis te r G, Chesworth
T, Hoffman P, Humphreys H. Behaviours and rituals in the
opera ting th ea tre. A report from the Hos pital Infec tion
Society Working Party on Infection Control in Operating
Theatres. J Hosp Infect. 2002;51(4):241-255.
12. Noble WC. Dis persa l of skin microorganisms. Br J
Dennatul. 1975 ;93 (4):477-485.
13. Nob le WC, Ha bbema JD , van Furth R, S mith I,
de Raay C. Qucmtitative stu dies on the dis persal of ski n
bac teria into the air. f Med Microbial. 19/6;9(1):53-61.
14. Bartlett GE, P ollard TC, Bowker KE , Bannis ter GC.
Effect cf jewellery on su rface bacterial counts of operating
theatres. f Hosp Infect. 2002;52(1):68-70.
15. Graves PB , Twomey CL. Surgical hand antisepsis:
an ev idence-based re vie w. Perioperative Nursing Clinics.
2006;1 (3):235-246.
16. Field EA, McGowan P, Pearce PK, Martin MV. Rings
and watches: shou ld they be re moved prior to operative
d ental procedures? J Dent. 1996 ;24(1-2):65-69.
17. Recomme nd e d prac ti ces fo r h a nd h yg ie n e in
the perioperative setting. In: Pe rioperative Standards
and Recommended Practices . De nv e r, CO: AORN , Inc ;
2010:75-90.
18. Jea n s AR , Moore J, Nico l C, Bates C, Read RC.
Wristwatch u sc and ho spital -acquin~d infection. f Hosp
Infect. 2010;74(1 ):16-21 .
·J9. Boyce JM, Pittet D, Health care Infection Control
Prac ti ces Advisory Committee, HICPAC/SHEA /A PIC
IIDSA Hand Hygi e n e Ta s k For ce . Guide li ne for
Hand Hy g i e ne in Health-Care Settings. Reco mmendations o f th e Healthcare In fec tion Control Practi ces Adv isory Committee and the H ICPAC/
SHEA/ APIC/IDSA Hand Hygi e ne Tas k Force. Society for H ea lthcar e Epid e mio l ogy of Am e ri ca
I Assoc iat ion fo r Profess ion a ls in Infec tio n Co ntrol
/ Infectious Diseases Society of Ame rica. MMWR Recomm
Rep. 2002;51(RR-16):1-45 , quiz CE1-4.
20. Sali sbury DM, Hutfi lz P, Tree n LM , Bollin GE,
Gautam S. The effect of r ings on microb ial load of health
care workers' hand s . Am f Infect Control . 1997;25(1):
24-2 7.
21. Kelsall NKR, Griggs RKL, Bowke r KE , Bannis te r
GC. S hould fing er rings be removed prior to scrubbing for
theatre? J Hasp Infect. 2006;62(4):450-452.
60
22. lhck WE, Ve rnon MO, Hayes RA, et al. Impact of
ring wearing on han d conta mina tion and compa rison of
ha nd hyg iene agents in a hospital. Clin Infect Dis. 2003;
36(11):1 383-1390.
23. Amirfeyz R, Ta s ker A. A li S, Bowke r K, Blom
A. Th ea tre shoes-a link in th e common pat h way of
postope rative wound in fection? Ann R Coli Surg Engl.
2007;89(6):605-608.
24. Occ up ationa l Safety and Healt h Sta nd ar d s
1910.1 36: Foot protecti on . United S tat es De partme nt
of Labo r http: / / www.os h a. gov/pls/ oshaweb/o wadi s p
.show document? p tabl e=STANDARDS &p id =9786 .
Accessed September 29, 2010.
25. Fairfax RE. Wearing "Crocs" brand s hoes with
a partia lly op en heel and a cov ered toe in a pharmacy
se tting [le tte r]. Ju ly 16 , 2006. http ://www.osha.gov/pls
/osh aweb/owadisp.sh ow document?p tablc- INTERPRE
TATIONS&p id=25439. Accessed Oc tober 4 , 2010.
26. Occupational exposure to bloodborne pathogensOSHA. Final ru le. Fed Regis/. 1991 ;5ti(2 35):64004-64182.
27. US Health and Human Services. Bloodborne patlloge ns. 29 CFR §1910.1 030.
28. 29 CFR 1910.132: Gen era l requirem e nt s. U nited
S tates Department of La bor. http://www.os ha.gov/pls
/os haw e b /o wadisp .sh ow docum e n t ?p t abl e =STAN
DARDS&p id=9777. Accessed September 29, 2010.
29. Barr J, Siege l D. Da ngers of rl ermatologi c s urgery: protec t your fe e t. Dermatol S urg. 2004;30(1 2 Pt
1):1495-1497.
30. Watt AM, P atkin M, Sinnott MJ, Black RJ , Maddern
GJ. Scalpe l sa fety in the operative setting: a syste ma ti c
revie w. Surge1y. 2010;147(1) :98-106.
31. AORN p os ition state m ent on th e ro le of th e
hea lth care i ndustry re prese ntative in th e perioperative
/invasive procedure sett ing. http://www.aorn .org/Prac
ticeResources/AORNPos itionState ments/. Accessed September 29, 2010.
32. Recommend ed p ractices for a safe e nvironment
of care. In : Perioperative Standards and Recommended
Practices. Denver, CO: AORN, Inc; 2010: 217-240.
33. Developing and imp lementing a workp lace violence prevention progra m a nd policy. In: Violence in the
Workplace: Risk Factors and Prevention Strategies. Was hington , DC: National Institute for Occupational Safety a nd
Hea lth ; 1996.
34. Hospital Accreditation Standards. Oakbrook Terrace, IL: The Joi nt Com missio n; 2009:47-68.
3S. Kot sfl nas D. Sr.o tt C, Gi ll r.~piP. EE, Korman TM,
Stuart RL. What's hanging around your neck? Pathoge nic
bacteria on identity badges and lanyards. Med J A us/ .
2008;188(1):5-8.
36. Kap lan C, Mendiola R, Ndj a tou V, Chap nick E,
Minkoff H. The role of covering gowns in reducing rates
of ba cterial contamination of scrub suits. Am J Obstet
Gynecol. 2003;188(5):1154-1155.
37. Trea kle AM, Thom KA, Furun o JP, Strauss S M,
Ha rri s AD , Pere ncevic h EN. Bac teria l contamination of
h ea lth ca re workers' white coa ts. Am J Infect Control.
2009;3 7(2):101-105.
38. Wong D, Nyc K, Hollis P. Mic robia l flora on doctors'
wh ite coats. BMJ. 1991;303[6817):1602-1604 .
39. Loh W. Ng VV, Holton J. Bacteria l flora on the wh ite
coats of medical students. f Hosp Infect. 2000;45[1):65-68.
40. Durai R, Ng PC, Hoqu e H. Methici ll in-res is tan t
Staphylococcus aureus: a n update. AORN f. 2010;91(5):
599-609.
_____BP: Surgical Attire
41. Wood MW, Lund RC, Stevenson KB. Bacterial con ta minat ion of stethoscopes with a ntim icrobial diaphragm
covers. Am I Infect Control. 2007;35(4):263-266.
42. Be rnard L, Kerevcu r A, Durand D, e t al. Bacteria l contam ination of hospital physic ians' stet hoscopes .
Infect Control Hasp Epidemiol. 1999;20(9):626-628.
43. Lecat P, Cropp E, McCord G, Haller NA. Ethano lbased cleanser versus isop ropyl a lcohol to d eco nta m i n ate s tet h oscopes. Am 1 Infect Control. 2009;37 (3):
24 1-243.
44. Lep ra t R, Minary P, Devaux V, d e Waz ie re B,
Dupond JL , Ta lon D. Why, w hen and how to clea n stet hoscopes. I Hasp Iufect. 1998:39(1):80-82.
45. Sood P, Mishra B, Mandai A. Po te nti a l infection
hazards of stet hosco pes. I Indian Med Assoc. 2000;98(7):
368-370.
46. Mi lam MW, Hall M, Pringle T, Buc hanan K. Bacter ial co ntamination of fabric s tet h oscope covers: the
velvetee n rabb it o f hea lt h ca re? Infec t Control Hasp
Epidemiol. 2001 ;22(10) :653-655.
47. Recommended practices for environmental clea ning in the perioperative setting. In: Perioperative Standards and Recomm e11ded Practices. Den ver, CO: AORN,
Inc; 2010: 241-256.
48. Standards of perioperative nurs ing. In : Periopera tive Standards and Recommended Practices. Denver, CO:
AORN, Iuc; 2010: 9-62.
49. Nee ly AN , Maley MP. Survival of enterococci and
s taphylococci on hospital fabrics and plastic. 1 Clin Microbioi. 2000;38(2):724-726.
50. Neely AN, Orloff MM. Surviva l of some medica lly
important fungi on hospital fabrics and plastics. I Clin
Microbial. 2001 ;39(9):3360-3361.
51. Sehulster L, Chinn RY, CDC, HICPAC. Guidelines
fo r environmenta l in fect ion control in health-care faci li ties. Recommendat ions of CDC and the Healthcare Infecti o n Con trol Practices Advisory Committee (HICPAC).
MMWR Recomm Rep. 2003;52(RR-1 0):1-42.
52. Lconas KK . Effect of laundering on th e barrier properties of re usable surgica l gown fabrics. Am I Infect Control. 1998;26(5):4 95-501 .
53. Scal tril i S, Cence tti S, Ro vesti S, Marc h es i I,
Bargell ini A, Borella P. Ri sk factors for parti c ula te and
mic robi a l con tamination of air in operating th ea tres.
I Hasp Infect. 2007;66(4) :320-326.
54 . Mangra m A}. Horan TC, Pearson ML, Silver LC,
Jarvis WR. Gu ideline for prevention of surgica l s it e infectio n, 1999. Hospi tal Infection Control Practices Advisory
Co mmittee. Infect Control Hasp Epidem iol. 1999;20(4):
250-278; quiz 279-80.
55. Callaghan I. Bacterial contamination of nurses' uniforms: a study. Nu rs Stand. 1998;1 3(1 ):37-42.
56. National Institute for OccuJ,Ja tion a l Safety an d
Health. Protecting Workers' Families: A Researc h
Agenda. DHHS(NIOSH) Pub No. 2002-113. http://w w w
.cdc .gov/niosh/ d ocs/ 2002-113/ 200 2- 113.html. Accessed
September 29, 201 0.
57. Summers MM, Lynch PF, Black T. Hair as a reservoir of staphy lococci. I Clin Path. 1965;18(1 3):13-15.
58. Din een P, Drusin L. Ep id e mics of postoperative
wound infections associated with hair carriers. Lancet.
1973;2( 7839):1157-1159.
59. Mastro TO, Farley TA, Elliott JA, et al. An outbreak
of surgical-wound infections due to group A streptococcus
carried on the scalp. N Eng/ 1Med. 1990;323(14):968-972.
60. Mase K, Hasegawa T, Horii T, et a l. Firm adherence
of Staphy lococcus au reus and Staphylococcus epiderm idis
to human hair and effect of detergent treatment. Microbial
lmmunol. 2000;44(8):653-656.
61. Friberg S, Ardnor B. Lundholm R, Friberg B. The
addition of a mobil e u lt ra-c lea n exponential laminar airfl ow screen to conve nti onal operating room venti lation
reduces bac terial contamination to operating box leve ls.
I Ha sp Infect. 2003;55(2):92-97.
62. Takas hima M, Shirai F, Sageshima M, Ikeda N.
Okamoto Y, Dohi Y. Di s tinc tive bacteria-binding p rope rty of cloth materia ls. Am I Infect Con trol. 2004;32(1):
27-30.
63. Healthcare Laundry Accreditat ion Counci l. Accred itat ion Staudards for P rocessi ng Reusable Textiles for Usc
in Hea lth ca rc Fa ciliti es. 2006. http://w ww. hlacn et. org
I Accredit%20Standards12.18.08.pdf. Accessed October 6,
201 0.
64. Fija n S, Sostar-Turk S, Ccncic A. Impl e m e nting
hygie ne moni toring systems in hospital laundries in order
to red uce m icrobial contaminat ion of hosp ita l tex tiles.
I Ha sp Infect. 2005;61(1 ): 30-38.
65. ANSI/ A AMI. ST65: Processing of reusable su rgica l
textiles for u se in health care faci lities. 2008.
66. Gerb& CP. Applica tion of quan tit ative risk assessment for formula ting hygiene policy in the domestic setti ng. I Infect. 2001 ;43(1):92-98.
67. Associat ion for Linen Managemen t. Clinical Talking
Points: Healthcare Textiles Bioburden (educational materiall . Richmond, KY: Association for Lin en Manageme nt ;
2009.
68. Perry C, Marsh all R, Jones E. Bacterial contamin ation of un iforms. 1 Ha sp Infect. 2001 ;48(3):238-241.
69. Hedin G. Stap hylococcus epidermidis-hospital
e pidemiology and the detection of methici ll in resistance.
Scand I Infect Dis Supp l. 1993;90:1-59.
70. Twomey CL, Beitz H, Johnson BJ. Bacteria l contam ination of surgica l scrubs and laundering mechanisms:
infection control imp lications. Infection Control Today.
2 009. http :/ /www.i nfe ctionc ontrol today. com/ articl es
/ b ac te ria I-c on t a mi n a lion- o f- s urgi ca l-sc rub s . h tm I#.
Accessed September 29, 2010.
71. Gerba CP, Ken nedy D. Enteric virus survival d uring h o u se ho ld laundering a n d impact of disinfe cti on
wi th so dium hypochlorit e . Appl Environ Microbial.
2007;73(14):4425-4428.
72. Boone SA, Gerba CP. Sig nifi cance of fo mites in
the spread of respi ratory an d enteri c vira l disease. Appl
Environ Microbiol. 2007;73(6):1667-1696.
73. Scheuer R. Dispensing of excess scrub expenses.
Mater Manag Heaith Care. ~006;1f:J(l):24 -~7.
74. Akridge J. No blanket strategies in texti le management. Healthc Purchasing News. 2007;31 (1 2):46, 48-49.
75. 2007 Guideline fo r Isolat ion Precautions: pre venting trans m iss ion of infecti ous agents in hP.fl ith r.a re settings. Centers for Disease Control and Prevent ion. http://
www.c dc.gov/ hic pac/2 007IP/2 007is ola tionPrecaution s
.html. Accessed Septe mber 29, 2010 .
76. Romn ey MG. S urgical face masks in th e operating th eat re: re-exam in ing th e evidence. I Hasp Infec t.
2001 ;4 7( 4):251-256.
77. Ba rbosa MH , Graziano KU . Influence of wearing
time on efficacy of disposable surgica l masks as mic robial
barri er. Braz I Microbial. 2006;37(3):216-21 7.
78. McClus key F. Docs wearing a face mask reduce bacteria l wound infection? A lit erature review. Br 1 Theatre
N urs. 1996;6(5):18-20, 29.
79. Carbone HL, Hell ickson LA, Thomasser AL, Vu LK.
Clos tridium difficile cross conta min ation in th e textile
61
-
RP: Surgical Attire
laundering process: the importance of selecting an ap propriate hard surface di sinfectant. Paper presented at: International Conference on Healthcare-Associated Infections;
March 19, 2010; At lanta, GA.
80. Duffy J, Harris J, Newhouse EN, et al. Zygomycosis
outbreak as~oc iated with hospital linens. Paper presented
at: In ternatiOnal Co nference on Healthca re-Associated
Infections; March 19, 2010; Atlanta, GA.
Acknowledgments
L t:AD AUTHORS
Joan Blanc hard, MSS, BSN, RN, CNOR, CIC
Perioperati ve Nursing Specialist
AORN Center for Nursing Practice
Denver, Colorado
Melanie Braswell, DNP, MS, RN, CNS, CNOR
Full-Time Faculty School of Nursing
Purdue University
Lafayette , hH.Iiana
CONTRIBUTING AUTHORS
George Allen, PhD, MS, RN, CNOR
Director of Infection Control
Downstate Me dical Center
Brooklyn , New York
Nancy Bjerke, MPH, RN, CIC
Consultant
Association for Professionals in Infecti on Control and
Epide miology, Inc (APIC)
San Antonio, Texas
Sorin Brull, MD
Americ an Society o f Anesthesiology
Professor of Anesthesiology
Mayo Clinic College of Medicine
Rochester, Minnesota
62
PUBIJCATION HISTORY
Originally published March 1975, AORN Journal, as
AORN "Stand ard s fo r p roper OR wea ring appare l. "
Format revision March 1978, July 1982.
Revised March 1984, March 1990. Publis hed as proposed recommended practices, August 1994.
Revised November 1998; published December 1998.
Re formatted July 2000.
Revised Novembe r 2004 ; pub lished in S tanda rds,
Reco mmen ded Pmctices, a nd Guidelines, 2005 edition. Reprinted February 2005, AORN Journ al.
Revised October 2010 for online publication in Perioperative Standards and Recommended Practices.
Reformatted September 2012 for publication in Perioperati ve Standards and Recommended Prac tices,
201 3 e dition.