There are many do's and don'ts when it comes to wearing surgical attire, and it's a matter of much more than fashion sense. A stray hair from a surgical cap or a spot of blood on a staffer's shoe, for example, can greatly increase the risk of spreading infection among your patients and staff. In this feature — the first in a yearlong series dedicated to stamping out surgical site infections — we look at some of the common mistakes surgical staff members make with 6 critical pieces of protective wear, and how wearing them the right way will help shore up barrier protection at your facility.

1. Scrub caps
You can walk into just about any OR and find surgical staff members with hair protruding from their scrub caps. This infraction can easily be ignored, but the microorganisms in loose hair or dandruff can contaminate the sterile field. In fact, SSIs have been traced to bacteria from the hair and scalp of surgical personnel. AORN recommends that surgical team members in the OR should wear low-lint and hood-style caps that cover all of the hair on their heads, including facial hair. Getting the entire team to do so, however, isn't always that easy. For example, a team member may be reluctant to point out to a surgeon that his hair is poking out from underneath his cap. Rely on your circulating nurse to impose this measure. The circulator has a panoramic view of the room, and can see if anyone is wearing scrub caps — or other pieces of surgical attire, for that matter — in an improper fashion. And, if your circulating nurse has trepidation about going to a doctor or other staff member who frequently makes this mistake, reassure her that she has your support in enforcing this policy, and encourage her to be vocal when she sees an infraction.

2. Gloves
Double-gloving has become a common practice in most ORs. Doubling up on gloves certainly cuts down on the risk of contamination from a needlestick, for example. But these gloves can still have difficult-to-see pinholes from which microbes can escape. Say, for example, these microbes come in contact with a staffer's skin, and then she touches her mouth or face without washing her hands. This clearly increases the risk of contamination. Of course, surgical staffers should wash their hands anytime they remove protective gloves.

Beyond enforcing proper hand hygiene, you should also be careful opening up supplies, and make sure gloves are packaged in a way that's conducive to removing them in a sterile manner. This small piece of the puzzle may get overlooked, but packages sometimes curl back when opened, and the gloves may touch the edges of the box or container when you remove them. When taking out gloves, remove them so that they don't touch the package's edges, where they could be slit, or make contact with harmful bacteria.

3. Protective eyewear
Most OR personnel wear disposable protective glasses. This is acceptable as long as they're actually thrown away after the case. But I've often seen surgical staff wear the same glasses for the next case, which raises the risk of pieces of the glasses flaking off and entering the sterile field. Reiterate to your staff that glasses should be disposed of after each use.

Others don't wear glasses at all, but eye protection is critical, given the likelihood of splash from blood or body fluids. Eyewear should have sidepieces to further prevent splashing in the eyes, and should ideally be made of hard plastic. Hard plastic eyewear isn't necessarily a requirement, but is recommended for some cases. For example, I've seen orthopedic procedures where hoses have popped off drills and gone flying across the OR. Hard plastic eyewear offers the most protection if such an event occurs.

4. Masks
Masks provide a strong barrier for pathogens to overcome on the way from the nose and mouth. Putting on a mask is second nature for OR personnel, but you sometimes see masks that aren't secured to the face quite tightly enough. Masks that aren't tied tight enough often pucker, which allows bacteria to escape through either end of the mask. The length of time a mask is worn is also important. You'll frequently see a staff member wear the same mask for several hours at a time, dropping it down below the mouth between cases and then retying it before the next procedure begins. This isn't a wise practice, as the mask becomes less effective at fending off airborne microorganisms the longer it's worn. OSHA also recommends that masks be changed before leaving 1 area of the facility to head to another, especially when leaving the OR.

Educate your staff on the importance of proper usage of surgical masks, which also includes removing masks by the strings. These are basic precautions, and you can turn to a number of resources — AORN, CDC and OSHA, for instance — for guidelines on applying and handling surgical masks.

5. Gowns
Some surgery centers use disposable gowns that are changed after each procedure. Much like eyewear, disposable gowns aren't always thrown away after 1 use, however. Be vigilant in ensuring gowns are properly disposed of between procedures. Reusable cloth gowns are another option. This may save money, but reusable gowns can accumulate hazardous materials with each use. Appoint a staff member to keep track of uses, and make sterile gowns easily accessible in your OR.

Another common infraction that I've seen with regard to gowns is staff members failing to turn their gown when turning their back to the surgical table. Some may not even realize they have this bad habit, or don't think it matters. But the back should not be exposed to the sterile field. Train your staff to make sure they turn their gowns before turning their backs to the table.

6. Footwear
OR floors are rife with potential contaminants, especially when performing bloody or wet cases, and most facilities will instruct employees to bring extra shoes to work in the operating room. Still, if you walk into an average OR, you'll probably see blood on the shoes of at least 1 or 2 staff members. OR employees who don't properly cover their shoes will carry that blood or fluid, or any number of hazardous materials, everywhere they go throughout your facility. It's wise to draft a policy that mandates proper protective footwear specifically for the OR, and that shoe covers be removed and replaced by new ones between each case. And be sure to keep these shoe coverings in a place that's easily accessible for OR employees.

Monitoring attire
Establishing safety conscious policies and communicating them to your surgical team are key first steps to improving barrier protection. But even the most comprehensive policies don't do much good if they aren't enforced.

Hold on-site training on barrier protection practices, and conduct periodic internal audits to make sure your policies are being put into action. Your auditor could be any staffer, but I'd recommend an experienced clinical team member with a strong infection control background to serve as your watchdog. With your auditor, make a checklist of attire your surgical team uses, and simply walk into the OR to make sure everyone is double-gloved, using protective eyewear, wearing gowns in the proper manner and so on.

Do these audits as often as you see fit, comparing checklists from one evaluation to the next and identifying areas that have yet to improve. Don't reprimand staffers for infractions. Rather, take the opportunity to reiterate to them the importance of safe barrier protection practices, and stress that fixing these issues will ultimately create a safer environment for them, their colleagues and their patients.