PROTECTIVE APPAREL Above all else, surgeons wants an impermeable barrier against bloodborne pathogens and viruses.

No doc wants to operate in a hot, heavy gown, but barrier protection trumps comfort and breathability every time. So long as there's no strikethrough, there's no problem.

"The biggest thing we need in a surgical gown can be summarized in one word: impermeable. That's it," says David Renton, MD, MPH, an assistant professor of surgery at Ohio State University's Center for Minimally Invasive Surgery in Columbus. "Some people may say they want it to breathe so it won't be as hot. Or to be soft so it's movable and feels good against the skin. But in the end, the most important thing is impermeability. We don't want exposure to the patient and vice versa in the OR."

The Buffalo Surgery Center in Amherst, N.Y., goes through about 25,000 gowns a year. The 3 things that matter most to the person with the purchasing power: good price, an ample cuff to grip gloves and strong permeability to prevent strikethrough.

"My surgeons would complain if I bought a gown that's not impermeable to strikethrough," says administrator Jeannette M. Moretti, RN, CNOR. "Otherwise, they just use what I give them."

Ms. Moretti recently switched gown vendors to take advantage of better pricing ($1.44 apiece). She stocks only 2 sizes — "large and extra large fit everybody" — and prefers a longer cuff that stays snug on the wrist and secures the gloves in place. "A shorter cuff can pull up and expose the wrist," she says, calling that gap a perfect opportunity for blood and bodily fluids to contact a surgeon's skin.

CUFF SIZE Surgeons prefer a longer cuff that stays snug on the wrist and secures the gloves in place.

Appropriate level of protection
How much barrier protection do your surgeons need? There are 4 levels of barrier performance, with Level 1 being the lowest level of protection and Level 4 being the highest. The barrier performance classification levels are determined by a couple of factors: the gown's resistance to penetration by liquid contact, and the anticipated blood and bodily fluid exposure from the case. Gowns classified as Level 1 or 2 offer minimal or low barrier protection, while Level 3 or 4 gowns provide moderate or high barrier protection. A cataract surgeon will need less protection than, say, a general or orthopedic surgeon.

"The only ones I have ever used are Level 3 and 4," says Dr. Renton. "Level 3 is a little lighter, and adequate for the majority of the cases I do. We have Level 4, and the cost difference is negligible, so when I need them, they are there."

For an open operation, Sharona B. Ross, MD, FACS, director of minimally invasive surgery and surgical endoscopy at Florida Hospital Tampa, would choose a Level 4 poly-reinforced breathable film sleeve lightweight and long sterile gown. For minimally invasive laparoscopic or robotic operations that have minimal blood loss, Dr. Ross says she'd don a lightweight, impervious, breathable sterile gown rather than a reinforced gown.

As a general rule, a surgical gown with minimal barrier protection is suitable for short procedures during which there is little or no anticipated exposure to blood or bodily fluids. A Level 1 gown would be a good choice for excisional biopsies, simple ENT procedures and ophthalmological cases. A Level 2 gown would be a good choice for tonsillectomies and adenoidectomies, endoscopic GI procedures, open hernia repair and simple orthopedic procedures during which tourniquets are used.

As the complexity, length and fluid exposure of the planned procedure increases — and with it increased potential for exposure to bloodborne pathogens — it would be prudent to select a gown with greater barrier capability. For example, use a Level 3 gown, which offers good fluid barrier protection, but is not considered impervious, for knee arthroscopy and open GI procedures. For any procedure in which the surgeon's hands and arms are in a body cavity, grab a Level 4, which provides an impervious barrier in the entire critical zone — including any seams or other attachments, such as the front belt on a gown, that are in the critical zone. The critical zone is the area of the gown where direct contact with blood, bodily fluids and other potentially infectious materials is most likely to occur.

Even though he uses a tourniquet for most of his cases "so I'm not generally showered in fluids," podiatric surgeon Jeffrey Blank, DPM, says he's most comfortable in a Level 3 gown. "That's what I usually wear," says Dr. Blank, of the Dundee Foot Center in Wheeling, Ill., and Foot First Podiatry in Crystal Lake, Ill. "The Level 3 gown provides the fluid resistance and antimicrobial protection that I need."

Dr. Blank's other preferences: a lint-free gown with a high tensile strength, a high burst strength and reinforced sleeves. "The reinforced or augmented sleeves offer a little more protection from penetration from some of the sharp instruments and bone fragments that I handle."

Let's not forget comfort
Is it too much to ask to be cool, comfortable and properly protected? The challenge with surgical barrier materials is that impervious fabrics can sometimes be uncomfortable to wear for long periods of time.

"I would like a gown that doesn't overheat me," says Dr. Blank. "There's nothing worse than feeling like I'm in a sauna while performing surgery. A cool, comfortable gown is always appreciated."

The microfiber technology used in some Level 4 gowns let the gown react to increasing temperature by increasing its moisture vapor transfer rate. Some Level 4 gowns are made of multi-layered, high-performance fabrics.

"An uncomfortable gown or even discomfort in a gown can cause big problems," says cataract and refractive surgeon T. Hunter Newsom, MD, of Newsom Eye & Laser Center in Tampa, Fla.

A gown must fit well at the neck — the Velcro adjustments can be bothersome — and especially at the wrists, he says. "If the gown is not comfortable at the wrists and then you put on gloves, this will make the problem worse," says Dr. Newsom. "Ultimately, a surgeon makes a living using his hands, so keep your wrists and hands happy."

For a high-volume surgeon like Dr. Newsom, ease of removal is an important consideration. "If I'm tearing a gown off 40 times in a day, I don't want to have to tug hard 40 times," he says. His trick: Don't tie the gowns so tightly that you can't easily tear it off at the end of the case.

One final piece of advice from Dr. Newsom: Have good backup gowns. "There's nothing worse than changing out of your great gown into an uncomfortable backup gown that isn't in your standard surgical pack." OSM

Anatomy of a Surgical Gown
Inside the barrier that keeps fluids out.

Disposable but indispensable, surgical gowns are a key component of infection prevention efforts for your patients. They're also the front line of barrier protection for your OR's occupants. The factors that determine just how effective they are in shielding your surgeons, staff and patients can help you decide which type to purchase, but trying them on will ensure that the protection you choose is also practical. Here's a review of the most important selection criteria.

— Outpatient Surgery editors

1 A level field. Surgical gowns were once marketed primarily through such descriptive but non-specific claims as "fluid resistant," "prevents strikethrough" and "impermeable." In 2003, however, a consensus standard from the Association for the Advancement of Medical Instrumentation and the American National Standards Institute established uniform testing methods for manufacturers to objectively rate their gowns' protection characteristics. The AAMI/ANSI PB70 standard, "Liquid Barrier Performance and Classification of Protective Apparel and Drapes Intended for Use in Health Care Facilities," was recognized by the U.S. Food and Drug Administration the next year. Gowns classified as Level 1 or 2 offer minimal or low barrier protection, while Level 3 or 4 gowns provide moderate or high barrier protection.

2 Testing 1, 2, 3, 4. A gown's level is determined through its performance in the following tests:

• Water resistance: impact penetration assesses how fibers, yarns and textile construction stand up to a 1-pound-per-square-inch (psi) water spray. A lower number represents higher repellency. All 4 levels meet acceptable quality scores.
• Water resistance: hydrostatic pressure pits gown fabric against a stream of water. A higher number represents greater resistance to penetration. Level 2, 3 and 4 gowns pass this test with progressively higher scores.
• Resistance to penetration by synthetic blood under conditions of continuous liquid contact. This test is graded pass/fail based on visual inspection.
• Resistance to penetration by bloodborne pathogens is what earns Level 4 gowns the highest classification. A non-infectious bacteriophage similar in size and shape to hepatitis C, the smallest bloodborne pathogen, is introduced through liquid contact. Resistance to penetration is reported as pass/fail.

3 Barrier protection. Surgical gowns, which the FDA regulates as medical devices, must meet a minimum of Level 1 barrier protection in their critical zones, the areas where direct contact with blood and bodily fluids is most likely: the front of the gown from the collarbones to below the waist, the sleeves' forearms, and any seams or points of attachment. If a gown's back panels don't meet Level 1 criteria, the gown (and not just its packaging) must be labeled with a warning.

4 Suiting the need. It's incumbent upon facilities to supply, and providers to choose, gowns that offer appropriate levels of protection for the cases at hand given the anticipated exposure to blood, bodily fluids and other potentially infectious materials. Outfitting staff in Level 4 gowns for every procedure is unnecessary (and cost-inefficient), particularly if they include such low-fluid cases with minimal blood loss as cataract surgery, ENT and laparoscopic hernia. On the other hand, staff who find impervious gowns warm and uncomfortable and opt for lightweight gowns in arthroscopic, joint replacement or open abdominal surgeries are putting themselves at risk.

5 Strength under pressure. Manufacturers may assess and report a gown material's resistance to tearing and puncture through a range of standard mechanical tests, including the grab test for breaking strength and elongation, the diaphragm bursting strength tester and the Elmendorf tear test, in which higher ratings equal stronger materials. Surgical gown material should also be resistant to abrasion under normal use, whether it's dry or wet, and the material should be low-linting or lint-free to prevent contamination of the sterile field and surgical site.

6 A breathable barrier. While levels indicate a gown's effectiveness as a protective barrier, breathability is essential to a wearer's comfort. Many products are made from multiple layers of non-woven fabric, microporous textiles and air-permeable films in different combinations that let heat and vapor escape without allowing the entry of fluid.

7 Choose comfort. A comfortable gown is a functional gown. Besides breathability, consider the ergonomics of gown textiles and construction during on-the-job trials for the best fit. Lightweight, flexible, soft and non-abrasive materials are easy to wear, while generous sizing offers freedom of movement. Sufficiently long sleeves with cuffs that grip gloves will prevent one mid-procedure inconvenience. And a gown made from quiet, non-glare material is a lot less annoying to work in and around.