Infection Prevention: The Latest on Surgical Attire Recommendations

You’re probably aware that AORN’s evidence-based surgical attire guideline promotes cleanliness in the surgical space to protect patients and personnel from transmission of pathogens. You might not know the guideline was updated in July 2019. “Many providers aren’t aware of the latest recommendations,” says Lisa Spruce, DNP, RN, CNOR, CNS-CP, ACNP, ACNS, FAAN, director of evidence-based perioperative practice at AORN. “They frequently refer to the 2015 guideline. Much of it has changed, so we need to emphasize that surgical teams should refer to the 2019 revision.” 

Here are some of the key updates to the latest guideline, along with clarification on some common areas of uncertainty:

• Laundering. The newest recommendations suggest laundering scrubs at healthcare-accredited laundry facilities or onsite if your facility has the proper equipment and can meet state regulatory requirements or the CDC’s recommendations for laundering. Rationale in the guideline provides a review of the evidence on home laundering. “Outpatient surgery facilities still frequently have their staff members wash their scrubs at home,” says Dr. Spruce. “Home washing machines are not monitored for quality, consistency or safety, and many energy-efficient home washers don’t get hot enough or agitate enough.” In addition, retail detergents usually aren’t powerful enough to properly clean soiled scrubs.

Dr. Spruce says installing a laundering system in your facility could allow you to address those deficiencies. “You can get a washer and dryer that conforms to state regulatory requirements to launder scrubs at your facility,” she explains. “If there are no state regulatory requirements, refer to the CDC’s recommendation for laundering.”

• Arm coverings. AORN previously recommended that surgical professionals keep their arms covered in semi-restricted and restricted areas. Now it simply recommends that arms may be covered during preoperative patient skin antisepsis. “There was no evidence found to evaluate the benefits or harms of wearing long sleeves at any other time than during skin prepping,” says Dr. Spruce, who acknowledges there has been pushback in the industry regarding long-sleeve requirements. “It’s not a must-have. It’s a personal decision.”

• Footwear. AORN recommends wearing clean shoes that are protective and meet healthcare organization safety requirements, including OSHA’s recommendations. Dr. Spruce notes that objects in the OR can pierce the soles of ordinary shoes. She recommends providers keep a dedicated pair of hard-soled shoes at the facility that they never wear outside.

Shoe covers are a frequent area of uncertainty and confusion, notes Dr. Spruce. “I see providers wearing them every day, and it’s just not necessary,” she says. “Covers need to be worn when you’re in a room where there are lots of fluids, gross contamination or blood. In these instances, wear a shoe cover, take it off, discard it and then perform proper hand hygiene.”

• Head coverings. AORN now recommends that providers cover their scalp and hair when entering semi-restricted and restricted areas, although it offers no recommendation on the specific type of head covering providers should wear.

“New evidence determined there is no association between the type of hair covering worn or extent of hair coverage with the outcome of SSI rates,” notes Dr. Spruce. She says an interdisciplinary team of perioperative staff and infection preventionists can determine the types of head covers that are allowed to be worn at their specific healthcare organization.

Earlier this year, AORN tweaked its 2019 guideline to address religious head coverings such as hijabs, veils, turbans and bonnets, saying those that meet certain specifications may be worn to cover the hair and scalp. “Policy restrictions or policies that do not address the use of religious head coverings in perioperative settings can be a barrier for members of some religious groups who currently work or aspire to work in procedural areas,” says Dr. Spruce. She points to one survey of female Muslim healthcare professionals that found more than half experienced problems trying to wear a headscarf in the perioperative setting, with many feeling embarrassed, anxious or bullied.

Religious head coverings should be clean, unadorned, constructed of tightly woven and low-linting material, and should fit securely, with loose ends tucked in the scrub top. Coverings such as kippahs and yarmulkes that cover only a portion of the hair and scalp may be worn under another head covering.

The guideline is such a great resource because it provides recommendations and the evidence to back them up.
— Lisa Spruce

AORN’s guideline also recommends that beards should be covered in restricted areas and when preparing items in the clean assembly section of the sterile processing area.

• Jewelry. Due to a lack of evidence, AORN currently offers recommendations only for earrings in its surgical attire guideline — not for necklaces, makeup or artificial eyelashes. One study AORN found demonstrated that pierced ear holes can be more contaminated than unpierced lobes, and thus the provider’s hand could be contaminated if they touch the hole. Another issue with earrings is that they could fall out in the sterile field and become retained surgical items. “Earrings should be contained in a head covering or not worn,” says Dr. Spruce.

AORN’s surgical attire guideline provides an evidence-based starting point upon which facilities can build further policies and protocols. “The guideline is such a great resource because it provides recommendations and the evidence to back them up,” says Dr. Spruce. For areas where evidence doesn’t exist, she suggests facilities form interdisciplinary teams consisting of nurses, surgeons, anesthesia providers and scrub techs that evaluate the guideline and decide how to proceed — or conduct studies of their own to add to AORN’s knowledge base.

“AORN puts out a list on its nursing research page of gaps in guidelines where we have no research, and we encourage interested nurses to contribute studies,” says Dr. Spruce. OSM