Abstract
The Association of periOperative Registered Nurses (AORN) Guideline for Surgical Attire has been updated and will be electronically published on the AORN Facility Reference Center on July 1, 2019. This document provides guidance on head coverings, shoes, wearing long sleeves, laundering, cover apparel, and the cleaning of personal items such as cell phones and briefcases. The guideline is based on a systematic review of the evidence published since 2014, which was the time of the last revision. Many of the recommendations have changed and AORN encourages healthcare organizations to form interdisciplinary teams that include all peri-operative team members including infection preventionists, to review the new recommendations, and determine whether policy changes are indicated. Involving representatives from all members of the peri-operative team in the decision-making process is critical for determining how the practice will affect each team member in their role. Some of the new recommendations are summarized below, although the guideline should be referred to in its entirety when making practice decisions.
Head Coverings
The hair and scalp of peri-operative team members should be covered when entering the semi-restricted and restricted areas. Wearing a head covering to contain shedding hair and scalp skin may minimize the patient's risk of surgical site infection (SSI) by preventing hair from contaminating the sterile field or open wound [1–3]. The evidence demonstrates that beards can also be a source of potentially pathogenic organisms and should be covered when entering the restricted areas [4].
No recommendation could be made for the type of head covers worn. Three recent studies did not demonstrate any association between the type of surgical head covering material or extent of hair coverage and the outcome of SSI rates [5–7]. An interdisciplinary team, including members of the surgical team and infection preventionists, may determine the type of head covers that will be worn at the health care organization.
No recommendation could be made for covering the ears. Although evidence indicates that the ears are a potential source of pathogens, the research has not demonstrated an association between covering the ears and the development of SSIs [4]. However, covering the ears of scrubbed team members who are wearing earrings may prevent them from falling into the sterile field and placing the patient at risk for a retained item [4]. Potential harms of covering the ears may include interfering with the fit of protective eyewear, loupes, stethoscopes, and impairing hearing, which could impede team communication [4].
Long Sleeves
The arms of the person performing the skin prep may be covered by long sleeves. This recommendation is rated as a Conditional Recommendation, which means that it may be implemented depending on the benefit–harm assessment for the specific setting. The benefits of wearing long sleeves during performance of pre-operative patient skin antisepsis are likely to exceed the harms if the sleeves do not come into contact with the preparation. The preparation technique and fit of the sleeves may be modified to reduce the potential harm of inadvertently contaminating the preparation. However, further research is needed to confirm the risk-benefit assessment and the effect on SSI outcomes [4].
Markel at al. [8] conducted an experimental study to compare air contamination during intra-operative patient skin preparation with and without arm coverage of the person performing the prep. A mock patient skin preparation was performed in three hospitals with a total of 12 experiments, six with bare arms and six with arms covered. The researchers used particle counters to measure airborne particulate contamination. Active and passive microbial assessment was measured using air samplers and settle plate analysis. In one operating room (OR), there was a decrease in 5.0 mcm-sized particles when the arms were covered. In the other two ORs, there was a decrease in total microbes when the arms were covered. Wearing long sleeves specifically appeared to decrease the amount of Micrococcus in the environment. The researchers recommended wearing attire with long sleeves when performing the intra-operative patient skin preparation.
Personal Clothing
No recommendation could be made regarding the wearing of personal clothing under surgical scrubs. No evidence was found to evaluate the benefits or harms of wearing personal clothing under scrubs. Facilities will need to establish and implement their own processes for managing any personal clothing that may be worn including types of fabrics, amount of fabric that can extend beyond the scrub attire, laundering method, and laundering frequency [4]. Peri-operative team members who wear personal clothing that becomes contaminated with blood, body fluids, or other potentially infectious materials should remember that those items must remain at the facility for laundering [9].
Personal Items
Peri-operative team members may need to bring personal items such as briefcases, backpacks, and cell phones into the restricted and semi-restricted areas. Facilities should establish a process to prevent contamination of the semi-restricted and restricted areas from briefcases and backpacks. Facilities may consider cleaning or containing the item or placing the item in a designated location [4]. These items may be difficult to clean and can harbor dust and pathogens. Cleaning these items may help to decrease the transmission of potentially pathogenic micro-organisms to surfaces in the peri-operative environment [4]. The evidence [10–18] demonstrated that cell phones, tablets, and other handheld personal devices are highly contaminated with micro-organisms, some of which are pathogenic. These items need to be cleaned according to the device manufacturer's instructions for use prior to bringing them into the OR and hand hygiene should be performed.
Conclusion
There is still much that is not known about how surgical attire affects the surgical environment and consequentially the risk of SSIs to patients. It is known that micro-organisms are shed from the skin and hair of peri-operative team members. Following evidence-based recommendations regarding attire, laundering, and cleaning may help to reduce patient exposure to these micro-organisms. Healthcare organizations should form interdisciplinary teams to make practice decisions specific to their setting and patient population with the input of all peri-operative team members and infection preventionists.