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2 3 i t i o n ~
Perioperative
Standards
and Recommended
Practices
For Inpatient and
mbulatory Settings
7/21/2019 2013 AORN RP's for Surgical Attire
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Recommended
Practices
for
Surgical
ttire
T
e following Recommended
Pr
ac
ti
ces for Sur
gica
l Attire were
developed
by
th
e AORN Rec
omme
nd
ed Practices
Com mitt ee a nd ha v e
been
approved
by th e AORN Board
of
Directors. They
were
prese
nted as proposed reco
mm
e
nd
ati
ons
for
commen ts by members and others. They
arc ef
fec
ti
ve
November 1, 2010.
The
se reco
mm
ended practices are
in teuded as ac hi evable recommendation s rep resent
ing what is beli
eved
to be an optimal level of
pra
c
ti
ce
. Po li
cies
and
procedures
will reflect variations in
practice se ttings and
/o
r clinical situations that
dctcr
miue the degree to w hich the rec01nmended practices
l:an be implemented. AORN
recogniz
es the various
se t t in gs in whic h pe riop
era
ti ve nurses p rac ti
ce.
These recommended prac tices are in tended as guide
lines
a
daptabl
e to
var
i
ous practic
e
se
ttin
gs.
Th ese
practi
ce
se tt ings
include
traditional operat ing rooms
(ORs).
am b
u latory surge ry ce
nters,
p h ys i c
ian
s'
offices, card iac catheterization laboratories, endoscopy
suites ,
rad
iology depar
tm en
t
s,
and
all
o
th
er areas
where
surgery and other invasive procedures may be
pe rformed.
Purpose
These recommended practices
provide
guidelines for
s
ur
gi
ca
l a ttire
in
c
ludin
g j
ewelr y
clothing , shoes,
hea d coverings, masks , jackets, and other accessories
worn in th e semires tri cted and restricted areas of th e
surgica l or
inva
s ive procedure se tt ing. The hu man
body a
nd inanima
te surfaces
in
herent to the s
ur
gical
environment are major
sourc
es
of
microbial co ntami
na tion and transmiss ion of microbes; there fore, su rgi
cal
at t
ire
an
d
app
ropriate perso na l
pr
ot
ec
ti ve
eq uip
ment (PPE) are wo rn to p romote
wo
rker safety and a
high leve l of
clea
nlin
ess
and hygiene wi
thin th
e peri
ope
ra
ti
ve tmv i
ro nm
ent. These reco mm
ended
p r
ac
tices arc not intend ed to address steril e s urgical attire
worn
a t th e surgi
ca
l field
or
all PPE.
Recommendation I
Surgical
attire s
hould be
made of low-linting material
contain
shed skin squames
provide comfort
and promote a
profes-
sional
appearance .
In a
pr o
sp
ec
tive
intervent
ional study of surgical att
ir
e
tha t wa s motiva ted by a n increase in endo phthalmitis
a ft er
ca
t
arac
t surgery, researchers co mpared several
t
ype
s of
po
lyester scrub att ire a
nd
c
otton
scrub a
ttir
e.
They found tha t surgical attire made of
100
spun
bond
pol
ypropylene decreased the bac terial load in
th e
air
by 50 co
mp
ared to
co tton
surgi
ca
l a
ttir
e.
R
esea
rchers also
fo
und tha t s
ur
gica l a tti re helps con
tai n
bacte
rial she
dd
ing and promotes environm ental
cont roJ.l In anoth er s
tud
y researchers found that th e
design of
the
s
ur
gical att ire was not as impor tan t as
th e material
of
whi ch it
was
mad c.a
I.a. Surgi
ca
l att ire fab rics sho uld be tight ly woven ,
stai n res istant , a nd du rabl e. S
ur
gica l at t ire
should provide comfort in terms of des ign, fi t,
breathability
and
the we ight
of
the fab ric.
Co
tton
fab r ics with
pore
s grea te r
th
an 80
mi crons may
allow
mi croorga nisms attac hed
to skin squam
es
to pass th rou gh the interstices
of
the material's weave.MTight ly woven
su
rgi
cal atti re (co
tt
on and
pol
yes te r [50/50) with
560 x 395 th read
s/1
0 em)
reduced
th e amount
of
bacte ria
shed
into the a ir by two to five
t
imes
, with th e excep ti on of me
th i
ci ll
in
r
es
is ta
nt
taphylococcus idermidis
(MRSE)
from MR
SE
c r r i e r s
Lb. Surgica l attire ma
de of
100 co tto n fle ece
should not be worn .
Scme fabrics made of co tton fleece materi al
co
ll
ec
t
and
sh
ed
lint. Lint may harbor microbial
l
ad e
n
du
st, ski n s
quam
es , an d res pi ratory
drop lets . In ad d it ion, fleece is made
up
of a
napped
sur
f
ace
w ith low
de
nsity
which
ren
ders t
more
Cotton fiber is one of th e mos t flam mable
fibers, and 10 0 co tton fleece wi th out fire
retard
an
t ch
em
ical treatment docs not m
ee
t the
federal flammability s tandard. z t Cotton blen
ded
wi th 10
to
20
po lyeste r may redu
ce th
e
fla
mm
ability u bu t th is is not alwa
y:;
success
ful. Application
of
a fire-r
etarda
nt chem ical
still may be re
quir
ed.a
Recommendation II
Clean surgical
attire
including shoes
head
covering
masks
jackets and
identification
badges should be worn in the
se
mirestricted and restricted areas
of
the surgical or invasive
procedure setting.
l.
lean a tt ire
minimi
zes t
he
intr
od
uction of
mic
r
oor
ganisms
am
i lint from health care perso nuel to clean
items and th e en
vi
ron men
t. I
Il
.a. Faci lity
-appro
ved, clean, and fres hl y la un
der
ed
or
dispo
sable sur
gica
l a ttire should
be
do n ned daily in a des ignat ed d ressing area
before entry or reentry into the semirest ricted
and res tricte d areas.
Changing from street ap
pa
re l in to fac il ity
approved , clean , and freshly laundered or dis
posa
ble
surgica l att ire in a de signated ar ea
decreases the po ssib ility of cross-contam ination
and assists with tra ffic co ntrol.
20
13 Perioperative Standa
rd
s and Recommended Practic
es
51
La
st rev
ised
: Oct
ober
2010. Copyright
©
2013
ORN
In
c. Al rights r
eser
ved.
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_
RP
Surgical
ttire
Il.a.1. When donning surgi cal attire, care s
hould
be taken to avoid contact of the clean attire
with the floor
or
other possibly co
nt
ami
nated surfaces.
II.a.2 . When wearing a two-pie ce scrub suit, th e
top of the scrub suit should be secured at
th e waist , tu cked into the pants, or lit close
to th e
bod
y to
pr e
vent
sk
in sq
uam es from
being dispersed into the environment.
Loos e sc r ub
tops
may a ll o w sk in
squames
to
disperse
into the
en
v
ironment
from
th
e axilla
and
ches
t. Th
e major source
of
bacte ri a dispersed into
th
e
air comes
from hea lth care providers' skin .
IJW.
When
s
kin
s
qu
ames
co
m o off the body s
urfa
ce,
they carry any microorganism that is found
on
the
su r face of
th
e indi vid ua l' s skin.
Every individual loses a complete layer of
s
kin
every four da
ys
(
about
10 ' s kin
s
quam
es every day . With just the move
me
nt of
wa lki ng, this may
cause
a loss
of
10
' s
quame
s
per minute.
u.u
II.a.3. Hea lth care personn el shou ld change into
s tr ee t
clothes
wh enever th ey leave th e
health car e facilit y or when traveling
betw een
building
s located on
separa
te
ca
mpu
ses.a
Surgical attire may become contam inated
by direct
or
indirect contact with the exter
nal environment.
II.b. Jewelry including earrings, necklaces, watches,
and bracelets that cannot be contained or con
fined
within th
e surgical attire s
hould not
be
worn.u Jewelry that cannot be confined within
the
surgica
l
attire
s
hould
be re
mo
ved
befor
e
entry in to th e se mi res tricted and restricted
areas.
Necklaces on the skin may con taminate the
front
of
the steril e gown
if
they are
not
confined
w
ithin the
surgica l attire.
Wea r
in
g fin
ge
r rings,
nose ring
s, a
nd
ear
pierc
in
gs increases bacteri al counts on skin sur
faces
both when th
e jewelry is
in pla
ce
and
a fter
removal.
One
study showed that earrings had
bacterial counts mo re th an 21 times hi gher
benea
th th
e earrings than on
th
e surface
of th
e
earrings. Bacterial co
un t
s w ere nine time s
greater on the skin beneath finger and nose rings
th
an
on
the rings themselves.
The
removal of watches
and
bracelets allows
for
more thorough hand
washing.
llll
Researc
h
ers
sa mp led
100 wristwatch wearers
in
the
hea lth care environment and f
ound
that imme
diatel
y after
th
ey removed
their
watches, 25
of th e wristwa tch wearers' wrists had positive
cultures for
Staphylococcus aureus a
II.b.1. Rings s
hould
be removed before hand
was
h
ing
or
using
hand
rubs.
52
Several studies have shown that wear
in
g
rings may r
esult in
co l
onization of health
care
providers' hand
s
wi th
gram-negative
and gram-positive pathogens .ll.JJ ill Finger
rings
ha
ve been found to increase
skin
sur
face bacteria l co unts. Although hand wash
ing
re
du ces th
ese
co
un ts,
th
ere are
more
bac teria und er rings than on th e adjacent
skin or th e
opposite
hand .
The
pathogens
id e
ntified in
one s
tu d
y were
coag
ulase
negativ
e st
ap
hyl
ococc
i ,
other
sk in flora
,
gram-negativ e cocci, Pseudomonas spp , and
Staphylococcus aureus
u
Removing rings be fore hand washing
may decrease th e potentia l for pathog
ens
to
rema in on
hand
s after hand washing .u
Removing ring s before hand hyg iene may
enh a nce the
effec
ti v ene ss of
th
e hand
hygiene procoss.ll
II.
c. Persons entering
th
e semirestricted or restricted
area s of the surgica l Sllite for a brief time for a
specific
purpo
se (eg, l
aw
enforcement officers,
parents, biomedica l engineers) should cover all
h
ea
d and facia l hair and s
hould
don either freshly
laundered surgical attir
e;
s
in
gle-use attire; or a
single -u se
jumpsuit
(eg, coveralls,
bunn
y suit)
designed to completely cover outside app3rel.
Clean a
nd
freshly laundered surgica l attire,
single-use attire, or single-use jumpsuits
donned
before entry into the se mirestricted and restricted
areas may minimize the potential for contamina
tion
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 perioperative environ
me
nt
should be clean Y·
Soiled s
ho
es
ha
ve
been found
to
contribute
to en v ironmental co nt
am
in a tion within th e
per
ioper
a tive environment. A s
tudy of shoes
worn outdoors and shoes worn only in the s ur
gi
ca
l sui te showed 98 of th e outdoor s hoes
were contaminated
wi
th coag
ul ase
-n egati ve
staphy lococci, co liform, a
nd
bacillus spec ie s
compared to 56 of the shoes worn only
in
the
sur gical
suite. Bacteria
on
the
periop era ti ve
floor ma y contribute up to 15 of co lo ny
forming
unit
s (CFUs) ,
whic
h are di spersed into
th e
air
by walking. Shoes that are
worn oniy
in
th e perioperative area may he
lp
to reduce con
tamination
of the
perioperative n v r o n m
II.d.l.
Shoes worn w ithin tho periop erative envi
ronment should have closed toes and backs,
low hee ls, non-skid so les, and must
me
et
Occupational Safety Health Administra
tion (OSHA) and
the
health care organiza
tion's safety requirements .u
Shoes that enclose the foot
with
backs,
low hee ls, and non-skid soles may red uce
the risk of
injur
y from slips and falls and
from dropped
it
ems. The OSHA regulations
r e
quir
e th e use of protec tive footwear in
areas where
th
ere is a
dan
ger
of
foot injuries
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f
ro
m fa ll i
ng
or ro ll i
ng
obj ec ts or objec ts
piercing the sole. Th e employer is responsi
ble for determining if foo t injury hazard s
ex ist and what, if any, protec ti ve footwear is
required.an The OSHA reg ulations man da te
that employers pe rform a workplace hazard
risk assess ment and ens
ur
e that employees
wea r protec
ti
ve foo
tw
ear to provide protec
tion
fr
om i
dent i
fied po tential hazard s (eg ,
need les ticks, scalpe l cut s, spl as
hin
g from
bl ood or o th er p
oss
ib l y
in
fec tiou s
mat
er
ials).=
Sh
oes th
at h
ave
hol
es or
pe
rf
ora
tion
s
may not protec t the fee t from ex posure to
bl ood,
bo
dy flu ids,
or
o
th
er liquids that may
conta
in
potentially infecti ous agents. Shoes
made of
clo
th , that are open-toed , or th at
have holes on th e top or sides do not o
ff
er
prot
ec
tion against spilled
liquid
s or sharp
items that may bP. dropped or kicked.
In
one
study, 1 5 different types of sh
oes we
re
tes te d with
an ap
p
ara
tu s th a t m eas ur ed
r
es
istan
ce
to penetration by scal
pe
ls. The
materia ls o f
th
e sho
es inclu
de d lea
th
er ,
suede, rubber, and canvas. Sixty pe rcent of
th e sho es sus tained sca lp el p en etra ti on
through the shoe
in t
o a s imuiated foot. Only
six materi als pr eve
nt
ed complete penetra
ti on . These mat
er
i als in c
lu d
ed sn ea ker
su ed e , s u ede w ith inn er m es h lining,
le
ath
er with inn er c
an
vas
linin
g, n on
pl ia
bl
e lea
th
er,
rubber
w
ith inn
er lea
th
er
lining, and rubber.=
I.e.
Id
entificati on badges should be worn by all pe r-
s
on n
el authorized to enter th e perioperative s et
tin g.
;tU,l
Health ca re pers
onn
e l
as
we ll as
patients s hould be able to identify caregivers .
Id
en
ti
fi
cation badges ass ist
in
identifying
per
sons authorized to be in th e perioperative setting
and sup
po r
t security meas
ur
es.:u.u
II. e. 1.
Id
entificati on badges should be secur ed on
th e surgical attire top, be vis ibl e, and be
cl eaned if they beco me soiled .
Badge hold ers suc.;h as lanyards, chains,
or b
ea
ds pose a risk for contamination and
may be very difficult to clean. One study of
identification badges
and
lany
ard
s showed
that th e median bacterial load isolated was
10-fo
ld
grea ter for lanya
rd
s (3.1 CFU
/c
m' )
th
an for identification badges
0.
3 CFU
/c
m' ).
The microorganisms recovered
fr
om lanyards
and
id
entifica ti
on
badges we re methicillin
sens
it i
ve ta ylococcus aureus
M
SSA),
methi cillin-resistant taphylococcus aureus
(MR
SA
), Enteroco
cc
us spp, and enterobacte
riaceae.n As with other personal attire, such
as s tethoscopes, id entification badges become
contamin ated over time.
ll.f.
Th
e use of cover app ar el (eg, lab coat , co
ver
gown) may be det
ermi n
ed at each
indi
vidual
pr
ac ti ce se
ttin g base d on s ta te
reg
ul a
to ry
RP Surgical ttire
requirements and th e culture of the health care
organization.
Wea ri ng cover app arel over surgica l attire
ou ts
id
e of th e p eri
op
era ti
ve
suite may be
required for some health care personne l in some
hea
lth
ca re organi zati ons for a va rie ty of rea
so ns , which may include profess ional ap pear
ance . This may be based on th e belief that cover
a
pp
arel decreases th e risk of
in f
ect ion.
Th
e use
of cover appare l has been
fo
un d to have littl e o r
no effect on reducing con tamination of surgica l
attire.; §
II.f.1 . Cover apparel should be laundered daily in
a health care-a
pp r
oved or -accredit ed laun
dry facility. (Sec Recommendation V.)
Health ca re personnel may carry staphy
lococci and enterococci on their clothin
g,
which may include surgi
ca
l atti re a nd cover
ap p are
t.
u Studi es of
cove
r appa re l have
shown that rath er
th
an pro tecting the cloth
in g
un d
e
rn
ea th th e cover gown,
cove
r
a
pp
arel m
ay
c
on t
aminate th e clo
th
es worn
un d
er th e cover a
ppa
re l. Researchers have
found that cover appa rel is not always di s
carded daily a fter use or laundered on a fre
quent basis.llll
In one s
tu
dy of cov
er
coats worn by 100
physicians,
ta
ylococcus aureus
was iso
lated
fr
om
25
of
th
e cover coats . The cuffs
and pockets of th e
coa
ts
we
re th e most
con taminated.
D
In anoth
er
study of 100 medical students,
mi croorga ni sms were
fo
und on the cuffs
and side po ckets of th e s tu de nt s
cove
r
app are
l.
Contamination was found un their
domin
ant
hand
sleeve cuffs a
nd
th e backs
of the cover apparel 10 em down from th e
co llar. These areas were contaminated with
Staphylococcu s s p on a
ll
cover app arel ,
Ac
in
etobac t
er
sp on seven stude
nts
cove r
ap p
arel, an d diphtheroi ds on 12 s tudents
cover appare
ll
In a st udy of hea lth care prac titioners'
cover appare
l,
researchers
fo
und that cover
app arel in
in
pa tient and
outp
atient areas,
in tensive
care
units, adminis tra tion areas,
a nd th e OR wa s co nt aminate d
with
ta
ylococcus
aureus, which in clud ed
sus cep tible and resistant iso lates . Health
care perso
nn
el
with
colo
ni
zation
we
re more
like ly to have home-laundered
th
eir cover
ap parel. Two-thirds of the h
ea
lth
ca
re
pr
ac
titioners perceived their cover apparel to be
di rty be
ca
use it had not been was hed in
more than a week. JI
Il.g. Ste th oscopes sh o
uld
be cl ean and not wo rn
around the neck.
Ina ni ma te objec ts, such as con taminated
stetho
sco
pe tubing and diaphragms, may trans
mit pa thogens such as MR SA by indi rec t con
tact (eg , by wearing
th
e s te
th
oscope around
th
e
53
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~
Surgical
Attire
ne
ck a
nd
co
ntaminating
th e s kin a
nd
surgical
a
ttir
e
).
ill Clea
ning
ste th oscopes in combination
wit
h health care personnel was
hing
th eir hands
b
etween
caring for
patient
s decreases
th
e po
ss
i
bility
of
t
ransmission
of pa th ogens to patients
and environmen tal
su
rfaces.
Steth oscopes ma y be th e mos t wide ly used
medi
cai dev ice in a he a lth ca re fac ility.
11
Although stethoscopes
are
not co ns idered par t
of
the surgical a ttire, health
cam provide
rs often
wear th em around th eir necks as th ough th ey
wer
e part of s urgical attire.
Ste
th oscopes
come
in
di r
ec t con tac t with patien ts skin
and
co uld
prov id e an oppor
tunit
y for tr ansm i
ssio
n
of
microbes from patient to patient, to h
ealth
care
perso
nn
e l, o r from hea lth
ca
re personnel to
patients. One s
tu d
y verified th at ste thoscopes
could be a vect
or
for transmiss ion to
patient
s.n
Anoth
er s
tu dy
condu ct
ed on
ste
th oscope
dia
phrag ms noted that , w h
en
cultured before
cleaning,
79.8
%
of
th e c
ultur
es gr
ew
gram-positive
baci lli ,
74.8 % h ad S t
aphy
l
ococcus spec
i es
non-aureus,
2.5% of baseline c
ultur
es sho we d MSSA , and
group A s treptococcus
wa
s
fo
und in 1%
of
cu ltures.u
A s tu dy showed recontamin ation of stetho
scopes cun occur by th e fifth time th e stetho
scope is used on different patients. The number
of
ba
cteria on a ste
thoscope
increases
with
each
use.u
Cleaning
th e steth oscope daily m
ay not be
adequa
te; clea ning s te
th oscopes
may be
requir
ed
betw
ee
n
ea c
h
pati
e
nt
u
sc
.
Several
s
tudi
es
on
c
ontamination of
ste
th o
scope di a
phragms a
nd
ea
rp i eces have heen c
ondur;t
ed
and
sh
ow
that 66 % to 100%
of
the diaphragms
are co nt
a
mi n
a ted.
11
One
s tu d y
no t
ed
th
a t to
avoid inc reasing e me r
ge nt
s tr ai ns, routin e
cl eaning of stethoscopes may help reduce bacte
rial
colony
coun ts.
II. g.1. Fabric ste
tho
scope
tubin
g covers should not
be used.
Addin
g fabric covers to steth oscope tub
ing may result in th e
cove
rs
ac tin
g as fomi
tes. One study of s tethoscope fa bri c covers
isolated gram-positive
aerob
i c bacteria ,
gram
-nega
tive
aerobic
bacteria,
a
naerob
es,
and yeas t. The
average
l engt h
of
time
between stethoscope cover laundering was
3.7 months, with some fabri c
co vers
that
were neve r laundered. §
II.h.
Fann
y packs, backpacks,
and
briefcases s
hould
not
be taken into the se mirestricted or restricted
areas
of
the peri
opera
tive s
ui te.
Item s
br
ought in to
th
e OR , such as fanny
pa
cks, backpacks, briefcases, and other
pe
rs
on
al
items that are constructed of porous materials,
may be difficult to clean or di sinfect adequately
5
and may harbor pathogens, dust,
and
bacteria. iZ II
Pathogens have been shown to smvive on fabrics
and plastics. i\l.lll Dust is made up of skin par ticles,
ha
ir
, fabr ic fibers, pollens,
mo
ld, fu ngi, in
sec
t
par ts, gl
ove powd
er, and paper fi bers, amo ng
other things . Bacteria may be
transport
ed from
one location to another by carriers such as dust
or
liquid
s,
and
may co
ntaminate
fan ny packs,
backpacks, and briefcases. iJ .mi
Th
e
type
of
envi
r
on
ment al surface an d its
ab ility to support microb ial grow
th
wi ll in flu
en
ce
microbial ca rriage. Gram-positive cocci (eg,
coagulase-negative st
aphy
lococci) may
per
sis t in
dr
y se tt ings. Settings that are moist and so iled
may support
gram-negative bacilli (eg,
fl
oors).
Fungi favo rs moist, fibrous material and are also
found in dus
t.
l
Recommendation ll
All Individuals who enter the semirestricted
and
restricted
areas
should
wear
freshly laundered surgical
attire that
is
aun
-
dered
at
health
care accredited
laundry facility or disposable
surgica
l
attire
provided by the facility
and intended
for use
within
the
perioperative setting.
Surg ica l a
ttir
e he
lp
s con ta in ba cterial sh
ed d
i
ng
and
promotes env ironmenta l cleanliness.
An in d ivid ua l
sheds
mill
ion s o f s
kin
squames daily. Five percent to
10% of sk in squames carry bacteria.a In a study on dis
persal of MRSE, carriers of MRSE were
seen
as possi
ble sources
of air
contam ination in OR
s.
}
Ill.a. Surgical a ttire should be changed dai ly
or
at the
end of the sh i f
t.
u
t
h
as
bee n reported that surgical at t ire may
h
ave bacteri
al
co
lony
co
un t
s
th
at
are hi
gher
when
sc r
ub clothing is remo ved, s tored in a
l
ocker,
and
usud agai
n.
Microbes
have been
s
hown
to survive for long periods
of
time on
fabrics such as surgical attire. ilUll.}}
III.a.1. Reusa ble or single-use
con
t
am
ina ted attire
s
hou
ld be placed in app ropria tely desig
nated
containers
after use. u Worn re
usable
surgical att ire should be left at
th
e he al
th
ca re facility for lau nd
er
ing.
III. <J.2. Surgical attire that h
as been penetra
t
ed
by
blood or ot her po tentially infectious materi
als s hou ld be
removed
im med iate ly or
as
soo
n as possible and
replaced
with
freshly
iaun de red, c l
ean
surgica l a tt i re.
When
ex
tensive contamina tion
of
th e
body occms,
a shower or bath
shou
ld be taken before
donnin
g fresh att ire.=
Changing con tam
in
ated, so iled,
or wet
att ire
reduces
th e
potential
for
contamina
tion
and
protects personnel from prolong
ed
exposure to potentially harmful bacteria.I i.u
III.a.3 . Wet
or
co ntamina ted
surg
ical att ire should
not
be rinsed or sorted in th e loca tion
of
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Rinsing or sorting
co
nta
min
ated reusable
a
ttir
e may
ex pose th
e hea lth ca re
worker
to blood , body fluids, or other liquids that
may conta in po tentiall y
in
fecti ous agents
a n d may co nt aminate th e pa t ie nt care
environment .ll
lll. a.4. Surgica l a
ttir
e con t
amina
ted w ith visi bl e
blood
or body
fluid
s
mu
s t r
emain
at
th
e
health care facility for la
un d
ering or be sent
to an accred ited laun
dr
y f
ac
il ity cont r
ac
ted
by th e health care 1 l i . A . l i - ~
Co
nt r
olled la
un d
ering of a ttire contam i
nated by bl
ood or
body flui ds redu
ces
th e
ri
sk
of trans ferring
path
ogenic microorgan
isms from the f
ac
il ity to the home or ge neral
p u b l i
(Sec Recommendation
V.
)
lll.b. When in th e se
mir
estricted or restric ted areas,
all
no n
sc rubb
cd
personn
e l s h ou l
rl
wear
a
fr
es
hl y la
un d
ered or s ingle-u
se
long-s
leeved
warm-up jacket snapp ed closed with the cuffs
d
ow
n to
th
e w
ri
sts.
Wearing the warm-up jacket snap ped cl
osed
pr
event s th e edges of th e front of th e jacket from
con tamina ting a skin prep ar
ea
or th e sterile
s
ur
gical
fi
eld. Long-sleeved attire helps c
ontain
skin s
qu
ames s hed from bare a rms.
ll l.b.l. All personal clothing should be comp letely
cove
r ed by
th
e s
ur
gi
ca
l att
ire
. U
nd
ergar
ments such as T-shirts with a
V-n
eck, w hich
ca
n be contai ned u
nd
erneath
th
e
scru
b
top
,
m
ay
b e
wo rn
; p er
so
na l c lo thin g th
at
ex t
ends
above th e
sc
rub top nec
kline
or
be low th e s leeve of the surgi
ca
l a ttire
sh
ould not be worn.
Personal c lothing is not la
un d
ered by a
health care-accredited la
undr
y faci li t
y.
(See
Recommendation V
)
Recommendation IV
All personnel shouldcover head and facia l hair including side
burns and
the nape
of the neck when in
the
semirestricted
and
restricted areas
Head cove
rin
gs co
ntai
n s
kin
s
qu
am
es
and
hair
shed
fro m th e
scalp
.
t
is impo
rtant
to
pr
event shed skin
sq
uames from
fa
lling o nto
th
e s terile
fi P
Ir
J.
u.» A
lthou
gh
group
A s tre
pt
ococcus is isolated in less
th
an 1 of
s
ur
gical site in fec
ti
ons (SSis)
i
e, 1 pe r 10,000), it is a
se rious
cau
se of SSis a nd can be carried on th e
An outbreak of SS is wa s attribut ed to g roup A
t i c
Streptococcus carried on the scalp
of
peri
op erati ve per
so n
nel.
Th
e report
id
entified group A
St
rep
tococcus in 20 patients w
ith
an SS
I.
In the outb
re
ak investigation, 88
pe r
iopcrative person
nel
we
re c
ultu
red . One was found to h
ave
eryth ema
and scaling o n th e sca
lp
a
nd
ears and under
the br
east.
Th
e
indi
vidual was
tr
ea ted with medica tion a
nd
relo
cated to a non-patie
nt
work area,
and
the o utbreak was
r e s o
RP Surgical Attire
Human ha ir can be a
site
of pa th
ogenic
b
acter
ia
such as MRSA. Routin e shamp ooing of hair
wi
th neu
tral detergents docs not remove
MR
SA
or
have a bacte
ricidal effec t.lill
IV.a. A clea n , low-lin t surgical head cover or hood
that
co
n fi n
es all
ha ir
and covers scalp skin
should he worn.
The
head cover or hood
shou
ld
be des i
gne
d to
min
i
mize
micr
ob
ial
dis
persa
l.
Hair acts as a
fil
ter when it is uncovered and
co lle
ct
s bacter ia
in propor
ti on to its lengt h ,
wa vin ess, and oiliness . Stud ies have shown that
t
p
hy locuccus ureus an
d a p h y
o c o c c u ~ >
epi
der
m
id
is
have a
tende
ncy to co lonize hair,
skin , and the n
asop
h
ary
nx.lill Head
cove
rings
designed
to
contai
n
hair
and
sca
lp
sk
in will
minimize microbial
dis
persaJ.
ll
Skull caps may
fa
il to contain the
side
ha
ir
above
and
in fron t o f
the ca rs and hair at the
nape of
the neck.
IV.
a.
l .
Us
ed
single-
usc
h
ead cove
r ings sho
uld
be
removed an d
disca
r
ded in
a des i
gnate
d
r
ecep
tacle dai ly
or
when co
nt
aminated.
Placing con tamina ted h
ead
coverings
in
a des ignated receptacle assists in mainta in
ing a clean and orderly area and
dec
reases
the possibi
li
ty
of
cross-contamination.
lV.a.2. Reusab le head cover
in
gs shou ld be
laun
de
red in a hea lth ca re-accred
ited
lau ndry
fa
cility a fter eac h
da
ily u
se
.ll (See
Re
com
mendation V.)
Recommendation
V
Surgical
attire
should be laundered in a health care-accredited
laundry
facility.
Surgica l a
ttir
e; street clothing; PPE; and other hospital
textiles (eg, bed linens, towels, privacy
cur
ta
in
s, wash
clo
th
s ) m
ay
b
ecome
contami
n
ated
by
bac
ter
ia
a nd
fu ng i during
wea
r or use. In
one
st udy, researchers
foun
d that mi crob
es
can survive on hosp ital textiles for
extende d periods of time. These text iles included
• 100 cotton cloth ing;
• 60 co tton and
40
polyes ter blend (eg, scrub
suits, lab coats);
• 100 polyes t
er
cloth in
g;
a
nd
• pol
ye th
yl
P
ne plastic
aprons
.
Researchers inoculated these tex tiles with stap hylo
cocc
i under laboratory
co
ndit ions.
Th
e textiles
we
re
a llowed to remain in ambient air with
ou
t any launder
ing for vari ous periods
of
time. Results showed that th e
s taphylococci s
ur
vived one to 56 days on po lyester
and
up
to 90 days on polyethylene plasti
c.
The larger
th e mi crobial inoculum of staphy lococci on polyes ter
a
nd
pol
ye th
ylen
e, th
e longe r th e sta
ph
yl
ococc
i sur
vived. Even if only a few hundred staph ylococci sur
vived, th
ey
were viable for clays on most textiles. The
shor tes t time fo r enterococci survival on tex tiles was
11 days.
Wll
Researchers in another stu dy tes ted fungal s
ur
vival
unde
r laboratory
conditions
on
• 100 cotton cloth in
g;
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RP
Surgical
ttire
•
60 co tton and 40 polyes t
er
blend (eg,
scrub
suits, lab coats, clothes);
• 100
polyes ter c
lothin
g; a
nd
• polyethylene plastic aprons.
The microorganisms
used
as the
in oc
ulum were
Candida albicans Candida tropicalis Candida krusei
Candida parapsilosis Aspergillu s flavus Aspergillus
fumigatu s Aspergiilus niger
As
pergillu s terreus
Fu
sa rium
sp ,
Mucor
s
p,
a
nd Paec
ilomyces s p.
These
pathogens were isolated in the researchers ' hea lth care
facility. The
da ta
co
llect
ed
showe
d
th
at
ca
ndid
a,
aspergi llu s, mucor,
and fu
sarium, which are known to
be hea lth care-associa ted
in f
ec tious agents, s
ur
vived
on fabrics and plastics
fo
r at least one day a
nd
often f
or
weeks.
Th
e survival
of the
se microorganisms
on
these
textiles and plastics shows that they may serve as rese r-
voirs or vectors for f u n g Another study showed that
Staphy lococcus aureus
and
P
seudom
onas aeruginosa
bind to polyester and acry lic fib ers. tl
Hea lth care-a
ccredited
l
aundry
fa c ilities are
pr
e
fe rred because th ey fo ll
ow
indus
tr
y st;mdards. The
H
ea lt hcare
La
un d
ry
Accreditation
Co
un
r.i
l (HLAl.)
offers voluntary accreditation for those la
undry
fac ili
ties that
process
reusable
h
ea lth
c
ar
e t
ex
ti l
es and
which incorporate OSHA
and
th e Centers for
Di
sease
Control and Preven ti
on CD
C) guideli nes and
prof
es
s ional association
recommended
practices.
Th
e HLAC
stand ard s for accred itation include,
but
are not limited
to,
• Tex ti le
quality cont ro
l
procedure
s
are defin
ed
and impleme nted.
•
The in vs ntor
y
sy stem
is ad e
qu
ate to ens
ur
e
supply.
•
So
il ed a
nd
cont
am inat
ed tex tile areas are
se
pa
rated by a
ph y
sica l barr ier.
•
Th
e ventilation is
controll
ed
with
negative
pr
es
sure in the so iled area, pos itive
pr
ess
ur
e from the
clean
textil e area through th fl
so
iled textile area, 6
to 10
air exc
hanges
per
hour, a
nd
a ir vented to
the outside.
• Clean textiles are stored
in
an area
fr
ee of vermin,
dust, and lint and at room te
mp
eratures of
68°
F to
78
° F (20° C
to
25.6° C).
• Storage shel ves are in ch to 2 inches from th e
wa ll,
th
e bottom s
helf
is 6
in
ches to 8 inches
fr
om
th
e floor, and
th
e top shelf is 12
inches
to
18
in
ches below the
ce
ilin
g.
• Hanel washing faci lities arc located in a ll areas with
soiled t i l e J and washing or antiseptic dispens
ers are in the clean textile area; and employees per
form ha
nd
was
hin
g a
ft
er
glove removal a
nd
rest
roo m use, b
efore eating,
a
nd when hand
s
are
contaminated with blood or other poten tially infec
tious materials.
• Working s
ur f
aces are clean and are disinfected if
they become contaminated with blood or other
potentially infectious material s.
•
The
OSHA Exposure Control Plan is in place and
PPE is s
uppli
ed and ava ilable.
• Personn el tra ining is provided and docum ented.
• Quality control monitoring a
nd
processes arc in
place.
56
• Material Safety Data Shee ts are avai lable for eac h
ch
em
ical used .
• Water quality is tested
on
a regular basis for hard
ness, alkalinity, iron content , and pH.
• So iled health care textil es are hand led, collected,
and
transported according to loca l , state,
and
fed
eral regulations.
• Each wash load is monitored and a
ppli
cab le data
f
or
each wash are recorded, inclu ding cycle, pre
wa
sh , wash , rinse , and final rinse times; wa ter
l
eve
ls
and
usage; tem
pe ratur
es; a
nd
chemi cal
usage.
• Water extraction a
nd
drying are perfo
rm
ed using
methods that preserve th e integrity of the tex ti les
and
minimi
ze bacterial growth.
• Cleaned texti les are packaged and stored in fluid
resistant
bundle
s
or
fluid-resistant carts
or
ham
pers
and
are h
and
led as little as po
ss
ible.
• Carts used for transport or storage are kept clean
a
nd
arc well maintain ed.
• Clean text iles nre stored
and
trnns ported se pn
rately from soiled textil es.
• Vehicles used to transport textil es provide sepa
ration
of
cl ean
and
soiled textiles, a
nd
the vehicle
in teriors are cleaned on a regular bas is.n
R
ou
tine monitoring
of laundry
processes,
including
cl
ea ning of work areas, e
qu ipmen
t , and good
hand
hygiene
pr a
ctices, is
imp
or tant to
minimi
ze cross-
contamin
ation of clean textiles. An acc re
di
t
ed
hea lth
care fa cility lau nd
er
ing process includes monito ring
correc
t
measurem
ent
of
c
hemica
ls, s
ufficient wa
ter,
correct temp erature, mechani cal action, and the dura·
tion of th e washing cyc le. Cleaning and d isi
nfec
ting
th
e work area incl
ud
es, but is not limited to, the wash
ers,
ex
trac tors, d ryers,
and
conveyor belts.
The pre
s
e
nc
e
of
skin
b
ac
teria on
processed
textiles
and
envi
ronmen tal s
urf
aces
in
one study di rec ted attenti on to
ha
nd
hygiene
of
th e lnu
nd r
y facility workers, a
ir
con
tamination, inadequate separation of so iled and clean
work areas, and the cleaning a
nd
disinfecting
of
a ll o t
th e e
qu i
pm ent and work s urfaces. li Water
can
be a
sour ce of
bacterial transmi
ss ion
,
which
makes
th
or
ough
drying
of textil es vitaJ. u Staphylococci ,
Sa
lmo
nella, and Mycobacterium are fairl y res istan t to heat
and may su rvive
Home laun dering is not monitored for quality, consi
s-
tency, or safet
y.
Exposure
of
health care pers
onn
el and
their family members to blood and
other po
tenti ally
infectious ma
tcrh1
ls may rosult
fro
m improper hanrlling
a
nd
decontamination
of
s
ur
gi
ca
l attire. Home washers
may have a lower temperature (ie,
< 160°
F
[71.1o
C])
or
washing parameters and temperatu res may not be adjust
able. Home washers may have limited capacity for c hem
ical
add
iti ves and may
not
have directions for using
alkalis
and
acids.
Home laundering may not meet
th
e speci
fied
mea
s
ure
s necessary to achieve a red uc t ion
in
mi
crob
ial
levels in
so
iled s
ur
gical attire. These measures involve
mechanical,
thermal , and c he mi
ca
l com ponent
s,
includin
g
•
diluting
and agitating the water to remove micr
o-
organisms and bioburdcn;
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•
se
lecting suitable
che
mica ls.
if
low-te
mper
a
tur
e
cycles(< 160° F [< 71.1°
C))
are used;
• using
prope
r chemical
concentrat
i
ons
if
lo
w
temperature cycles are used ;
• using water te
mp
era
tu r
es
>
160° F
(>
71.1
o C)
for
more than 25 minutes for hot-water cycles;
• using c
hlorin
e bleach,
which
gives
added
mi cr
o
bicidal benefit: a
nd
•
addin
g chemicals
known
as sour to the water to
neutralize alkali n
it
y
in
th e
water,
soa p , or
detergent.
These measures cause a shift
in pH fr
om 12 to 5,
in
ac tiva
tin
g some mi croorgani sms. Low
temperatur
es
(ie , < 160° F [< 71.1°
C])
may be
us
ed so
lon
g
as
the
dr
y
in
g temperatures and ironing temperatu res provide
th e additional microbicidal benefits to
ensure
surgical
att ire is clean.
ll-lil
A stu d y
on
bac t
er
ial co ntamination of h ome
la
under
ed uniforms beg
an
by c
ulturin
g
uniform
s
worn
at the beginning o f the shift. Thirty-nine percent
of th
e
uniforms identified as clean had one or more micro
organisms
(eg,
va
ncom
yc in-
resis tant
en
t
erococc
i ,
MRSA,
lostridium
diffici/e) identified. Uni f
orms
were
tes ted again at the e
nd
of th e s hift and 54 had one or
mor
e microorganisms; some that were po sitive at the
beginning of the shift were negative at the end of th e
shift. ln o
ne
demonstration, bac
illus
spores
we
re trans
ferred from health ca re
pro
vid er
s'
aprons
and
cotton
uniforms to a mock patient. lill
A s tudy of home
-laund
ered uniforms involved tak
ing
surveill ance
cu
ltur
es from five patie
nt
s . Results
showed
th
at th ree of the patients were
co
lonized wi
th
th e s ame s train of microorgani sm as th at cultured from
th e hea lth care proviclers'
uniform
s . With uniforms
co
ntamin
ated
with
microorganisms a t
the
beg
innin
g of
a s
hift
,
th
e researchers suggested
that inappropriat
e
launder
ing practices may be the cause. lli
Home la
un d
er
in
g has been shown to be less effec
tiv
e for
cleaning surgical
a
ttir
e
than launder
in g
by
hea lth care
fa
cilities
or
commerc
iallaundri
es.lll
A quantitative stu dy was perfo
rm
ed in 20
diff
erent
geog
raphi
ca l areas.
lll
Eight lau n
dering
me
th ods we
re
s
tu
died:
• reusable clean scrubs
laundered
at the facility
in
which
th ey were used;
• reusable
worn
scrubs la
undered
at
th
e facility
in
which
the
y were us
P.d;
• reusable clean scrubs that wore homo laundered;
•
re
u
sa
ble wo
rn scrub
s
th
at
were hom
e
laund
ered;
•
reusable
clean
scrubs laund
er
ed
by
an out
si
de
la
undr
y f
ac
ilit
y;
•
reusab
le
worn
sc
rub
s la
un dered
by an
ou
ts
id
e
laundry facility;
• packaged , clean, s
in
gle-use,
non-woven sc
rubs;
and
• packaged, worn, s
in
gle-use, non-woven scrubs.
Re
sults of the s tudy showed that th e bioburden on
hom
e-l a
und
ered surgical attire was significantly greater
than
on
s
ur
gical attire that was faci lity-laundered; laun
dered by a third-part
y;
or single-use, disposable.
Hom
e
la
un d
ered clean scrubs at the beginning of the day had
RP Surgical
Attire
th e sa me amount of organisms as
did
worn scrubs at the
end of the work day.lll
A quantitative study was performed on cotton strips
of
fabric that were inoculated with 10 mL
of
a viral sus
pension
to discover
if enteric
viruses
i
e, ade
no
virus,
rotavirus, hepatitis A viru s) survive d a home-laundering
pr
ocess
. The
inoculated
fabric s
trip
s
were was
h
ed,
rin
sed,
and dried
on
a 28- minute permanent p ress
cycle in home
w
as
h
ers.
lt
was found th
at
enteric
viruses remained on th e fabric str ips after th ey were
washed.n
V.a
. La
un d
ered surg ica l at ti re sh
ou
ld be pro t
ected
during
trans
port
to the
pr
ac tice
se
tti ng to
pre
vent contamination.
:m
PropP.r
tm n
sfer and storage
of
s
ur
gica l attire
protec ts s urgical attire from contamination by
preventing any
ph
ysical d amage to la
undr
y,
minimi
z
in
g
mi
c
robial
c
ontamination
from
environmenta l surfaces. and
preventing
an
y deposits from airborne sources
such as dust to settle
on
laundry.
Jtu
V.a.l. S
ur
gical attire should be tra nsported in a
cl
ea
n vehicle and e n c losed
ca r
ts or
con
tainers
JMu
La
undr
y vehicles can be a source of con
tamination. Cleaniug and disinfection on a
regular basis are required.
V.b. Clean s
ur
gical attire should be s tored
in
a clean,
enclosed cart or cabine
t. 2-M
V.b.1.
S
torin
g clean surgica l a
ttir
e
in
a l
ocker
with
personal items from outside of th e hosp i tal may
cont aminate th e clean surg ica l a ttire. Ent
er
ic
viruses
have b
ee
n detected
in
lo ckers w here
contaminated attire
ca
n ac t as r
ese
rvo
ir
s f
or
viral
tr
ansmi
ss
ion J
Lll
Surgical attire may be stored
in
a d ispens
ing mac
hin
e. Di
spe
nsing
machin
es s
hould
be routinely emptied and cleaned according
to
th
e ma
nu f
ac
tu rer
's d irections.
Attire-di
spens
ing mac
hin
es m3y
be used
to
in
crease
individu
al acco
unt
abilit
y,
pro
mote cost
conta inment
, facilitate an ade
qu
ate sup pl
y,
and provide clean storage for
s
ur
gical attire. l Zf
Recommendation VI
All
individuals
entering
the
restricted
areas
should wear sur-
gica l mask when open sterile supplies and equipment re
present
A s
ur
gical mask protects both the s
ur
gical team
and
the
pat ient from transfer of microorganisms.H The surgical
m
as
k
prote
cts hea
lth care providers
from
droplet
s
greater than 5 mi cromet
ers
in siz e. Examples of
di
seases th at
produce dropl
ets include group A
streptococcus, adenovirus, and Neisseria me
nin
gitides
.Z->
A s
in
gle surgical mask is worn to protect the health care
provider from contact with infectious mat
er
ial from the
patient (eg,
respiratory
secretions, sprays of blood or
bod y fluids) and
to
protect the patient from expos
ur
e to
7
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RP Surgical ttire
in fectiou
s age
nt
s ca rri ed in
the
provider'
s
mouth
or
nose. Surgi
ca
l
ma
sks
protec
t s
ur
gical te
am
memb er
s'
noses a
nd
mo
uth
s from inadverte
nt
splashes
or
splat
ters
of
blood
and oth
er bod y fluids.ll A s
tudy
involving
8,500 surgica l proce
du r
es showed that 26 of ex
po
sur
es to blood
wer
e to
th
e h
ea
ds
and
necks
of scrubb
ed
personn
el, a
nd that 1 7 of blood ex
pos
ures
were to
circula
tin
g pers
on n
el outs
id
e the
st
eril e
fi
e
ld
.
lli
Vl. a.
Th
e mask should cover the mouth and nose and
be sec
ur
ed in a ma
nn
er to prevent ve
ntin
g.
A mask that is s ec
ur
ely tied at
th
e back of the
head a
nd
be
hind
th e neck dec reases
th
e risk
of
health care personnel transmitting naso
ph
aryn
geal a
nd
res
pir
atory
mi
croorganis
ms
to pa
tient
s
or th e s terile field. Infectious particles can r
eac
h
th
e wearer's nose
and
mo
uth
by pa
ss
ing
thr
ough
leaks at the mask-face seal.
VI.b. A fresh, clean surgical mask sho
uld
be wo
rn
for
e
ver
y proce
du r
e.
Th
e mask
sh
o
uld
be replaced
and disc ard
ed
when
e
ver
it bec
om
es wet
or
soiled .
Th
e filtering capacity of a mas k is
co
mpro
mis
ed
when
it be
com
es wet. In a s
tud
y to dete
r-
mi ne
micr
o
bi
al b
ar
ri er e ffi cacy
of
s
urgi
c
al
ma
sks
with
9
5
bac teria l filt ra
tion
a t one-,
two-, three-, a
nd
four-hour
in t
e rvals showed
that
after four
hour
s, the masks had dec reased
efficacy. Avoiding un n
ece
ssa ry sp P-aking and
ke
e
pin
g
in mind the
patie
nt '
s
po
ss ible
immuno
logical s
tatu
s are important.
This
res
ea r
ch s
tud
y
s
how
ed that all c
ount
s of CFUs
we
re
low
er
than
4 x
10
2
,
which c
ould
cau
se an SS
I
in
patie
nt
s
with po
or
immunity, tho
se
with surgical
wound
c
ompli
ca
tion
s (eg, isc hemia , he
matom
a), or
those
under
going s
ur
gery
with
an implant. u
VLb .l. Masks s
hould
not be
worn hangin
g
down
from the neck.
Th
e
fi
lter portion of a s
ur
gical mask har
bors bacteria collec ted from the nasopharyn
gea l
airw
ay.
Th
e
contam
inated m
as
k
ma
y
cross-
co
ntaminate
th
e s
ur
gica l att ire top.
VL
c. Surgi
ca
l
ma
sks s
hould
be di
scard
ed after each
proce
du
re. Masks
shou
ld be removed carefully
by
handling
only th e mas k ties.
Hand
hygiene
should
be performed after removal of mas ks.ll
Removing masks by the ties preve
nt
s possible
c
ont
amination of
th
e ha
nd
s.
Th
e filter
portion
of
the
ma
sk
harbor
s
ba
cte
ria
co
lle
c
ted fr
om
th
e
na
s
op h
aryngeal airwa
y.
VI.d.
Onl
y
on
e s
ur
gic
al ma
sk s
hould
be w
orn
at
a
tim
e.
M
as
ks are
in t
e
nd
e d to c
on t
a
in and
filter
dropl ets
of
mic roorga
nism
s expelled from
th
e
mouth
and nasop
ha r
ynx
durin
g talking, sneez
ing, a
nd cou
ghing.
LI
Use
of
a double ma
sk
cre
a tes an impediment to brea thing and
do
es not
incr ease filtr
a
tion
;
th
ere fo r
e, th i
s is
not
reco
mm
e
nd
ed.
Zll
8
Recommend
ation
VII
Health care
personnel
should
receive
initial and ongoing
educa
-
tion and
demonstrate competency on
appropriate surgical
attire .
Comp eten
cy
assessment verifies that health c
ar
e pe
r-
s
onn
el have an
under
sta
nding
of the arti cles a
nd
pur
pose of surgical a ttir
e.
This knowledge is essential for
re
du
c
in
g
th
e risk of health
ca
re-associated
in f
e
ction
s.
VILa. Health care perso
nn
el should receive e
du
cation
a
nd
gui da n
ce
on a
pp
r
op
ria te a rticles
of
s
ur
gical
attire worn in
th
e periopera ti ve environment at
ori ent ati on and a ft er cha nges are mad e.ull.
Hea lth ca re
pe rso nn
el s
ho
u ld be informed of
a
nd
be compliant with the hea lth care organi za
tion s
s
ur
gi
ca
l a ttire polic
y, includin
g l
aund
e
r-
ing policies.
On
going e
du
ca tion of perioperative perso n
nel f
ac
ilita t
es th
e dev
elopm
ent
of kno
wledge,
skills , and
attitud
es
th
at a ffec t pa
ti
e
nt
a nd
wo
rk
er safet
y.
VII.a.1. He
alth
c
ar
e pers
on n
el should
under
sta
nd
th
e
ri
sk
of
beco
min
g co
loni
zed or
in f
ected
with microorganisms from patie
nt
s
or
th e
enviro
nm
e
nt
when s
ur
gical
attir
e is cleaned
improperly.
RecommendationVIII
Policies
and procedures for surgical attire should
be
developed
reviewed period
ically and be
readily
available within
the prac
-
tice
setting.
Policies a
nd pr ocedu res
serve as
op
era
tiona
l
guid
e
li n
es and es ta
bl i
s h a
uthorit
y, res po ns
ibility,
a nd
a
ccountabilit
y
within th
e organi za
tion
.
Policie
s and
proce
du r
es
al
so ass ist in the deve
lopm
ent
of
pati e
nt
s
af
ety, quali ty assessment , and im provement ac tivities.
VIlL
a. Surgical a ttire polices
and
pr
oc
edures shou
ld
in
c lu de, but not be limited to , requirem ent s
related to
o fac ili ty-a
pp r
oved and sta
nd
ardi zed s
ur
gical
attire,
o areas wh ere s urgical attire is worn ,
o
inf
ection
pr
evention
and
c
ontr
o
l,
o use
of
PPE,
o laundering,
o
transport a
nd
storage
of
clean atti re, a
nd
o compliance monitoring.
An un ders
tandin
g of su
rg
ical
attir
e policies
a
nd
pro
cedu r
es assists hea
lth
c
ar
e pers
onn
el in
pr otecting the pati ent, th emse lves , and th e ir
family members.
VIII.b. Policies and procedures sho
uld
be introduced
a
nd
reviewed
in
th e
initi
al o
rient
a
tion
,
wh
en
now surgi
ca
l
attir
e is
intr
o
du ce
d , a
nd durin
g
on
going e
du
cation of health care personne
l.
Re
vi
ew of
poli
ci
es
a
nd
proc
e
du res ass
ists
health ca
re pers
onn
el in be
in
g kn owl edgeable
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about
and
compli
ant
with th e health care orga
nization s policies and procedures.
Recommendation
IX
The hea
th care
organization s
qua ity management
program
should
evaluate compliance with
surgical
attire
policies
and
identify
and respond to
opportunities for improvement.
Quality management programs that enhance personal
performance a
nd
monitor surgica l attire
practices
are
established to promote patient
and
health care personnel
safety. Health care l
aundry
processing requires special
ized
equ
ip
ment
,
adequate
space, qualified
personnel
with ongoing
tr
a ining, and continuous
monitoring
for
quality
s s u r n c e
IX
.a. S
tru
cture, process,
and
perfo
rman
ce
measures
should
be identified.
Structure, process,
and
performance mea
sures can
be used to improve
surgical at t
ire
quality and monitor compliance with
facility
policies and procedures, national
s t
andards,
and regulatory
requirements.
IX.a.1 .
Quality
indicators
for
surgical attire may
include, but are not limited to,
• h
ead
coverin
gs completely cover th e hair
and
sca lp ;
•
warm-up
jackets wi th wrist- l
ength
sleeves are worn
and
are snapped;
• identification badges are worn, visible,
and clean;
• shoes are clean
and
protect heal th care
personnel's feet;
•
visibly soi
l ed or we t surgica l at t ir e is
removed and
cleaned
at
an accredited
health care la
undr
y facility;
• masks,
when
worn, are ti
ed
securely
and
are discarded after each procedure;
and
• cover apparel, if worn, is l
aunde
red daily
at th e organization
or
an accredited laun
dry facility.
IX.b.
Quality assurance monitoring
of
laundry
pro
cesses should be ongoing.
A study of the risk of
Clostridium
diffici e
cross-contaminati on in the
l
aundry
process
illnstrates th at cross-contamination occurs with
the
use of
nonsporicidal disinfectants,
but
that
the use of sporicida l disinfectant cloths showed
significantly
reduced
CFUs.
The researcher
con
cluded that cleaning Clostridium difficile-
contaminated
surfaces
wit
h
nonsporicidal
dis
infectants
crea tes a vector for cross
contamination to
ot h er
textiles via the
laundering process. Cleaning contaminated sur
faces with sporicidal disinfectant may not com
pletely e
limin
ate this vector,
but
does signifi
cantly reduce associat
ed
risk.
lll
A rare outbreak
of
zygomycosis in a hospital
was investigated by the CDC using standard out
break protocols. Zygomycosis
is
an invasive
fungal in f
ection caused
by mucormycetes,
RP
Surgi.cal Attire
which includes a Rhizopus species (ie, a group
of molds
that is commonly f
ound
in
the
envi
ronment) . Infections wi th this microorganism
are rare and usually
occur
in people who have
underlying medical conditions. A cluster
of
six
cases occurred from August 2008 to July 2009.
Of
the six cases, five patients died (ie, prema
tu r
e
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 ch ild). Hospital lin
ens were the on ly items common to these cases.
Environmental cu ltures taken
at
the hosp
ita l
revea
led
Rhizopus
species
on
26
out
of 65
swabs (40%) of clean linens
and
areas
in
con
tact w
ith
clean linens,
and on
1
out of 25
sam
ples
(4%) of items not
in
contact
with
linens.
Cl
ean
linen closets were
cultured,
including
those in the OR, where two items were found to
be Rhizopus-positive. Researchers
determined
th
e h
osp
ital linens to be
th
e most likely vehicle
of
transmission to
patients
skin. Co
nt
am
in
ation
of
linens may have occurred during laundering,
en
route
to
the
hospital,
or during
delivery to
the hospital. The hospital changed commercial
l
aundry
facilities, replaced a ll of its linens, dis
infected all lin
en
storage closets, and used a dif
ferent delivery area for its linens
in
an effort to
prevent reoccurrence of this type of u t b r e k
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
and facial
hair, including sideburns,
beards, a
nd
necklines.
Sem irestricted area:
Includes
th
e peripheral
support
areas of the surgical su
it
e
and
has storage areas for ster
ile
and
clean
supp
lies, work areas for storage
and
pro
cessing in
s
trum
en ts,
and corrid ors
l
eading
to
the
restricted areas of the surgical suite.
Surgical attire:
No
nsterile
appare
l designated for
the
OR practice setting that includes two-piece pantsuit s,
cover jackets, head coverings, shoes, masks, protective
eyewear,
and
other protective barriers.
FEREN ES
1. Andersen
BM,
Solheim
N.
Occlusive scrub suits
in
operating theaters
during
cataract surgery: effect on
airborne contamination. Infect Control Hasp Epidemio l
2002;23 4) :218-220.
2.
Tammelin A, Hambraeus
A,
Stahle E Source and
route of methicillin-res istant Staphylococcus epidermidis
transmitted
to
the surgical wound during cardia-thoracic
s
ur
gery. Possibility of preventing wound contamina
tion 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. 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.
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7/21/2019 2013 AORN RP's for Surgical Attire
http://slidepdf.com/reader/full/2013-aorn-rps-for-surgical-attire 11/13
RP Surgical
ttire
5. Tamme
li
n A, Domice l P,
Hambra
eus A, Stahle E.
Di
spersa l of me
thicillin
-res ista nt
Staph
ylococcus epider
midi
s by s t
aff in
an
operatin
g s
uite
for
th
oracic a
nd
car
diovascul
ar
surgery: rel
atio
n to s
kin carr
iage
and
clothing.
JHa sp In fect
2000;44(2):119-126.
6. Wu
X,
Yang CQ. Fl
am
e retardant fin is
hin
g of cotton
fleece fabric: part
III
- the
combina
tion of ma leic acid a
nd
sodium
h
ypophosphi te. J
Fire Sci 2008;26(4):351-368.
7.
US De
pa
r
tm
e
nt
of
Health
a
nd Human
Serv
i
ces.
Standard
for the flammability of
clothin
g tex tiles. 16 CFR
§1610.
8. Yang CQ,
Qiu X.
Fl
am
e-reta
rdan
t finishing of
co
t
ton
fl
eece fa
br ic:
Part
I. Th
e usc of a hy
droxy
-func
tiona
l
org
an
op
ho
sp
horus ol igo me r a n
cl
d imethy lo l
ei
ihydr ox
ylethylene
urea
. Fire
and Ma
terials 2007;31(1):67-81.
9. AAMI. ST79:
Co
mprehensive Guide to Steam Ster-
ilization and Sterility ssurance in Health Ca re
Fa
cilities
2009.
10
. Mi t
che ll NJ,
Evans DS, Kerr A. Re
du
ction of
skin
bacter ia in thea tre air
with
co
f
ortable, non-woven dis
po
sa
bl
e cluthing for
operating-t
he
at r
e s taff. Br Med f
1978;1(6114):696
-698
.
11
.
Woodh
ead K, Taylor EW, Bannis ter G, Ch
esworth
T, Hoffman
P,
Humphr
eys H. Behaviours
and
rituals
in
the
opera
ting
th
ea tre. A r
ep ort
from
th
e Hos
pital
Infec
tion
Society Working Party on I
nfec
ti
on
Control
in
Operating
Theatres.
JHosp In fec t
2002;51(4):241-25 5.
12. Nob le WC.
Di
s
persa
l of
sk
in microorganisms. Br
J
Dennatul 1975
;93
(4):477-485.
1
3. Nob
le WC, Ha
bbema JD
,
van
Furth R,
S
mith
I,
de
Raay C. Qucmtitative stu
di
es on the
di
sper
sa
l of skin
bacteria
into
th
e a ir.
f Med Microbial 19
/6
;9(1):53-61.
14. Bartlett GE , Po
llard
TC, Bowker
KE
, Bannis ter
GC.
Effect f j
ew e
llery on
su rface
bacterial
counts
of
ope
r
ating
th
ea
tr
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RP Surgical ttire
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Acknowledgments
L t:AD UTHORS
Joan Blan
chard , MSS, BSN, RN, CNOR, CIC
Perioperati ve Nursing
Specialist
AORN Center for
Nursin
g Practice
Denver
, Col
orado
Melanie
Braswell,
DNP, MS, RN, CNS, CNOR
Fu ll -T
im
e Faculty School of Nursing
Purdue University
Lafayette , hH.Iiana
CONTRIBUTING UTHORS
George All
en,
PhD, MS, RN, CNOR
Director of
Inf
ection Control
Down
state Medica l Center
Brooklyn , New York
Nancy Bjerke, MPH, RN, CIC
Consultant
Association
for Profess ionals in Infec tion Control and
Epidemiology, Inc (APIC)
Sa
n Antonio, T
exas
Sorin Brull, MD
American
Socie
ty o f
Anesthe
siology
Professor of Anesth esiology
Mayo Clinic College of
Medicin
e
Roches ter,
Minn
eso ta
PUBIJC TION HISTORY
Originally pu blished M
ar c
h 1975, AORN Journal as
AORN S tand ard s fo r p r
oper
OR wea ring
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Format revision March 1978, July 1982.
Rev ised March 1984, March 1990. Publis hed as pro
posed recommended practices, August 1994.
Rev ised November 1998; published December 1998.
Refo
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July 2000.
Rev ise d November 2004; pub lished
in S ta
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ards
Recommen ded Pmct i
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and Guidelines 200 5 ed i-
tion. Reprinted Feb
ru
ary 2005, AORN
Journal
Revised October 2010 for o
nlin
e publicat ion in
Peri-
operative Standards and Recommended Practices.
Reformatted Sep tember 2012 for publication
in
Peri-
operat
i ve
Standards and Recommended
Prac
ti
c
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2
01
3 e dition.