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RECOMMENDED PRACTICES
Implementing AORNRecommended Practicefor Surgical AttireMELANIE L. BRASWELL, DNP, RN, CNS, CNOR;LISA SPRUCE, DNP, RN, ACNS-BC, CNORwww.aorn.org/CE
3.6
personnel.de periop-g surgical
ure appro-d wearing. The rec-
evidencers to helparios haved practices.011.10.017
el, home
ABSTRACT
Surgical attire is intended to protect both patients and perioperativeAORN published the “Recommended practices for surgical attire” to guierative RNs in establishing protocols for selecting, wearing, and launderinattire. Perioperative RNs should work with vendors and managers to enspriate surgical attire is available, model the correct practices for donning ansurgical attire, and teach team members about evidence-based practicesommendation that surgical attire not be home laundered is supported bythat perioperative nurses can share with their colleagues and managesupport appropriate practices. Hospital and ambulatory surgery center scenbeen included as examples of appropriate execution of these recommendeAORN J 95 (January 2012) 122-137. © AORN, Inc, 2012. doi: 10.1016/j.aorn.2
Key words: AORN recommended practices, surgical attire, cover apparlaundering.
endedmenORN
mended
urpose of
(RP) docu-
urgical at-
es, head cov-
ssories worn
eas of the
.”1(p57) The
document
epresent
vel of prac-
contac
rn the
wing
leting
ation
hours
The revised AORN “Recommtices for surgical attire” docupublished electronically in A
indicates that continuing education
hours are available for this activity. Ea
tact hours by reading this article, revie
purpose/goal and objectives, and comp
online Examination and Learner Evalu
http://www.aorn.org/CE. The contact
this article expire January 31, 2015.
122 AORN Journal ● January 2012 Vol 95
prac-t was’s
Perioperative Standards and Recom
Practices in November 2010. The p
the revised recommended practices
ment is to “provide guidelines for s
tire including jewelry, clothing, sho
erings, masks, jackets, and other acce
in the semirestricted and restricted ar
surgical or invasive procedure setting
practice recommendations in the RP
are intended to be achievable and r
what is believed to be an optimal le
t
con-
the
the
at
for
tice, and these recommendations can be adapted
doi: 10.1016/j.aorn.2011.10.017
No 1 © AORN, Inc, 2012
nd ot
replas forwere
andge incagainprob
the Rons acons
ntrod, Coloe pubf 201ubmitWhen1 AOia, th
g thehomeativepractenda
gicalattirece abers,not ssurgi04 reof su
trovereithere 200ses wsoile
er ands laun
e last load,er placingg itemsire wash andrms into thelothing, andof the wash-shed surgical
ed since thed AORNering of sur-wever, thee periopera-
e launderingment now
eet the speci-reduction in
l attire,”1(p64)
epth.
te personalicted ands promotesanliness innderstoodsurfaces in
of microbialion. Cleanintroductionlth care per-ment. Al-
n nonsterileical site in-e a patient’ss skin, mu-
dry facilityies followaundry Ac-y accredita-ocess health
RP IMPLEMENTATION GUIDE: ATTIRE www.aornjournal.org
to various settings where surgical avasive procedures are performed.
WHAT’S NEW?The new surgical attire RP document2004 AORN “Recommended practicecal attire.” Some significant changesto the RP document during its reviewquent update. The most notable chanthe stronger stance AORN has takenlaundering of surgical attire, which isthe least popular recommendation inment. Based on the number of questicomments that AORN received fromwhen the recommendation was first ithe 2010 AORN Congress in Denverand when the RP document was in thcomment phase during the summer oRP document was revised and then sfor a second public comment phase.RP document was featured at the 201Congress in Philadelphia, Pennsylvancontinued to be questions surroundinmendation that surgical attire not bedered. This article may help perioperimplement the revised surgical attireommendations, including the recommagainst home laundering.
The previous RP document on surstated, “Home laundering of surgicalrecommended. Without clear evidensafety for patients, health care worktheir family members, AORN doesthe practice of home laundering ofattire.”2(p299-300) Additionally, the 20mendations stated “Home launderingattire that is not visibly soiled is conand there is no concrete evidence toport or refute the practice.”2(p300) Thdocument provided perioperative nursuggestions for how to home laundercal attire, including the type of washtemperature settings to use, as well a
surgical attire in a separate load with no oher in-
ces thesurgi-madesubse-ludesst homeablyP docu-ndtituentsuced atrado,lic
0, thetedtheRN
ererecom-laun-
nursesice rec-tions
attireis notout the
andupportcalcom-rgicalsial,sup-
4 RPithd surgi-
waterdering
items, laundering surgical attire as thwashing one’s hands immediately aftsurgical attire into the washer, keepincompletely submerged during the entrinse cycles, not placing hands and alaundry or rinse water to submerge cthoroughly cleaning the door and liding machine before removing the waattire.
Research and evidence have evolv2004 RP document was published, anmaintains the statement “Home laundgical attire is not recommended.” Horevised RP document does not providtive nurses with suggestions for homof soiled surgical attire. The RP docustates, “Home laundering may not mfied measures necessary to achieve aantimicrobial levels in soiled surgicaand details those measures in more d
RATIONALEWearing surgical attire and appropriaprotective equipment in the semirestrrestricted areas of health care facilitiepersonnel safety and helps ensure clethe perioperative environment. It is uthat the human body and the variousthe perioperative setting are sourcescontamination and microbe transmisssurgical attire helps to minimize theof microorganisms and lint from heasonnel to clean items and the environthough there is no direct link betweesurgical attire and the impact on surgfections, it seems prudent to minimizexposure to a surgical team member’cous membranes, or hair.
Using a health care-accredited launis preferred because accredited facilitindustry standards. The Healthcare Lcreditation Council provides voluntartion to those laundry facilities that pr
ther care textiles and incorporate Occupational Safety
AORN Journal 123
nd CCDC)ontroindus; monoutines corrater tation
ce recse recects o
stricteludinre andspecinot b
how and, as well asompetencyedures, andogram. Thisenting the
practiceurse’s role inical attire
ive nursesow-lintingis comfort-RN recom-
ly woven,esearchattire is notit is made.3
not r
January 2012 Vol 95 No 1 BRASWELL—SPRUCE
and Health Administration (OSHA) afor Disease Control and Prevention (lines, including establishing quality ctoring and using processes based ondards; regularly testing water qualitywash loads and recording data; and rmonitoring laundry processes, such ameasurement of chemicals, correct wtures, mechanical action, and the durwashing cycle.
DISCUSSIONThere are nine evidence-based practimendations in the RP document. Themendations pertain to the various aspcal attire in the semirestricted and reof the perioperative environment, incommendations about materials that anot acceptable for surgical attire, thetypes of attire that should and should
Figure 1. Attire made of 100% fleece is
in the perioperative practice setting, the clea
124 AORN Journal
entersguide-
l moni-try stan-itoringlyectempera-of the
om-om-f surgi-d areasg rec-
arefice worn
and laundering of surgical attire, andwhen to wear surgical attire correctlyrecommendations for education and cvalidation, creating policies and procestablishing a quality management prarticle offers suggestions for implemrecommendations in the perioperativesetting with a specific focus on the nestablishing safe and appropriate surgpractices.
Recommendation IIn selecting surgical attire, perioperatshould choose attire that is made of lmaterial, catches shed skin squames,able, and looks professional.1(p57) AOmends choosing fabrics that are tightstain resistant, and durable. In fact, rshows that the design of the surgicalas important as the material of which
ecommended for the OR.
nliness Surgical attire should not be highly flammable,
ot ret shedtory df apps canatalogne byess anfferswarmducatide th
retutmenton wecreaioperspectnnelrgicalgical
r facility
facets off the attire,
, what not tosuggestionsof shoes to
ation (ID)items that
ricted or re-ses).1(p57-61)
e personnelareas wearndered, orshoes, headges.1(p57)
ge into sur-reas to de-mination
be de
RP IMPLEMENTATION GUIDE: ATTIRE www.aornjournal.org
which is why 100% cotton fleece is nmended4 (Figure 1), and it should noharbor dust, skin squames, or respira
To ensure surgical attire is made omaterials, perioperative staff memberlabels carefully, review health care cinteract with vendors. This can be doing the Exhibit Hall at AORN Congring vendor meetings. If the vendor othat are 100% cotton fleece, such asjackets, perioperative nurses should eabout the misuse of cotton fleece insoperative suite. The vendors can thentheir research and development deparredesign jackets that are made of cot10% to 20% polyester blend, which dshedding component. In addition, perstaff members can work with their reterials management department persoing decisions about obtaining new suThey can also discuss the revised sur
Figure 2. Use of cover apparel should
RP document, which provides detail on fa
com-lint or
roplets.ropriatereads, andvisit-d dur-
items-upe theme peri-rn tots toith ases the
ativeive ma-in mak-
attire.attire
specifications, with vendors and othestaff members.
Recommendation IIRecommendation II deals with manysurgical attire, including cleanliness owhere and how to don surgical attirewear (eg, jewelry, open-toed shoes),for head coverings and the best typeswear, how and why to wear identificbadges, the use of cover apparel, andshould not be taken into the semireststricted areas (eg, backpacks, briefcaIt is recommended that perioperativin the semirestricted and restrictedfacility-approved, clean, freshly laudisposable surgical attire, includingcoverings, masks, jackets, and ID badPerioperative personnel should changical attire in designated dressing acrease the possibility of cross-conta
termined on a facility-by-facility basis.
bric and to assist with traffic control and should
AORN Journal 125
ey nbuildal attironml mayigured toer shacilitys betwxampor fr
nel shng onrrivalsingscrubnal tr
infecave a
d be in-ting from
ar jewelryor braceletssurgical
k of contam-ho wearings as re-Research
mes higherrings than
e nurse’s ori-uss theseuide, the pre-mphasize thatry to thering mayparing surgi-, laceration,
d or confinedorn.
January 2012 Vol 95 No 1 BRASWELL—SPRUCE
change back into street clothes if thleave the facility or travel betweento prevent contaminating the surgicthrough contact with the external envAdditionally, the use of cover apparedetermined by the practice setting (F
Surgical personnel who are requirefrom one health care facility to anothwear the same surgical scrubs from ffacility. Wearing contaminated scrubfacilities can transfer pathogens, for efrom clothing to the transport vehiclepatient to patient. Health care personchange into street clothes when leaviity and don clean surgical attire on asecond facility. While possibly increatime factor, the benefits of changingweigh the costs; the provider’s persovehicle will not come in contact withmaterials, and the next patient will h
Figure 3. Jewelry, including earrings, nwithin the scrub attire should not be w
vider who is wearing a clean, noncontamin
126 AORN Journal
eed toingsireent.be
2).travelould not
toeenle,omoulde facil-at thethes out-ansporttedpro-
pair of scrubs. Time allotments shoulcluded for providers who are commufacility to facility.
Perioperative nurses should not wesuch as earrings, necklaces, watches,that cannot be contained within theattire5 (Figure 3) because of the risinating the surgical attire. Nurses wjewelry should be aware of the findported in the revised RP document.now shows that bacteria are nine tion the skin beneath finger and noseon the rings themselves.5 During thentation phase is a good time to discfindings. Using safety as his or her gceptor can relay these findings and ewearing rings may, in fact, cause injuwearer or to patients. For example, abecome caught while the nurse is precal equipment and result in an injury
ces, watches, and bracelets, that cannot be containe
ecklaated or avulsion. The ring may become contaminated
g a suhe rinplac
ry toing itRing
emov
andshoe
nd nohaved. Pe
regar inhazarplashs mat
toes
droppedd or other
h commit-research.l questionacks, ortricted areasthe perioper-ture relatedacteria and, or other
ely usedgh stetho-ire, perioper-r themre inanimate
eg, methicil-
porousbacteria.
RP IMPLEMENTATION GUIDE: ATTIRE www.aornjournal.org
with unknown microorganisms durinprocedure, causing the skin beneath tbecome colonized. If nurses prefer toelry in a personal locker or pin jewelclothing, they increase the risk of losmay become dislodged or misplaced.beneath gloves may be accidentally rthe gloves and possibly lost.
Shoe selection also is important,erative personnel should wear cleanclosed toes and backs, low heels, asoles.6 Shoes made of cloth or thator perforations are not recommendeative nurses should adhere to OSHAthat pertain to the choice of footwepractice setting related to potentialas needle sticks, scalpel cuts, and sblood or other potentially infectiouCloth shoes or shoes that have open
Figure 4. Fanny packs, backpacks, briematerials may be difficult to clean or d
backs, for example, increase the wearer’
rgicalg to
e jew-their. Ringss worned with
periop-s withnslipholesrioper-ulationstheds suches fromerials.
or
of sustaining a sharps injury from ainstrument or being exposed to bloobodily fluids.
Perioperative nurses maintain a higment to evidence-based practice andTherefore, when health care personnethe prohibition of fanny packs, backpbriefcases in the semirestricted or resof the perioperative suite (Figure 4),ative nurse must be able to cite literato studies confirming the growth of bmicrobial carriage on fabrics, plasticsporous materials.7-10
Stethoscopes may be the most widmedical device in health care. Althouscopes are not part of the surgical attative health care providers often weaaround their necks (Figure 5). They aobjects that can transmit pathogens (
s, and other personal items that are constructed ofct adequately and may harbor pathogens, dust, and
fcaseisinfe
s risk lin-resistant Staphylococcus aureus) by indirect
AORN Journal 127
withcreaseNursers toationsible fonmeeasurshou
tive ns autFaci
safetys relaalth crrivaleck in. Thiinformph, the per
resented tors must sub-
an additionale into the, the vendorser to retrievefacility-is-e periopera-sure ofear at theuthorizedng these pro-or visitore that nod the appro-out the nec-should notve beenhorized visi-for furthercumentation
oscopesthe ne
January 2012 Vol 95 No 1 BRASWELL—SPRUCE
contact. Cleaning stethoscopes alongwashing between treating patients depossibility of pathogen transmission.provide antibacterial wipes for providtheir stethoscopes at hand washing st
The perioperative nurse is responsmaintaining a safe and secure envirall times; therefore, as a security mpersonnel in the perioperative settingID badges. This allows the perioperawell as patients, to identify all personto be in the perioperative setting.11,12
can ensure patient and staff memberimplementing policies and procedurevisitors in the OR. For example, a hefacility’s policies may state that on afacility, vendors and visitors must chthrough an automated badge terminalprint a photo/ID badge that containssuch as the date and time, a photograpany represented, and the name of th
Figure 5. Identification badges shouldshould be clean and not worn around
they are visiting. On arrival to the periope
128 AORN Journal
hands the
es canuse on
.ornt ate, allld wearurse, ashorizedlities
byted toareto the
s willatione com-
son
services area, the photo/ID badge is pthe control center. Vendors and visitomit their driver’s licenses to receivebadge that authorizes their admittancOR. On completion of their businessand visitors return to the control centtheir driver’s licenses and return thesued badges. Securing and locking thtive suites will add an additional measafety. Visitors or vendors are to appdoor, ring the bell for help, and be aentrance to the control center. Knowicedures are in place before a vendorarrives at an OR, the nurse can ensurperson enters without having followepriate steps. If someone appears withessary stickers and badges, he or shebe allowed to enter until the steps hacompleted. The nurse can refer unauttors or vendors to the control centerguidance and to complete required do
cured on the surgical attire top and visible, and stethck.
be se
rative before they are permitted to enter.
stionwha
ines fes ofwear,actice
restrireshlred aility o
theriope
ace wgainvivesurg
posetemsf the
ity of
ong deterrente nurses can
s manage-adequateuse by per-f staff mem-onal lockers.rm-up jack-ures. Mem-ve teamsingle-useed closededding skin
. Periopera-ed warm-upere there isets shouldaccommo-
pping thethat thento contact
personal
warm-upown
RP IMPLEMENTATION GUIDE: ATTIRE www.aornjournal.org
Recommendation IIIRecommendation III includes suggehow often to change surgical attire,when attire is contaminated, guidelusable and single-use attire, the typthat nonscrubbed personnel shouldwearing personal clothing in the prsetting.1(p61-62)
All individuals who enter the semiand restricted areas should wear fdered surgical attire that is laundehealth care-accredited laundry facposable surgical attire provided byand intended for use within the pesetting.1(p61)
Perioperative personnel should not plsurgical attire in lockers to be worn astudies have shown that microbes surperiods on fabrics.9,10,13 Storing usedattire in one’s personal locker can experioperative nurse’s other personal icrobes that may fall from the fabric oAs previously discussed, the possibil
Figure 6. All nonscrubbed personnel shjacket snapped closed with the cuffs d
transmission of microorganisms to the nur
s fort to door re-attireand
ctedy laun-t ar dis-
facilityrative
ornbecausefor longicaltheto mi-attire.the
individual belongings should be a strfor this type of behavior. Perioperativspeak to their managers and materialment personnel to ensure there is ansupply of surgical attire available forsonnel to help offset the possibility obers retaining used attire in their pers
Surgical attire should include waets with long sleeves and snap closbers of the nonscrubbed perioperatishould wear a freshly laundered orlong-sleeved warm-up jacket snappwith cuffs to the wrist to contain shsquames from bare arms (Figure 6)tive nurses should don a long-sleevjacket before prepping a patient whrisk of skin squames shedding. Jackbe available in a variety of sizes todate every staff member. While prepatient, the nurse should take caresleeves of the jacket do not come iwith the sterile field.
Surgical attire should not include
wear a freshly laundered or single-use long-sleevedto the wrists.
ould
se’s clothing that extends above the top neckline or
AORN Journal 129
al attnd ofes weel winto
to parmfutensivembettire.cate,withted,se maman
tive tr whoe occsoonber
tate t
ly harmfulards.
ad and facialrestricted
over facialneck. Peri-the risk ofhead andames andg onto therecom-etely coverl to coverthe earsFigure 8).ir depart-ment depart-ability of
a variety of
e com
January 2012 Vol 95 No 1 BRASWELL—SPRUCE
below the sleeve (Figure 7). Surgicshould be changed daily or at the eand should not be worn if it becomcontaminated. Perioperative personnattire becomes soiled should changelaundered attire as soon as possibleprolonged exposure to potentially hteria.14,15 When their bodies are excontaminated, perioperative staff mshould bathe before donning fresh aThe perioperative nurse, as an advoassist other perioperative personnelopportunity for changing contaminaor wet attire. The perioperative nurto contact the charge nurse or floorand request an additional perioperamember to relieve the team membetire becomes soiled while the changthis is not immediately possible, astime permits, the affected team membe relieved. Managers should facili
Figure 7. All personal clothing should b
reliefs to decrease the amount of time a
130 AORN Journal
irea shiftt or
hosefreshly
reventl bac-elyrs14,16
shouldthe
soiled,y need
agereamse at-urs. Ifas
shouldhese
member is exposed to any potentialbacteria as outlined in OSHA stand
Recommendation IVAll personnel should cover their hehair when in the semirestricted andareas.1(p62) Hair coverings should chair, sideburns, and the nape of theoperative nurses can help minimizesurgical site infections by coveringfacial hair, which prevents skin squhair shed from the scalp from fallinsterile field.17,18 Skull caps are notmended because they do not complthe wearer’s hair and skin; they faithe side hair above and in front ofand the hair at the nape of the neck (Perioperative nurses can talk with thement managers and materials management personnel to eliminate the availskull caps. Providing bouffant caps in
pletely covered by the surgical attire.
team sizes will allow perioperative team members
caps
ld pnate
ntamire acwearsableily i
ity.19
at thly labrtme
ceptark wperso
y sewr thatA nohouldr ontpartmcontao thelp prere fary ba
ry bagsr of theesia person-ear personalld have anent marker,me and de-rovideindividual
oiled, per-
a healthhould not beORN haslaunderinge laundering
nded. Thet is that re-me launder-
facility laun-ioburdenniforms atme launder-und on uni-
primary
neck, whenas.
RP IMPLEMENTATION GUIDE: ATTIRE www.aornjournal.org
choices when converting to bouffantskull caps.
Perioperative team members shousingle-use head coverings in a desigceptacle after daily use or when coPersonal, reusable head coverings aable for perioperative personnel toare covered with a single-use dispocovering or if they are laundered dahealth care-accredited laundry facilsonal head coverings are launderedty’s laundry, they should be properwith the employee’s name and depaplaced in an appropriate laundry rePerioperative team members can wotheir managers and laundry facilityrecommend labels that can be easilironed into the personal head cap osecurely affixed by another means.ing, nonfading, permanent marker sused to place the name of the ownelabel. Working with the laundry deensure all necessary information isthe label to ensure the caps return tful departments and owners will helost personal items. Many health canow provide individual mesh laund
Figure 8. All personnel should cover hein the semirestricted and restricted are
perioperative personnel to use for person
over
laced re-nated.cept-if theyhead
n aIf per-
e facili-elednt andcle.ithnnel ton orcan be
nbleed-be
o theent toined onright-vent
cilitiesgs for
usable caps. Labels and mesh laundshould be provided to every membeperioperative team, including anesthnel and other team members who whead caps. Mesh laundry bags shouaffixed label, written with a permanthat identifies the staff member’s napartment. A facility may prefer to plarger mesh laundry bags instead ofmesh laundry bags for depositing ssonal caps.
Recommendation VSurgical attire should be laundered incare-accredited laundry facility and slaundered at home (Figure 9).1(p63) Anot changed its position on the homeof surgical attire since 2004, and homof surgical attire is still not recommedifference in the revised RP documensearch now shows definitively that hoing is less effective than health caredering. Studies have shown that the bfound on the health care providers’ uthe beginning of a shift following hoing is the same as the bioburden foforms at the end of their shifts. The
d facial hair, including sideburns and the nape of the
ad anal, re- reason is that accredited laundry facilities
AORN Journal 131
DC gtion
t surginanpara
pecifires thels in
e lited to tationgers
d ineeti
s as aearchinst herativ
anare teation
ion o
the shift wereith one or
ncomycin-istant Staphy-
fficile.1(p64),21
cottoned with 10that entericrus, and ade-ips after theuded being-minute per-
d areasen sterile
1(p65) Thee periopera-microorgan-
ve team areWearing aoviders from
ttireomme
January 2012 Vol 95 No 1 BRASWELL—SPRUCE
incorporate numerous OSHA and Clines as well as professional associatice recommendations to ensure thaattire and textiles are free of contamas bacteria and fungi.1(p63-64),20 Comhome laundering may not meet the schanical, thermal, or chemical measunecessary to reduce antimicrobial levsurgical attire.1(p64)
Perioperative nurses should providto perioperative team members relateils of home laundering. This informbe distributed to perioperative manawell. Information may be distributeform of staff bulletin boards, staff meducational venues, or journal clubto share the findings of relevant resAORN has used to recommend agalaundering of surgical attire. Periopnurses can provide staff members, mand all other perioperative health camembers with the following inform
� In a study of bacterial contaminat
Figure 9. Home laundering has been shlaundered by health care facilities or c
laundered uniforms, 39% of uniforms i
132 AORN Journal
uide-prac-icalts suchtively,ed me-at aresoiled
raturehe per-shouldas
thengs,means
omee
gers,am:
f home-
fied as “clean” at the beginning ofactually found to be contaminated wmore microorganisms, including varesistant enterococci, methicillin-reslococcus aureus, and Clostridium di
� A quantitative study performed onstrips of fabric that were inoculatmL of a viral suspension showedviruses such as hepatitis A, rotavinovirus remained on the fabric strhome-laundering process that inclwashed, rinsed, and dried on a 28manent press cycle.22
Recommendation VI“All individuals entering the restricteshould wear a surgical mask when opsupplies and equipment are present.”mask protects both the patient and thtive team members from exposure toisms. All members of the perioperatiat risk for exposure from droplets.surgical mask protects health care pr
to be less effective for cleaning surgical attire than arcial laundries.
own
denti- droplets greater than 5 micrometers in size. Ex-
ropleteptoces.the pacarrie. Wea
careus maretioning at splahe hedy of
of bks ofrevead in ttside
ce the
wear, re-uld cover the1(p65) Theyhead andof transmit-
icroorgan-.1(p66) Con-priately canhing thethrough
surgicalneck or awet (Figure
at a time,iscarded anduld confronting a con-ember’s, the periop-
orn to
RP IMPLEMENTATION GUIDE: ATTIRE www.aornjournal.org
amples of diseases where potential dsures may occur include group A Stradenovirus, and Neisseria meningitid
Wearing a surgical mask protectsfrom exposure to infectious materialhealth care provider’s nose or mouthsurgical mask also protects the healthvider from exposure to other infectiofrom patients, such as respiratory secsprays of blood or body fluids. Wearmask decreases the risk of inadvertensplatters of blood or body fluid into tcare provider’s mouth or nose. A stusurgical procedures revealed that 26%exposures were to the heads and necscrubbed personnel. The same studythat 17% of blood exposures occurrenonscrubbed, circulating personnel ousterile field.23
Perioperative nurses can help redu
Figure 10. Surgical masks should be w
fer of microorganisms when they instruct
expo-occus,
tientd in thering apro-terials orsurgicalshes oralth8,500lood
ledhethe
trans-
team members about how to properlyplace, and discard masks. Masks shomouth and nose and prevent venting.should be secured at the back of thebehind the neck to decrease the riskting nasopharyngeal and respiratory misms to patients or to the sterile fieldversely, surgical masks applied approprevent infectious particles from reacwearer’s nose and mouth by passingleaks at the mask-face seal.
Surgical attire should not include amask that is worn hanging from thesurgical mask that becomes soiled or10). Only one mask should be wornand soiled or wet masks should be dreplaced. The perioperative nurse shoany health care provider who is weartaminated surgical mask. If a team msurgical mask becomes wet or soiled
cover the mouth and nose.
other erative nurse should inform the team member and
AORN Journal 133
led m
sk sh
the ti
r her
d per
er tea
sks a
ing th
mber
s pro
ill he
acles
iately
also w
urses
ts, ca
l of a
ment
the e
. As
e foll
rative
ked t
surg
ions
roced
prov
ment
Pers
ucatio
to the
men
nity
nd va
ncies
ive Jo
n Too
lopin
developed,essary, andg. New orpresent anith nurses
s in the facil-cies and pro-d practices.emplates,of 15 sam-
lates basedand Recom-provementient safetydetails on thethat are spe-this article,
document.
RIOulatory sur-w AORNl attire.” Oneubbed per-mirestrictedleeved scrub. The intentmediately.to assist
carpal tunnel
arm up foret and pro-n Nurse Jmoved thee to take offet somethingto be wornspond?
that whileas, all non-ly laundered
ets. The rec-
January 2012 Vol 95 No 1 BRASWELL—SPRUCE
assist him or her in replacing the soi
After each procedure, the surgical ma
discarded by carefully handling only
the mask.1(p66) After discarding his o
the perioperative team member shoul
proper hand hygiene.24
Perioperative nurses can coach oth
members to discard their surgical ma
form hand hygiene afterward. Provid
propriate receptacles for the team me
deposit used surgical masks as well a
alcohol foam hand wash in the OR w
cilitate compliance. Additional recept
hand hygiene stations located immed
the exit from the perioperative suite
facilitate compliance. Perioperative n
laboration with infection preventionis
velop signage to indicate that remova
gical masks before exiting the depart
required. The signs may be placed at
each OR and at each department exit
to ensure infection control policies ar
any person found outside the periope
wearing a surgical mask should be as
move it.
The Final ThreeIn the “Recommended practices for
attire,” the final three recommendat
education/competency, policies and p
and quality assurance/performance im
These topics are integral to the imple
of AORN practice recommendations.
should receive initial and ongoing ed
competency validation as applicable
Implementing new and updated recom
practices affords an excellent opportu
ate or update competency materials a
tools. AORN’s perioperative compete
has developed the AORN Perioperat
scriptions and Competency Evaluatio
assist perioperative personnel in deve
petency evaluation tools and position desc
134 AORN Journal
ask.
ould be
es of
mask,
form
m
nd per-
e ap-
s to
viding
lp fa-
and
before
ill help
, in col-
n de-
ll sur-
is
xit to
a means
owed,
suite
o re-
ical
discuss
ures,
ement.
ation
onnel
n and
ir roles.
ded
to cre-
lidation
team
b De-
ls25 to
g com-
Policies and procedures should bereviewed periodically, revised as necreadily available in the practice settinupdated recommended practices mayopportunity for collaborative efforts wand personnel from other departmentity to develop organization-wide policedures that support the recommendeThe AORN Policy and Procedure T2nd edition,26 provides a collectionple policies and customizable tempon AORN’s Perioperative Standardsmended Practices. Regular quality improjects are necessary to improve patand to ensure safe, quality care. Forfinal three practice recommendationscific to the RP document discussed inplease refer to the full text of the RP
AMBULATORY PATIENT SCENAStaff members at a freestanding ambgery center have implemented the ne“Recommended practices for surgicaof the many changes is that all unscrsonnel working in the restricted or searea are now required to wear long-sjackets that are buttoned up the frontis for everyone to comply starting imHowever, when Nurse J enters OR 1Nurse W in prepping a patient for arelease, she encounters a problem.
While Nurse J holds the patient’sNurse W, Nurse W removes her jackceeds to prep the patient’s arm. Whequestions Nurse W about why she rejacket, Nurse W says, “It is ok for mmy jacket to prep; otherwise I may gon it. AORN doesn’t state that it hasfor the prep.” How should Nurse J re
Nurse J should explain to Nurse Win the semirestricted or restricted arescrubbed personnel should wear freshor single-use long-sleeved scrub jack
riptions. ommended practice is that perioperative nurses
acketof sk
ts shementy turnyer. Aed intactereld aprominfecinterfith ades, or
ital fice isspitallwaysnd plhe baed, dmadany
or sev
nd imthat idingictede can, he btold oI havears,see t
peratcticel invo
olders anden a news an attireicians mayor con-
he changeive person-updating ation earlyenting amade, peri-at barrierses of physi-rtant totients aserioperativee in imple-
ges.xplain theffer to showcles that sup-e presentedgers andfurther dis-uld discussheir buy-in.ion session tod. Withtermine how
nded prac-hallengingtive nurses.ecommenda-nge from
l question thenurse shouldations aree RP docu-dditional
RP IMPLEMENTATION GUIDE: ATTIRE www.aornjournal.org
should don a long-sleeved warm-up jprepping a patient where there is risksquames shedding. The jacket prevenof skin squames into the OR environsterile field. Healthy skin is constantlover and forming a new protective laskin cells are shed, they are disseminatenvironment, taking with them viable bcould potentially land on the surgical fipatient. This could contribute to a comsurgical field and potential surgical siteNurse W’s jacket is too large and maythe surgical prep, Nurse J may assist wmeasures such as tucking the front, sidof the jacket to maintain a sterile prep.
HOSPITAL PATIENT SCENARIODr R has been working in Gold Hospyears as an anesthesiologist. His serva large specialty group that Gold Hotracts for anesthesia services. Dr R ahis large bag into the OR with him aon the floor by the anesthesia cart. Textremely worn. It is made of a crackleather-type material. The handles arefabric and are also extremely worn. Minside the bag may have been there fmonths to several years.
Gold Hospital has recently written amented a new policy on surgical attireall of AORN’s recommendations, incluing bags in the semirestricted and restrWhen a colleague informs Dr R that hger bring his bag into the OR with himirate. Nurse G is nearby when Dr R ispractice change. “Nurse G!” he yells. “bringing my bag into the OR for five ynow you tell me that I can’t? I want todence that this causes problems!”
This is a dilemma that many perionurses encounter. How could this prahave been better communicated to al
What should Nurse G do?beforeinddingand theings these
o theia thatnd theisedtion. Ifere withditionalsleeves
or fivepart ofcon-brings
aces itg isry,e ofitemseral
ple-ncludesprohibit-areas.no lon-ecomesf the
e beenandhe evi-
ivechangelved?
It is important for all key stakehphysician groups to be included whpolicy that will affect them, such apolicy, is being created. Many physfeel that they are being manipulatedtrolled if they are not involved in tprocess. To prevent this, perioperatnel who are involved in creating orfacility policy should provide educaand ask for feedback before implemprocess change. Before a change isoperative nurses must determine whthey may face. What are the attitudcians and staff members? It is impocommunicate the benefits for the pawell as the benefits for personnel. Pnurses should expect some resistancmenting facility-wide practice chan
In this scenario, Nurse G should erationale for the change. She could oDr R the evidence-based practice artiport the change. These articles can bto perioperative and anesthesia manaother perioperative staff members toseminate the information. Nurse G cothe articles with managers to obtain tShe could offer to provide an educatoutline the changes that have occurremanagers’ support, Nurse G could derepeat offenders should be reported.
CONCLUSIONImplementing the AORN “Recommetices for surgical attire”1 presents a cand unique opportunity for perioperaNurses implementing these practice rtions may encounter resistance to chaperioperative staff members who wilupdated practices. The perioperativereiterate that the practice recommendwritten by expert content authors. Thment authors include content from a
expert sources as well, such as the AmericanAORN Journal 135
e Amocietr Profologyon ofemenove s
in theatingocessr, ricecom
now wce recten, rnteddocu
llingstron
rgicalparty thecommg theortedellingd comd no
y—wtraditphysiatory,t, orperfonityple.
s a “cat is
s Ku
for creating
ire. In: Periop-actices. Denver,
ire. In: Periop-actices. Denver,
ource and routepidermidis
g cardio-thoraciccontamination
fect. 2001;47(4):
g of cottonmaleic acid and
6(4):351-368.annister GC.ounts of operat-8-70.ds 1910.136:nt of Labor.sp.show__id�9786.
tal cleaning inive StandardsO: AORN, Inc;
erioperative. Denver, CO:
rococci andastic. J Clin
e medicallyplastics. J Clin
ronment of care.mended Prac-5-236.rook Terrace,
nurses’ uni-37-42.thogens—235):64004-
Silver LC, Jar-gical site infec-ractices Advi-pidemiol. 1999;
orne pathogens.
r as a reservoir
January 2012 Vol 95 No 1 BRASWELL—SPRUCE
Association of Nurse Anesthetists, thCollege of Surgeons, the American SAnesthesiologists, the Association foals in Infection Control and EpidemiCDC, and the International Associaticare Central Service Materiel Managintent of all RP documents is to imprmember and patient safety.
As of September 2011, AORN isning stages of putting an “evidence rmentation” phase into the creation preach of its RP documents. As strongeand more robust scientific evidence bavailable, perioperative nurses will kcertainty that each of AORN’s practimendations has been researched, writviewed, revised, and publicly commeFor instance, in the surgical attire RPthe literature review provided compedence that prompted AORN to take astance against home laundering of suAlthough this has not been a popularrevised RP document, as evidenced bber of Congress attendees and publicwho have expressed concern regardinchanges, the recommendation is suppentific research with extremely compTherefore, perioperative nurses shoulwith all parts of any RP document anthe “popular” parts. On any given dait is an inpatient hospital setting in aOR, an ambulatory surgery center, aoffice, a cardiac catheterization labordoscopy suite, a radiology departmenother area where invasive procedures areperioperative nurses have the opportuthemselves apart and to lead by exammenting AORN’s recommendations iaction” for standing up and doing whaccording to the evidence.
Acknowledgement: The author thank
Jones, graphic designer/medical illustrator
136 AORN Journal
ericany ofession-, theHealth-
t. Thetaff
begin-imple-for
her,esith
om-e-upon.ment,
evi-gerattire.
of thenum-enters
seby sci-results.ply
t justhetherionalcian’san en-
anyrmed—to setImple-all toright—
rt
Creative at AORN, Inc, Denver, CO,
the artwork in this article.
References1. Recommended practices for surgical att
erative Standards and Recommended PrCO: AORN, Inc; 2011:57-72.
2. Recommended practices for surgical atterative Standards and Recommended PrCO: AORN, Inc; 2009:299-306.
3. Tammelin A, Hambraeus A, Stahle E. Sof methicillin-resistant Staphylococcus etransmitted to the surgical wound durinsurgery. Possibility of preventing woundby use of special scrub suits. J Hosp In266-276.
4. Wu X, Yang CQ. Flame retardant finishinfleece fabric: part III—the combination ofsodium hypophosphite. J Fire Sci. 2008;2
5. Bartlett GE, Pollard TC, Bowker KE, BEffect of jewelery on surface bacterial cing theatres. J Hosp Infect. 2002;52(1):6
6. Occupational Safety and Health StandarFoot protection. United States Departmehttp://www.osha.gov/pls/oshaweb/owadidocument?p_table�STANDARDS%26pAccessed September 2, 2011.
7. Recommended practices for environmenthe perioperative setting. In: Perioperatand Recommended Practices. Denver, C2011:237-250.
8. Standards of perioperative nursing. In: PStandards and Recommended PracticesAORN, Inc; 2011:3-52.
9. Neely AN, Maley MP. Survival of entestaphylococci on hospital fabrics and plMicrobiol. 2000;38(2):724-726.
10. Neely AN, Orloff MM. Survival of somimportant fungi on hospital fabrics andMicrobiol. 2001;39(9):3360-3361.
11. Recommended practices for a safe enviIn: Perioperative Standards and Recomtices. Denver, CO: AORN, Inc; 2011:21
12. Hospital Accreditation Standards. OakbIL: The Joint Commission; 2009:47-68.
13. Callaghan I. Bacterial contamination offorms: a study. Nurs Stand. 1998;13(1):
14. Occupational exposure to bloodborne paOSHA. Final rule. Fed Regist. 1991;56(64182.
15. Mangram AJ, Horan TC, Pearson ML,vis WR. Guideline for prevention of surtion, 1999. Hospital Infection Control Psory Committee. Infect Control Hosp E20(4):250-278; quiz 279-280.
16. US Health and Human Services. Bloodb29 CFR §1910.1030.
17. Summers MM, Lynch PF, Black T. Hai
, IKON of staphylococci. J Clin Pathol. 1965;18(13):13-15.perativLancet
. Guidh-carelthcare(HICPA1-42.cil. AcTextilw.hlaessed
contam238-24rvivalinfectiorobiol.
e operInfect
in theand Renc; 201
petency Evalu-n press.OM]. 2nd ed.
NS, CNOR,ai Hospitalno de-
eived ast in the
CNOR, isical services
ussia, PA.that could
nflict of in-.
racticest. Individu-and refer-
RP IMPLEMENTATION GUIDE: ATTIRE www.aornjournal.org
18. Dineen P, Drusin L. Epidemics of postoinfections associated with hair carriers.2(7839):1157-1159.
19. Sehulster L, Chinn RY, CDC, HICPACenvironmental infection control in healtRecommendations of CDC and the HeaControl Practices Advisory CommitteeMMWR Recomm Rep. 2003;52(RR-10):
20. Healthcare Laundry Accreditation Countion Standards for Processing Reusablein Healthcare Facilities. 2006. http://wwAccredit%20Standards12.18.08.pdf. Accber 2, 2011.
21. Perry C, Marshall R, Jones E. Bacterialof uniforms. J Hosp Infect. 2001;48(3):
22. Gerba CP, Kennedy D. Enteric virus suhousehold laundering and impact of dissodium hypochlorite. Appl Environ Mic73(14):4425-4428.
23. Romney MG. Surgical face masks in thatre: re-examining the evidence. J Hosp47(4):251-256.
24. Recommended practices for hand hygieneative setting. In: Perioperative Standardsmended Practices. Denver, CO: AORN, I
This RP Implementation Guide is indocument upon which it is based anals who are developing and updatin
ence the full recommended practices doce wound. 1973;
elines forfacilities.InfectionC).
credita-es for Usecnet.org/Septem-
ination1.duringn with2007;
ating the-. 2001;
perioper-com-1:73-86.
25. Perioperative Job Descriptions and Comation Tools. Denver, CO: AORN, Inc. I
26. Policy and Procedure Templates [CD-RDenver, CO: AORN, Inc; 2010.
Melanie L. Braswell, DNP, RN, Cis an advanced practice nurse at Sinof Baltimore, MD. Dr Braswell hasclared affiliation that could be percposing a potential conflict of interespublication of this article.
Lisa Spruce, DNP, RN, ACNS-BC,the corporate clinical manager of surgat UHS of Delaware, Inc, King of PrDr Spruce has no declared affiliationbe perceived as posing a potential coterest in the publication of this article
d to be an adjunct to the complete recommended pot intended to be a replacement for that documenanizational policies and procedures should review
tended is ng org
ument.
AORN Journal 137
.6.aorn.org/CE
EXAMINATION
CONTINUING EDUCATION PROGRAM3wwwImplementing AORN Recommended
Practices for Surgical Attire
mmended
al attire.”
ns for surgi-
ur conve-e Exami-
PURPOSE/GOAL
To educate perioperative nurses about how to implement the AORN “Recopractices for surgical attire” in inpatient and ambulatory settings.
OBJECTIVES
1. Identify the purpose of AORN’s “Recommended practices for surgic2. Discuss why home laundering of surgical attire is not recommended.3. Identify appropriate materials for surgical attire.4. Discuss AORN’s practice recommendations for surgical attire.5. Identify methods for implementing AORN’s practice recommendatio
cal attire.
The Examination and Learner Evaluation are printed here for yonience. To receive continuing education credit, you must complete thnation and Learner Evaluation online at http://www.aorn.org/CE.
endede guid_____ictedetting
4, and, 3, 4
the reis the
ative
e OR.e.
s preferable to
ing and usedards.ata.
urement, wa-n, and wash
nd 4
QUESTIONS
1. The purpose of AORN’s “Recommtices for surgical attire” is to providfor surgical attire including ______worn in the semirestricted and restrthe surgical or invasive procedure s1. clothing2. head coverings3. jackets4. jewelry5. masks6. shoes
a. 1, 3, and 5 b. 2,c. 1, 2, 3, 5, and 6 d. 1, 2
2. Perhaps the most notable change tomended practices for surgical attire
stance AORN has taken against138 AORN Journal ● January 2012 Vol 95
prac-elines
_____areas of.
6, 5, and 6
com-stronger
a. wearing jewelry in the periopersetting.
b. wearing 100% cotton fleece in thc. home laundering of surgical attird. taking briefcases into the OR.
3. Using accredited laundry facilities ihome laundering because they1. establish quality control monitor
processes based on industry stan2. monitor wash loads and record d3. regularly test water quality.4. routinely monitor chemical meas
ter temperature, mechanical actiocycle duration.a. 1 and 2 b. 3 a
c. 1, 2, and 3 d. 1, 2, 3, and 4No 1 © AORN, Inc, 2012
f com
nd 42, 3, a
approers shontrol
nd 42, 3, a
ge frohey nbuildi
soilethe a
ludesne-sizingle-
earin
ping to ensurenot come into
’s attire andted, actionsncludebility for.oor managere staff memberd.mber whosethe OR as
f time themember isul bacteria.nd 42, 3, and 4
iscarding ofe thatns two masks
ose and isnd behind the
the neck after
carefully han-
d after the
nd 5, 4, and 5
with consulta-
e Education.
of interest in
CE EXAMINATION www.aornjournal.org
4. Surgical attire should be1. 100% fleece.2. made of low-linting material.3. professional looking regardless o4. stain resistant and durable.
a. 1 and 3 b. 2 ac. 2, 3, and 4 d. 1,
5. To ensure surgical attire is made ofmaterials, perioperative staff memb1. conduct flammability tests in a c
environment.2. consult attire vendors.3. read attire labels carefully.4. review health care catalogs.
a. 1 and 3 b. 2 ac. 2, 3, and 4 d. 1,
6. Perioperative personnel should chansurgical attire into street clothes if tleave the facility or travel betweena. true b. false
7. If worn surgical attire is not visiblyoperative personnel can opt to placea locker to be worn again.a. true b. false
8. Correct use of warm-up jackets inca. ensuring jackets are available in ob. donning a freshly laundered or s
long-sleeved warm-up jacket.c. snapping the jacket closed and w
cuffs to the elbow.
The behavioral objectives and examination fo
tion from Rebecca Holm, MSN, RN, CNOR,
Ms Retzlaff, Ms Holm, and Ms Bakewell hav
the publication of this article.
fort.
nd 4
priateouldled
nd 4
m theireed tongs.
d, peri-ttire in
e-fits-all.use
g the
d. removing the jacket during prepthat the sleeves of the jacket docontact with the sterile field.
9. When a perioperative team memberbody become extensively contaminathe perioperative nurse might take i1. assisting the person with accessi
changing the contaminated attire2. contacting the charge nurse or fl
to request relief personnel for thwhose attire became contaminate
3. ensuring the perioperative staff meattire became contaminated leavessoon as time permits.
4. helping to decrease the amount ocontaminated perioperative staffexposed to any potentially harmfa. 1 and 2 b. 3 ac. 1, 2, and 4 d. 1,
10. Proper wearing, replacement, and dsurgical masks includes making sur1. any team member who is sick do
to prevent disease transmission.2. the mask covers the mouth and n
secured at the back of the head aneck.
3. the mask is worn hanging fromthe procedure is finished.
4. surgical masks are discarded bydling only the ties.
5. proper hand hygiene is performemask is removed and discarded.
a. 1 and 2 b. 2, 4, ac. 1, 3, 4, and 5 d. 1, 2, 3
program were prepared by Kimberly Retzlaff, editor/team lead,
editor, and Susan Bakewell, MS, RN-BC, director, Perioperativ
eclared affiliations that could be perceived as potential conflicts
r this
clinical
e no d
AORN Journal 139
.6.aorn.org/CE
LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM3wwwImplementing AORN Recommended
Practices for Surgical Attirethe exgramscribe
tives o
ecom
rgical
rgical
dation. 5.
ORNtire.
se yo
objechion fr
esult of read-tion #9A. If
e? (Select all
team regard-
to change/ure.
eeting withand acceptance
valuate theintervals untilest practice.
as a result ofthat apply)t relevant to
teach othersd change.port to make
t we verifythe 3.6 con-16-minute)
This evaluation is used to determinewhich this continuing education prolearning needs. Rate the items as de
OBJECTIVES
To what extent were the following objeccontinuing education program achieved?
1. Identify the purpose of AORN’s “Rpractices for surgical attire.”Low 1. 2. 3. 4. 5. High
2. Discuss why home laundering of sunot recommended.Low 1. 2. 3. 4. 5. High
3. Identify appropriate materials for suLow 1. 2. 3. 4. 5. High
4. Discuss AORN’s practice recommensurgical attire. Low 1. 2. 3. 4
5. Identify methods for implementing Atice recommendations for surgical atLow 1. 2. 3. 4. 5. High
CONTENT
6. To what extent did this article increaknowledge of the subject matter?Low 1. 2. 3. 4. 5. High
7. To what extent were your individualmet? Low 1. 2. 3. 4. 5. Hig
8. Will you be able to use the informat
applicant who successfully completes this program
140 AORN Journal ● January 2012 Vol 95
tent tomet yourd below.
f this
mended
attire is
attire.
s forHigh’s prac-
ur
tives
om this
9. Will you change your practice as a ring this article? (If yes, answer quesno, answer question #9B.)
9A. How will you change your practicthat apply)1. I will provide education to my
ing why change is needed.2. I will work with management
implement a policy and proced3. I will plan an informational m
physicians to seek their inputof the need for change.
4. I will implement change and eeffect of the change at regularthe change is incorporated as b
5. Other:9B. If you will not change your practice
reading this article, why? (Select all1. The content of the article is no
my practice.2. I do not have enough time to
about the purpose of the neede3. I do not have management sup
a change.4. Other:
10. Our accrediting body requires thathe time you needed to completetinuing education contact hour (2
dentialing Center
eptance of this
ers. Each
article in your work setting? 1. Yes 2. No program:
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Creapproves or endorses products mentioned in the activity.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for accactivity for relicensure.
Event: #12503; Session: #0001; Fee: Members $18, Nonmembers $36
The deadline for this program is January 31, 2015.
A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answ
can immediately print a certificate of completion.No 1 © AORN, Inc, 2012