Surgical Attire: Are We Doing this Right?

Surgical Attire: Are We Doing this Right?

Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.

Developed and originally presented by

Patricia C. Seifert, MSN, RN, CNOR, CRNFA, FAAN

Antonia B. Hughes, RN, BSN, MA, CNOR

Claire Everson, RN, CNOR

Deena Young Guren, MSN, RN, CNOR, CNS-CP


Objectives

• Describe four challenges related to implementing evidence-based practices for surgical attire.

• Discuss four ways to implement a change in practice related to surgical attire.


The Skull Cap … we stopped ordering them, but we keep finding them on the shelves

Why do we need to replace them?

Challenge


• Bare skin (ie, baldness) contains skin squames and

microorganisms.• Skin organisms may be dispersed in air.• No convincing evidence that head coverings reduce

surgical site infection (SSI) rates.• Hair can carry microorganisms and bacterial

contaminants.

Reasons


• Cover the head, hair, ears, facial hair, and nape of neck when entering the semi-restricted and restricted areas.

• Non-disposable head coverings should be covered with a disposable head cover.

• Non-disposable head coverings should be laundered in a health care-accredited laundry facility.

Rationale: Reduction of patients’ exposure to potentially pathogenic organisms from clinicians’ hair and bare skin (ie, bald head); a skull cap does not cover all areas recommended.Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:97-120.

Recommendation and Rationale


• Engage surgeon and anesthesia champions to support changes in head coverings.

• Provide available research on OR head covering to medical and nursing staff.

• Have the most current AORN Guideline for Surgical Attire readily available.

• Offer interactive inservice programs for staff and ensure adequate time for discussion, Q&A, and “push back.”

Ideas for Success


Head covering should cover the head, hair, ears, facial hair, and nape of neck when personnel enter the semi-restricted and restricted areas.

Head Covering


I am hot and I’m NOT the patient … why do I need to cover my arms with a scrub jacket if I’m not scrubbed !!??

Challenge


• Skin contains skin squames. • Skin is the source of multiple organisms.• Skin organisms may be dispersed in air.• Tightly woven attire can reduce dispersal.• No direct connection between squames and SSI.

Reasons


Wear scrub attire that covers arms when:─ prepping the patient─ preparing and packaging sterile items in the

clean assembly area of sterile processing

Rationale: minimize dispersal of material and/or organisms on the skin

Recommendations and Rationale


• Create a notebook of supporting research on OR attire for managers, OR staff, and sterile processing professionals.

• Ensure an adequate supply of disposable and/or non-disposable jackets.

• Have most current AORN Guideline for Surgical Attire readily available.

• Offer interactive education for staff and ensure adequate time for discussion, Q&A, and “push back.”

Ideas for Success


Surgical attire and personal protective equipment are worn to provide a high level of cleanliness.

Surgical Attire


Questionsand Answers


I am COLD and I am not the patient!

Why can’t I wear a fleece jacket or turtleneck?

Challenge


Suggestions:–have the jacket laundered at the facility–wear undershirts that are V-neck or wear camisoles

• Fleece can be worn if it is tightly woven without holes. • Don’t forget: Clothing that comes from home should

not be in contact with the surgical environment.

Good Question!


Challenge

Why can’t I launder the scrub clothes at home?


Home laundry ─ does not have parameters for hot/cold water

temperature. ─ does not have standards for detergent or water

treatments. There is a potential for contamination from patients to home or home to patients when home laundering is used.

Concerns


Some facilities may not offer a laundry service.

More about home laundering

If home laundering is done; ─ the scrubs should be isolated from the other laundry.─ scrubs should be thoroughly dried and isolated for the

return to the point of use. ─ the use of bleach is recommended.


Challenge

Wow, you are wearing a matching ring-set, watch, earrings, and necklace! Can you please remove it?

I know you are a medical student/MD/experienced RN/surgical technologist/anesthesia provider, but you are not following the policy about surgical attire….


Reasons

• Patient safety and considerations comes first.

• Wearing jewelry was found to increase bacterial counts on skin surfaces when the jewelry is in place.



• “Jewelry that cannot be contained or confined within the scrub attire should not be worn in the semi-restricted or restricted areas.”

• Ring wearing associated with a 10-fold higher median skin organism count on the hands.

• Hand hygiene reduces bacterial skin count but more bacteria is found under the rings than on adjacent skin or on the opposite hand.


Ideas for Success

• Involve the team to brainstorm creative ways to confine and contain jewelry– rings, bracelets on a long chain that can be worn under scrub

top– watch confined under scrub jacket

• Hand hygiene demonstrations using reactive gel or powder– volunteer willing to wash hands while wearing a plain ring – examine under black light for residual materials


Ideas for Success

Emphasis always on patient safety• Risk of SSI• Risk of scratches from elevated settings• Risk of tubes and catheters becoming entangled in

jewelry with associated risks


Challenge

We wrote a new policy

So why isn’t anyone following it?


Reasons

• Perceptions–written in the Ivory Tower–meant for everyone else but ___(me)–my jewelry could get lost if I left it in my locker

• Education and orientation with little emphasis on attire, changes in policy

• Leaders not leading by example



• Commitment from leaders–at the beginning to support change–hold each other accountable

• Leaders hold staff accountable


Ideas for Success

• Involve a multi-disciplinary team – researching and writing policy – reflective of all roles in the perioperative environment

• Involve that same multi-disciplinary team – sharing the information– formal and informal education– multiple times– multiple formats


Challenge

How to sustain the change?


Ideas for Success

• Recognition patrol• Acknowledgment for change in personal practice • Periodic reminders

─ What is happening around us? ─ How it could apply to these recommendations?

• What should health workers do with jewelry worn while caring for a patient with an infectious disease?

• What would you do with your jewelry if you discovered, after caring for someone, they had a previously unknown infectious disease?


We have four sites and four different surgical attire policies: now what?

Challenge


• Impetus for change• Consistent standard of practice

Reasons


• The guidelines are intended to be achievable recommendations.

• Policies and procedures will reflect variations in practice settings.

• Ensuring and monitoring personnel compliance



• Implementing change is challenging!• Consider Change or Process

Improvement Models• Don’t forget data:

before and after change

Ideas for Success


• Group meeting of OR directors from all 4 institutions• Directors asked Standardization Committee for help• Draft of a Surgical Attire Policy

–consolidating four different ones• Identification of the groups it would affect

Ideas for Success


• Directors met again• Plan for change• Make the case for change!• Rolling out means:

– Start early! – Say it often! – Say it to everyone!

– Seek informal leaders/colleagues in other departments

Ideas for Success


Technology is in the OR: We’re seeing more cell phones, tablets, laptops, briefcases in the OR. Is this okay? What should we do?

Challenge


• Briefcases/backpacks/personal items – difficult to clean– potentially may bring pathogens into the OR environment– should not be placed on the OR floor

• Cell phones/tablets/hand-held devices – should be cleaned before entering and leaving the perioperative

setting• Department of Health regulations• Issue of distraction

Reasons


• Briefcases, backpacks, personal items taken into the semi-restricted or restricted areas – should be cleaned (moderate evidence)

• OR and procedure floors are considered contaminated– items should not be placed there (moderate evidence)

• Evidence does not suggest prohibiting items– but evidence emphasizes the need for thorough

cleaning and disinfection (moderate evidence)



• Evidence demonstrates that cell phones, tablets, and other devices are highly contaminated with microorganisms.

• Other considerations concerning cell phones, pagers, or hand-held communication devices



• Institutional policies restricting/prohibiting– laptops/bags/backpacks– cell phones/pagers/devices

• Cleaning stations– laptops/bags/backpacks– cleaning products– hand hygiene– other technologies

Ideas for Success


• American Association of Nurse Anesthetists Position Statement: Mobile Device Use. Formerly Position Statement Number 2.18. http://www.aana.com/resources2/professionalpractice/Documents/PPM%20PS%202.18%20Mobile%20Device%20Use.pdf . Accessed October 21, 2014.

• Andersen BM, Solheim N. Occlusive scrub suits in operating theaters during cataract surgery: effect on airborne contamination. Infect Control Hosp Epidemiol. 2002;23(4):218-220. doi:10.1086/502040. [IIIC]

• Krueger CA, Murray CK, Mende K, Guymon CH, Gerlinger TL. The bacterial contamination of surgical scrubs. Am J Orthop. 2012;41(5): E69-E73. [IIIA]

• Noble WC. Dispersal of skin microorganisms. Br J Dermatol. 1975;93(4):477-485. [VA]

• Noble WC, Habbema JD, van Furth R, Smith I, de Raay C. Quantitative studies on the dispersal of skin bacteria into the air. J Med Microbiol. 1976;9(1):53-61.

• Guideline for environmental cleaning. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:9-30.

References


http://www.aana.com/resources2/professionalpractice/Documents/PPM%20PS%202.18%20Mobile%20Device%20Use.pdf



• Guideline for sterile technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2014:67-96.

• Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:97-120.

• Guideline for prevention of transmissible infections. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:419-451. [IVA]

• Robb W. Distractions in the operating room threaten patient safety. AAOS Now. American Association of Orthopaedic Surgeons/American Academy of Orthopaedic Surgeons. 2012. http://www.aaos.org/news/aaosnow/may12/clinical5.asp. Accessed October 21, 2014.

• Saver C. Patient safety: cell phones are everywhere, but do they belong in the OR?” Reprinted from OR Manager. 2011:27(2):1-3. ECRI. https://www.ecri.org/Documents/Reprints/Cell_Phones_are_Everywhere,_but_do_they%20Belong_in_the_OR(OR_Manager).pdf. Accessed October 21, 2014.

• Sivanandan I, Bowker KE, Bannister GC, Soar J. Reducing the risk of surgical site infection: a case controlled study of contamination of theatre clothing. J Perioper Pract. 2011;21(2): 69-72. [IIIB]

References


http://www.aaos.org/news/aaosnow/may12/clinical5.asp

http://www.aaos.org/news/aaosnow/may12/clinical5.asp

https://www.ecri.org/Documents/Reprints/Cell_Phones_are_Everywhere,_but_do_they%20Belong_in_the_OR(OR_Manager).pdf

https://www.ecri.org/Documents/Reprints/Cell_Phones_are_Everywhere,_but_do_they%20Belong_in_the_OR(OR_Manager).pdf

• Tammelin A, Domicel P, Hambraeus A, Stahle E. Dispersal of methicillin-resistant Staphylococcus epidermidis by staff in an operating suite for thoracic and cardiovascular surgery: relation to skin carriage and clothing. J Hosp Infect. 2000;44(2):119-126. doi:10.1053/jhin.1999.0665. [IIC]

• Tammelin A, Ljungqvist B, Reinmüller B. Comparison of three distinct surgical clothing systems for protection from air-borne bacteria: a prospective observational study. Patient Saf Surg. 2012;6(1). [IIIC]

• Tammelin A, Ljungqvist B, Reinmuller B. Single-use surgical clothing system for reduction of airborne bacteria in the operating room. J Hosp Infect. 2013;84(3):245-247. doi:10.1016/j.jhin.2013.03.007; 10.1016/j.jhin.2013.03.007. [IIIC]

• Trick WE, Vernon MO, Hayes RA, et al. Impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital. Clin Infect Dis. 2003;36(11):1383-1390. [IIA]

• Wiener-Well Y, Galuty M, Rudensky B, Schlesinger Y, Attias D, Yinnon AM. Nursing and physician attire as possible source of nosocomial infections. Am J Infect Control. 2011;39(7): 555-559. [IIIA]

• Images on slides 36,38,42 accessed from Office.com Clip Art Royalty-free photos and illustrations.

References


http://office.com/

Surgical Attire: Are We Doing this Right?

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