“Bad habits are hard to break when it comes to surgical attire, but the evidence linking improper attire to surgical site infection is stacked against you and your facility if you are not following safe practices,” says Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, AORN director of Evidence-Based Perioperative Practice. 

“Fortunately, this same evidence is also the tool you can use to convince team members (even surgeons) why they need to break bad habits, and convince hospital leadership to invest in safe surgical attire practices,” she acknowledges.

Spruce drills down four of the most common and most dangerous surgical attire sins and identifies: what the sin looks like in common practice, the correct practice, why the correct practice is safer, and examples of evidence that perioperative nurses can use to encourage the correct practice.

Sin #1: You don’t cover your hair completely
You wear a skullcap or other headwear that allows hair to be exposed, including hair on the back of your neck.

What you should do: Wear a clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck, according to Recommendation III in the Guideline for Surgical Attire.

Why it’s safer: Hair can harbor potentially pathogenic organisms such as methicillin-resistant Staphylococcus aureus that becomes firmly attached to hair, even at the cuticles, and cannot be removed by washing. If not covered, these organisms can be dispersed into the environment.

Supporting evidence: Dineen and Drusin investigated two outbreaks of postoperative wound infections and found infections were directly related to personnel carrying Staphylococcus aureus in their hair.

Sin #2: You don’t cover your ears
You wear a skullcap that comes above your ears or you wear a bouffant cap tucked behind your ears.

What you should do: Wear a clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck, according to Recommendation III in the Guideline for Surgical Attire.

Why it’s safer: Ears harbor bacteria that can become dislodged and released into the surgical environment.

Supporting evidence: Owers et al conducted a non-experimental study in which OR team members had their foreheads, eyebrows, and ears cultured. The researchers found significantly more bacteria were isolated from the ears than from the foreheads and eyebrows of the surgical team members.

Sin #3: You let your mask hang around your neck
After a case you pull the mask off your face but do not remove it, instead leaving it hanging around your neck.

What you should do: A fresh surgical mask should be donned before performing or assisting with each new procedure. The mask should be replaced and discarded whenever it becomes wet or soiled, or has been taken down, according to Recommendation I.h.3 in the Guideline for Surgical Attire. This is also an OSHA requirement.

Why it’s safer: The surgical mask serves as a filter that harbors bacteria collected from the nasopharyngeal airway. The contaminated mask may cross-contaminate the scrub attire top or long-sleeved jacket when worn hanging around the neck.

Supporting evidence: Surgical masks should be removed and discarded by handling only the mask ties. Hand hygiene should be performed after removal of masks.

Sin #4: You launder your scrubs at home
Your health care facility requires you to transport your worn surgical scrub attire from your practice setting to your home for laundering and back to wear at work.

What you should do: All individuals who enter semi-restricted and restricted areas should wear scrub attire that has been laundered at a health-care accredited laundry facility or disposable scrub attire provided by the facility and intended for use within the perioperative setting, according to Recommendation II in the Guideline for Surgical Attire.

Why it’s safer: Home laundering cannot be conducted with the same rigid standards and processes as a health-care accredited laundering facility. These processes include correct water temperature, detergent, drying, and transport. Home laundering also presents a risk of transmitting bacteria from the practice setting to the health care worker’s family and community.

Supporting evidence: Wright et al discussed three cases of postoperative Gordonia bronchialis sternal infections after coronary artery bypass grafting surgery that were linked to G. bronchialis isolated from the scrub attire, axilla, hands, and purse of a nurse anesthetist.

“Cost can be a concern when implementing safe surgical attire practices such as making the switch away from home laundering,” Spruce acknowledges. “However, when you consider the cost of a surgical site infection, including no reimbursement—it’s clear that making changes to optimize surgical attire and create a hygienic perioperative environment provides a safer setting for patients and health care workers.”

Additional Resources

Purchase AORN’s new Guideline for Surgical Attire.

Guideline Essentials for Surgical Attire are now available. Purchase the all-new tool designed to help nurses easily understand and quickly follow AORN’s evidence-based guidelines.  

for managers

Access these resources to help you implement the Guideline for Surgical Attire in your practice setting.