The Dress Code for SPD Personnel and Scrub Laundering

By Nancy Chobin, RN, AAS, ACSP, CSPM

Q: My facility does not launder our scrubs, we must take them home. I have heard from other colleagues that their facilities provide and launder their scrubs.  What is the recommended dress code for SPD in the clean/sterile areas and should our scrubs be laundered by the facility?

A: I can understand your confusion. Unfortunately, not all facilities comply with the standards and therefore do not provide laundered scrubs to sterile processing staff. I do not really understand the non-compliance by facilities when one considers that SPD personnel are preparing sterile product for use on patients. Therefore every effort should be made to keep bioburden levels to a minimum.

Let’s look at what the standards say regarding home laundering of scrub attire.
According to AAMI ST-79 (Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities (2013):
4.5 Attire
4.5.1 General considerations
All personnel entering the decontamination, preparation, sterilization, and sterile storage areas should wear clean uniforms that are provided by and donned at the facility. Attire should be changed daily or more often as needed (i.e., when wet, grossly soiled, or visibly contaminated with blood or body fluids). Reusable uniforms that are visibly contaminated by blood or body fluids must be laundered in the laundry facility or area designated by the health care facility for the decontamination of reusable surgical textiles (see ANSI/AAMI ST65).

Rationale: Appropriate, clean attire minimizes the introduction of microorganisms and lint from personnel to items being processed and to the environment. Controlled laundering of garments contaminated by blood or body fluids reduces the risk of transferring pathogenic microorganisms from the healthcare facility to home and family.

According to the Association of periOperative Registered Nurses (AORN)'s Guideline for Surgical Attire (2016) there is significant evidence of the impact of home laundered scrubs.  “The benefit of wearing clean surgical attire may include a reduction in the number of microorganisms in the…environment and reduce the potential for healthcare workers to transport microorganisms from the facility…into the home or community.”

There are many inconsistencies that can result from home laundering (i.e., who uses cold water, hot water, different detergent types, etc.). These can all impact on the cleanliness of the scrub attire. At home, laundering cannot be standardized, which can negatively affect the control of microorganisms in processing areas. 

Regarding the general dress code for SPD:  The general dress code for all SPD staff members includes scrub suits provided by and donned at the healthcare facility (ANSI/AAMI ST79). Scrubs should be laundered by the facility, not taken home by employees (AORN, 2016; ANSI/AAMI ST79; AST, 2008). Furthermore, undergarments should not be visible beneath scrub attire (e.g., a long-sleeved shirt under a scrub shirt (AORN, 2016). In the preparation and packaging area, warm-up jackets are advised to prevent bacterial shedding from bare arms (AORN, 2016). Cloth head coverings or specialty warm-up jackets should be laundered by the facility after each use, like other scrub attire. Attire should be changed daily or more often as needed (i.e., when wet, grossly soiled, or visibly contaminated with blood or other body fluids). See Chapter 5 for the required dress code for decontamination activities.

Personnel do not need to wear a cover garment when leaving SPD; however, if the scrub attire becomes visibly soiled or wet, it must be changed. Scrubs should not be worn outside the building, even with a cover garment.

Shoes worn in the processing area should be clean, have non-skid soles, and be sturdy enough to prevent injury if an item drops on the foot. Open-toed shoes, including clog-type shoes with openings, are also not recommended because they will not protect the feet from injuries from dropped items.

Hair coverings are required in all areas of SPD. To contain hair and bacteria, hair coverings should completely cover the hair. All facial hair (except for eyebrows and eyelashes) must also be covered. According to AORN (2016), “OR personnel should NOT remove the surgical head covering when leaving the perioperative area. The purpose of the head covering is to contain hair and minimize microbial dispersal. When the head covering is removed, hair and microbes may be shed onto scrub attire.” SPD personnel should also comply with this guideline.

Visitors to SPD (e.g., sales representatives, service or repair personnel) should don clean scrub attire or jumpsuits, shoe covers, and hair coverings before entering the department.

Artificial nails should not be permitted (CDC, 2002) because of the danger of fungal contamination under the nail, which can contaminate packs, and because artificial nails can tear packs. Long finger nails can prevent thorough cleaning, puncture gloves or tear packs, or break off, leaving an undetected foreign object on a tray or instrument. Nails should be trimmed to one-quarter inch from the tip of the finger.

Jewelry (including earrings, necklaces, rings, bracelets, wristwatches) that cannot be contained within scrub attire should not be worn in the decontamination, preparation, sterilization or sterile storage areas. Jewelry should not be worn because it is not easily or routinely cleaned daily, can harbor microorganisms, can become dislodged and fall into processed items, and can cause holes in gloves or other barrier protection. Wristwatches and rings, in particular, can catch on equipment or instruments, injuring personnel or damaging the item or packaging. (ANSI/AAMI ST79). Furthermore, rings in particular, interfere with hand hygiene and there is evidence of a dramatic increase in was associated with a tenfold higher median skin organism count on the hands. For individuals with eye or nose piercings they should be completely covered with a surgical mask or head covering.  (AORN Guideline for Surgical Attire, 2016). For the Decontamination Area of the SPD: PPE FOR DECONTAMINATION PERSONNEL

Because of the potential for soaking of clothing, splashing, and the aerosolization of fluids and contaminants, and the consequent need to protect employees from exposure to both microorganisms and chemicals, appropriate PPE in the decontamination area includes the following items:
- Surgical scrub attire that is laundered by the facility and changed daily or whenever it becomes wet or soiled
- A long-sleeved, impervious (fluid-proof) or fluid-resistant gown or jumpsuit (not an apron)
- Eye and face protection including, but not limited to, a full face shield or goggles that prevent splashed fluids from entering from above, below, or the sides.
- A fluid-resistant mask. A fluid-resistant mask has been added as part of the required PPE for decontamination personnel because of the likelihood that, when personnel are performing typical activities, there is a real risk of exposure due to splash or splatter. This is in keeping with AAMI recommendations (ANSI/AAMI ST79). 
- A head covering that covers all head and facial hair (except for eyebrows and eyelashes).
Note: A head covering is not considered PPE, but, rather, part of the required dress code. However, it does prevent hair and fallout from hair from getting into trays and sets.
- Fluid-protective shoe covers with slip-proof bottoms.
- Heavy-duty, powder-free protective gloves with long fitted cuffs that prevent fluid from entering the glove during use. The style of glove should protect the wearer from contact with contaminated water. (For example, a glove that is too short can permit water to enter the glove when the wearer is moving his or her arms up and down.) A cut-resistant glove liner may be used beneath the decontamination glove as additional protection.

Staff members should be trained with competencies verified for donning and removal of PPE.

It is recommended that you start a discussion regarding attire with your supervisor as well as infection prevention and risk management departments. Ask them to refer to the aforementioned documents.

In summary, do not rely on what other facilities do; just because another facility does not provide laundered scrubs, does not mean this is acceptable practice. Your facility should always follow the standards and guidelines meant to protect you and your patients.

Nancy Chobin, RN, AAS, ACSP, CSPM, is a sterile processing consultant and educator.