Scrubs as Streetwear

The scrubs-as-streetwear debate has been ongoing for more than a decade and no definitive resolution has been made. Should healthcare workers (HCWs) be allowed to wear their scrubs outside the hospital walls? Wear them home? Wash them at home? Wear them upon their return to the healthcare facility?

The debate is now morphing into the operating room (OR) realm. Some are considering the practice of wearing scrubs outside of the OR and returning for the next case an A-OK thing to do. Others argue that the OR is too risky of an environment for such things to be allowed and are vehemently against such practices. But what about those working with neonates, or on the bone marrow transplant ward, or in the burn unit ... one could argue those in intensive or critical care may be considered at increased risk for infection as they may be severely immunosuppressed from whatever is ailing them. So why would the practice be OK for the hospital at large, but not OK for the OR? Are the overall conditions really that different?

Another interesting facet to consider in this debate is the argument that no concrete studies have shown an increase in surgical site infections (SSIs) with the use of home-laundered scrubs or those that have been worn outside of the OR.

Bill Carroll, former executive director of the Healthcare Laundry Accreditation Council (HLAC), says healthcare professionals must be aware of the risks that exist wherever they may be working. “They become aware of the risks only if they have become educated to that level and it is instilled in them the concern and the precautions necessary to be used. Each area has its own characteristics and may require different levels of precautions than do some other areas,” he explains.

This whole scrubs/OR debate is one area in which Carroll says he becomes “biased, pigheaded, and opinionated.”

“I think the scrubs individuals wear in surgery should be covered by a protective barrier while they are in surgery doing their job, and if they are going to wear their scrubs, say to the cafeteria or the credit union or wherever outside the operating room area, they need to change their protective barrier, but have another protective coat on while they are out walking the halls of the hospital so that they do not inadvertently pick up airborne particles.”

He continues, “I don’t know that we have ever documented that someone has become infected because of the textiles we used in surgery, but that was always something that was a concern to me.”

Raymond B. Otero, PhD, an independent healthcare consultant, agrees that there are no well-controlled studies evaluating the scrub suit laundering/SSI risk factor, however, he offers a formula for deciphering the likelihood of such an occurrence: 
D x V ÷ R = SSI 
Dose of bacterial contamination (x) times the virulence (÷) divided by the resistance of the host patient (=) equals the risk of SSI.

“If they’re going to do it, there has to be a standard,” Otero offers. “It has to be written, and it has to be applied, and it has to be used. And the standard is, if they are going to wash them at home, don’t wear them to work. If they are going to take them home — of course if they are full of blood, OSHA says they can’t — but wash them, dry them properly, fold them, put them in a bag, and then carry them to work and put them on there.”

He says when HCWs stop for coffee or run other errands on their way to work that this is when uniforms are at an increased risk of contamination.

Ramona Conner, RN, MSN, CNOR, manager of standards and recommended practices with the Association of periOperative Registered Nurses (AORN) Center for Nursing Practice Health Policy and Research says AORN’s position remains the same. “We recommend that people do not do home laundering. We have not changed that. As a matter of fact, evidence seems to be growing that home laundering is not a good idea.”

Some such evidence could be the number of documented studies that insinuate the chance for detrimental occurrences exist.

A study conducted at Shriners Hospitals for Children at the University of Cincinnati College of Medicine in Cincinnati found that gramnegative bacteria¹, gram-positive bacteria², and fungi³ all are hitchhikers of fabrics and each can live for unbelievably long periods of time on various fabric materials.

Pure cotton clothing, cotton terry cloth towels, 60/40 blend of cotton and polyester (the material commonly used for scrubs), polyester used for privacy curtains, and polyethylene splash aprons all were found to be carriers of gram-positive microorganisms.² In fact, methicillin- resistant Staphylococcus aureus (MRSA) survived on polyester for seven weeks and on polyethylene for 12 weeks. More shocking is the fact that vancomycin-resistant enterococcus (VRE) survived for even longer periods.

Candida spp., Aspergillus spp., a Fusarium sp., a Mucor sp., and a Paecilomyces sp. all survived on hospital fabrics and plastics, although the viability was variable with most fungi surviving at least one day, but many living for weeks.³ As Otero concludes, “The word is not out there. Many people think that a problem exists, and many hospitals follow AORN’s recommendations, but the decision ultimately remains with the HCW.” 

References

1. Neely AN. A survey of gram-negative bacteria survival on hospital fabrics and plastics. J Burn Care Rehabil. 2000 Nov-Dec;21(6):523-7.

2. Neely AN, Maley MP. Survival of enterococci and staphylococci on hospital fabrics and plastic.

J Clin Microbiol. 2000 Feb;38(2):724-6.

3. Neely AN, Orloff MM. Survival of some medically important fungi on hospital fabrics and plastics. J Clin Microbiol. 2001 Sep;39(9):3360- 1. ART: Shutterstock image 1243680

Is It Safe To Wash At Home?

Some guidelines says “normal laundry cycles,” like those recommended by washer and detergent manufacturer’s, are fine.¹ Others say a 20-minute drying time is what will make it safe; and still others cite water temperature in the washing machine to be the decisive factor.

One study demonstrated that domestic washing machines reduce viable counts of Staphylococcus aureus to below detectable levels — even when using low temperature (40 degrees Celsius) cycles.² What’s interesting to note is the researchers also found the machine itself to be the source of environmental organisms — predominantly gram-negative flora. However, the organisms were destroyed by tumble drying or ironing; so the researchers concluded that “domestic laundering of uniforms is an acceptable alternative to hospital laundering if combined with tumble drying or ironing.”

The overall factors which contribute to a safe washing process are:

• Temperature 
• Soap and detergents 
• Bleach/chlorinating 
• Rinsing/changes of water 
• Thorough drying 

Perhaps the true decisive factor is the type of organism to eradicate from the load. One study cites 60 degree Celsius as the magic temperature to rid textiles of Trichophyton rubrum, Trichophyton mentagrophytes, Candida albicans and Scopulariopsis brevicaulis, “regardless of the textiles and detergents used.”³ However, in a study using Enterococcus faecium, Staphylococcus aureus, Mycobacterium terrae, Enterobacter aerogenes, and Pseudomonas aeruginosa for determining the antibacterial laundering effect; and Candida albicans for determining the antifungal laundering effect, it was found that E. faecium, S. aureus, E. aerogenes, and P. aeruginosa survived at 60 degrees Celsius, but no microorganisms were found at 75 degrees Celcius.

References

1. Guidelines for Laundry in Health Care Facilities. CDC/OhASIS. 1997.

2. Patel SN, Murray-Leonard J, Wilson AP. Laundering of hospital staff uniforms at home. J Hosp Infect. 2006 Jan;62(1):89-93. Epub 2005 Oct 7.

3. Ossowski B, Duchmann U. Hautarzt. Effect of domestic laundry processes on mycotic contamination of textiles. 1997 Jun;48(6):397-401.

4. Fijan S, et. al. Antimicrobial disinfection effect of a laundering procedure for hospital textiles against various indicator bacteria and fungi using different substrates for simulating human excrements. Diagn Microbiol Infect Dis. 2006 Oct 12.