Surgical Attire: Policy Development Resources

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According to the Surgical Site Infection Guidelines published in 2017 by the American College of Surgeons and Surgical Infection Society, the most common and costly type of health care–associated infections (HAIs) are surgical site infections (SSIs), accounting for 20% of all HAIs. SSIs occur in an estimated 2% to 5% of patients undergoing inpatient surgery and up to 25% of major surgical procedures.^1,2 Annual incidence of SSIs in the United States is between 160,000 and 300,000, costing from $3.5 billion to $10 billion annually. On average, an SSI increases a patient’s length of stay by 9.7 days, yet approximately half of all SSIs are preventable when evidence-based prevention strategies are implemented.¹

Figure: Timeline of Surgical Attire⁴

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Infection preventionists (IPs) are vital in supporting the perioperative team by sharing the most current, evidence-based surgical infection prevention strategies to help improve SSI prevention. The operating room (OR) is a challenging environment, with various surgical personnel and medical devices coming together to help improve patients’ lives. Covering surgical services as a novice or even a seasoned IP can be intimidating. In addition to the basic environment of care items, the OR has unique infection prevention challenges. Surgical attire, or OR scrubs (the special surgical clothing required for personnel within the OR suite), is intended to promote cleanliness and reduce microbial contamination in the surgical suite to prevent SSIs.

The human body is a significant source of bacterial contamination in the surgical environment. SSIs have been traced to bacteria from surgical personnel’s hair, scalp, and skin.³ However, maintaining a clean surgical space and reducing microbial contamination wasn’t always a consideration. Through the timeline of surgical attire (Figure), one can begin to see the development of a better understanding of infection and organism transmission through the changes in clothing.

The Evolution of Scrubs

Surgical attire was initially known as surgical greens because of their color, then were later referred to as scrubs because they’re worn in a scrubbed environment. In 1894, Dr Hunter Robber said, “It is safer and better that all should put on a complete change of costume rather than simply don a sterilized coat and pair of trousers over ordinary clothing.”⁴ He also suggested that the clothing be made white so they could easily be washed.

When electricity was discovered and electric lights were used in the OR instead of windows and skylights, the combination of bright lights and white attire led to significant glare. “There was a green ghosting effect when shifting gaze from bloody red innards to white backgrounds,” Hunter said.

In 1914, Harry Sherman, MD, FACS, believed that a color scheme might evolve from the red of blood and tissues. He recommended green, a color “less wearisome to the eyes, and [one that] minimized reflection.” He also said green “keeps the surgeon’s eye acute to red and pink.”⁴ Sky blue became popular for surgical apparel in the 1950s when color television began to be used for videotaping and closed-circuit teaching.⁴ Today, our surgical scrubs are primarily jade green or misty blue, depending on the vendor’s name given to the color.

Surgical Attire Policy Development

Surgical attire has come a long way, but it is—and will probably always be—a hot-button issue due to the variety of organizations and agencies providing input as well as the difficulty of creating and enforcing policies designed for patient and staff safety. The guidance and recommendations are plentiful, which is why it’s vital for IPs covering the OR and the perioperative team to know what the surgical attire policies are as well as the sources used to develop them. Some of the regulatory agencies and professional organizations that have provided recommendations, guidelines, or position statements include the following:

• Association of periOperative Registered Nurses (AORN)
• Association of Surgical Technologists
• American College of Surgeons
• American Society of Anesthesiologists
• Centers for Medicare & Medicaid Services (CMS)
• Occupational Health and Safety Administration
• CDC
• Association for Professionals in Infection Control and Epidemiology
  
  

To further complicate the surgical attire issue, some states have established their own surgical attire dress code requirements or have adopted a version of AORN or other guidelines. Your local health department may also have further information about state-specific surgical attire requirements, so be sure to contact them as you develop your surgical attire policy.⁵

If your health care facility participates in the CMS programs, you’ll need to follow their surgical attire requirements to be in compliance. They have their own Hospital Infection Control Survey Worksheet that includes a section on surgical procedures with specific surgical attire elements to be assessed by surveyors.6 You’ll need to follow these or risk getting cited. In some instances, they do differ from AORN. Some medical devices and equipment also include manufacturer instructions for use (MIFU) that require wearing specific surgical attire. Check those devices and equipment MIFUs carefully.

Ensure your health care facility’s surgical attire policy complies with the state and local agencies, MIFU, and CMS (if applicable). If none of these are relevant, then the health care facility’s chosen surgical attire, evidence-based guidelines, and consensus statements can be used to develop policies. If your health care facility does not have specific state or local surgical attire requirements, does not have MIFUs that mandate specific surgical attire, is not a CMS participant, and a Joint Commission standard does not explicitly require your facility, then you can choose which evidence-based guidelines or consensus statements to develop your surgical attire policies.⁵ Surveyors, like The Joint Commission, will survey your specific surgical attire policy. As you know, they don’t make the policy; they confirm that you are following your surgical attire policy.

ICT 2020 AORN surgical attire guidelines

Most facilities follow AORN’s surgical attire guidelines or incorporate parts of them into their facility-specific surgical attire policies. AORN recently updated the 2015 guidelines on surgical attire in 2019, published in 2020. IPs, including me, have struggled with issues that are addressed in these updated guidelines, including head coverings, arm coverings, beards, shoes, and scrubs outside the surgical suite. What’s not discussed in AORN’s 2020 surgical attire guidelines are patient clothing or linens used in the OR, masks as personal protective equipment, and the use of masks at the sterile field. If you want this information, refer to the AORN Guideline for Sterile Technique⁷ and the AORN Guideline for Transmission-Based Precautions.⁸ The AORN Guideline for Hand Hygiene⁹ addresses wearing rings, bracelets, watches, nail polish, artificial nails, and other nail treatments.

The rationale for AORN’s 2020 Guideline for Surgical Attire¹⁰ includes recommendations for selecting, wearing, and cleaning surgical attire. They are based on the highest-quality evidence available. Recommendations are rated as regulatory requirement, recommendation, conditional recommendation, or no recommendation. These categories are based on the level of evidence, an assessment of the benefits vs harms of implementing specific interventions, and consideration of resources required to implement the interventions¹⁰.

• Regulatory requirement: Perioperative team members must implement the recommendation.
• Recommendation: Perioperative team members should implement the recommendation unless there is a clear and compelling rationale for an alternative approach.
• Conditional recommendation: Perioperative team members may implement the intervention, although the degree of implementation may vary depending on the benefit-harm assessment for the specific setting.
• No recommendation: Perioperative team members will need to evaluate whether to implement the practice issue.⁷

AORN states that the guidelines’ recommendations are intended to be achievable and represent what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and clinical situations that determine the degree to which the guideline can be implemented. AORN recognizes the “many diverse settings in which perioperative nurses practice; therefore, this guideline is adaptable to all areas where operative or other invasive procedures may be performed.”⁷ AORN recognizes that one size does not fit all, and not every organization or professional specialty will use or agree with these guidelines. However, the document does provide evidence-based guidance on surgical attire that can serve as a credible resource to help health care facilities develop perioperative policies and procedures while also considering guidance from professional organizations, state and local agencies, MIFU, and CMS (if applicable).

Development of policies and procedures for surgical attire should be a team sport, ensuring input from all the disciplines (eg surgeons, anesthesia, nursing, infection prevention, environmental services, sterile processing, nurse educator) that contribute to providing quality patient care based on the most up-to-date, evidence-based best practices, with SSI prevention at top of mind.

References

1. APIC Implementation Guide: Infection Preventionist’s to the OR. Association for Professionals in Infection Control and Epidemiology. Accessed March 12, 2023. https://apic.org/Resource_/TinyMceFileManager/Implementation_Guides/APIC_ImplementationPreventionGuide_Web_FIN03.pdf
2. Owens CD, Stossel K. Surgical site infections: epidemiology, microbiology and prevention. J Hosp Infect. 2008;70(suppl 2):3-10. doi:10.1016/S0195-6701(08)60017-1
3. AST standards of practice for surgical attire, surgical scrub, hand hygiene and hand washing. Association of Surgical Technologists. Accessed March 12, 2023. https://www.ast.org/uploadedfiles/main_site/content/about_us/standard_surgical_attire_surgical_scrub.pdf
4. From formalwear and frocks to scrubs and gowns: a brief history of the evolution of operating room attire. American College of Surgeons.Accessed March 13, 2023.https://www.facs.org/media/0ypjk2ki/01_formalwear_and_frocks.pdf
5. Does Joint Commission require that organizations follow specific requirements for operating room dress/surgical attire? The Joint Commission. Updated on November 30, 2021. Accessed March 13, 2023. https://www.jointcommission.org/standards/standard-faqs/critical-access-hospital/leadership-ld/000002266/
6. Hospital infection control worksheet. Centers for Medicare & Medicaid Services. Accessed March 12, 2023. https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/SC15-12.02.FY%202015%20Hospital%20Infection%20Control%20Worksheet%20-%20Public.pdf
7. Guideline for surgical attire. Association of periOperative Registered Nurses. Updated July 1, 2019. Accessed March 13, 2023. https://pdihc.com/wp-content/uploads/2019/10/AORN-Guideline-for-Surgical-Attire.pdf
8. Kennedy, Lynne. (2013). Implementing AORN Recommended Practices for Sterile Technique. AORN journal. 98. 14-26. 10.1016/j.aorn.2013.05.009.
9. The guideline for transmission-based precautions - association of peri. Aorn.org. Accessed April 14, 2023. https://www.aorn.org/article/2019-10-09-Transmission-Based-Infection-Guideline
10. Periop today - 5 new hand hygiene practices to reduce infection - asso. Aorn.org. Accessed April 14, 2023. https://www.aorn.org/article/2022-10-10-New-Hand-Hygiene-Practices