Guideline for Surgical Attire

SURGICAL ATTIRE

GUIDELINE FOR SURGICAL ATTIRE

he Guideline for Surgical Attire was approved by the author until August 2018. The lead author requested addi- AORN Guidelines Advisory Board and became effec- tional articles that either did not fit the original search cri- T tive as of July 1, 2019. The recommendations in the teria or were discovered during the evidence appraisal pro- guideline are intended to be achievable and represent what cess. The lead author and the medical librarian also is believed to be an optimal level of practice. Policies and identified relevant guidelines from government agencies, procedures will reflect variations in practice settings and/or professional organizations, and standards-setting bodies. clinical situations that determine the degree to which the Search terms included armpit, axilla, backpack, bacterial guideline can be implemented. AORN recognizes the many load, badge, beard, bedding and linens, bouffant, briefcase, bunny diverse settings in which perioperative nurses practice; suit, cell phone, cellular phone, clean room, clothing, colonization, therefore, this guideline is adaptable to all areas where computers, computers (handheld/hand-held/portable), computers operative or other invasive procedures may be performed. and computerization, coveralls, cross infection, dandruff, dermatitis (exfoliative/seborrheic), desquamate, desquamation, disease transmission, disposable hats, dust, ear, environment (controlled), Purpose epithelial cells, epithelium, equipment contamination, eyelashes, facial hair, fanny pack, fleece, fomites, fungi, groin, hair, head This document provides guidance to perioperative team covering, hoods, infection control, infectious disease transmission, members for laundering surgical attire; wearing long iPad, iPhone, jewelry, jumpsuit, lanyard, laundering, laundering sleeves, cover apparel, head coverings, and shoes in semi- scrubs, laundering service (hospital), mobile communication restricted and restricted areas; and cleaning identifica- device, mobile phone, mold, nosocomial, pollen, protective cloth- tion badges, stethoscopes, and personal items such as ing, purse, scalp, scrubs, seborrhea, seborrheic dermatitis, shed, backpacks, briefcases, cell phones, and electronic tablets. shedding, skin, skullcaps, smartphone, squames, stethoscopes, sur- Surgical attire and personal protective equipment (PPE) gical attire, surgical cap, surgical wound infection, tablet com- are worn to provide a high level of cleanliness and hygiene puter, textiles, tie, uniforms, and washing machine. within the perioperative environment and to promote Included were research and non-research literature in patient and worker safety. Reducing the patient’s exposure English, complete publications, and publications with to microorganisms that are shed from the skin and hair of dates within the time restriction when available. Excluded perioperative personnel may reduce the patient’s risk for were non-peer-reviewed publications and older evidence surgical site infection (SSI). within the time restriction when more recent evidence This document does not address patient clothing or lin- was available. Editorials, news items, and other brief items ens used in health care facilities. The use of masks as PPE were excluded. Low-quality evidence was excluded when and the use of masks at the sterile field are outside the higher-quality evidence was available, and literature out- scope of this document; the reader should refer to the side the time restriction was excluded when literature AORN Guideline for Sterile Technique1 and the Guideline within the time restriction was available (Figure 1). for Transmission-Based Precautions2 for additional infor- Articles identified in the search were provided to the mation. The wearing of rings, bracelets, watches, nail polish, project team for evaluation. The team consisted of the lead artificial nails, or other nail enhancements is outside the author and one evidence appraiser. The lead author and the scope of this document; the reader should refer to the AORN evidence appraiser reviewed and critically appraised each Guideline for Hand Hygiene3 for additional information. article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. A second appraiser was con- sulted if there was a disagreement between the lead author Evidence Review and the primary evidence appraiser. The literature was independently evaluated and appraised according to the A medical librarian with a perioperative background strength and quality of the evidence. Each article was then conducted a systematic search of the databases Ovid assigned an appraisal score. The appraisal score is noted in MEDLINE®, Ovid Embase®, EBSCO CINAHL®, and the brackets after each reference as applicable. Cochrane Database of Systematic Reviews. The search was Each recommendation rating is based on a synthesis of limited to literature published in English from January 2014 the collective evidence, a benefit-harm assessment, and con- through February 2018. At the time of the initial search, sideration of resource use. The strength of the recommenda- weekly alerts were created on the topics included in that tion was determined using the AORN Evidence Rating Model search. Results from these alerts were provided to the lead and the quality and consistency of the evidence supporting a

Figure 1. Flow Diagram of Literature Search Results

Records identified by librarian through Additional records identified: 145 database search: 788

Ovid MEDLINE and EMBASE: 457 CINAHL: 316 Cochrane: 15

Records including duplicates: 933 Identification

Records after 30 duplicates removed: 903 Records excluded by librarian: 578

Records screened by author: 325 Records excluded by author: 79 Screening

Full-text sources excluded: 146

Out of scope: 90 Full-text sources requested by author: 246 Duplicate: 4 Editorial: 16 Eligibility Lower quality: 12 No guidance: 23 Unable to obtain full text: 1

Full-text sources cited in guideline: 100 Included

Adapted from: Moher D, Liberati A, Tetzlaff J, Atman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(6):e1000097.

recommendation. The recommendation strength rating is 1. Laundering noted in brackets after each recommendation.

Note: The evidence summary table is available at http://www. 1.1 Wear clean surgical attire when entering the semi- aorn.org/evidencetables/. restricted and restricted areas. [Recommendation] Wearing clean surgical attire may protect Editor’s note: MEDLINE is a registered trademark of the US patients from exposure to microorganisms that National Library of Medicine’s Medical Literature Analysis and could contribute to an SSI. Retrieval System, Bethesda, MD. Embase is a registered trademark of Elsevier B.V., Amsterdam, The Netherlands. CINAHL, Cumula- 1.2 After each daily use, launder scrub attire at tive Index to Nursing and Allied Health Literature, is a registered • a health care–accredited laundry facility, trademark of EBSCO Industries, Birmingham, AL. iPad and iPhone • the health care organization according to state are registered trademarks of Apple, Inc; Cupertino, CA. regulatory requirements, or

4 SURGICAL ATTIRE

• the health care organization according to G bronchialis. The authors concluded that the home Centers for Disease Control and Prevention washing machine was the likely bacterial reservoir. recommendations for laundering4 in the Home laundering may not reliably kill all patho- absence of state requirements. gens, and the pathogens may survive in the form of [Recommendation] biofi lm within the washing machine. Biofi lms have Wearing attire that is laundered at a health been implicated in malodor emitting from washing care–accredited laundry facility or at the health machines. The authors recommended that hospital care organization in accordance with state regula- laundering of scrub attire be implemented as a tory requirements provides control of the launder- measure to reduce patients’ risk of developing an ing process and helps ensure that effective launder- SSI. Further research is needed to demonstrate a ing standards have been met. causal relationship between home laundering and Home laundering is not monitored for quality, human disease. consistency, or safety. Home washing machines In a nonexperimental study of OR surgical attire may not have the adjustable parameters or controls conducted as the result of an increase in multidrug- required to achieve the necessary thermal mea- resistant organisms and HAIs, Nordstrom et al17 sures (eg, water temperature); mechanical mea- took swatches from unwashed, hospital-laundered, sures (eg, agitation); or chemical measures (eg, home-laundered, new cloth, and disposable scrub capacity for additives to neutralize the alkalinity of attire and tested them for the presence of microor- the water, soap, or detergent) to reduce microbial ganisms. The researchers found that the home- levels in soiled scrub attire. laundered scrub attire had a signifi cantly higher Moderate-quality evidence demonstrates that total bacterial count than the facility-laundered scrubs become contaminated with bacteria during attire, and they found no signifi cant difference in the workday, including potentially pathogenic bacterial counts between hospital-laundered, organisms that can be transmitted to other people or unused, or disposable scrub attire. The researchers the environment.5-15 Several studies have found that concluded that although it is not known how con- microorganisms can survive the home laundering taminated scrub attire contributes to the spread of process due to low water temperature and house- HAIs, hospital administrators and infection preven- hold detergents and can be transferred to other gar- tionists need to consider the potential for transmis- ments.16-19 Biofilm may form in home washing sion of infection versus cost savings to the facility if machines, which can be transferred to other cloth- home laundering is allowed. The researchers ing and textiles washed in the same machine.18,20 advised that health care workers be made aware of After performing a systematic review, Goyal et the risks of home laundering and be provided with al15 concluded that provider attire is a potential instructions for best methods for home laundering source of pathogenic bacterial transmission in in order to reduce the risk of infection. health care settings. There is limited data to link Mitchell et al10 conducted a literature review on provider attire and health care–associated infec- the role of health care apparel and other textiles in tions (HAIs). This review gave some guidance on the transmission of pathogens and determined that strategies to reduce the spread of bacterial patho- laundering scrubs at home may not be safe. Due to gens, including multidrug-resistant organisms that child safety laws to prevent scalding and burns, have the potential to cause HAIs. The authors rec- typical home washing machine temperatures do ommended that facilities determine where scrubs not exceed 110° F (43° C) and cannot reach the rec- will be laundered and, when required, provide ommended water temperature of 160° F (71° C) laundering instructions for home laundering, such required to remove signifi cant quantities of micro- as to use hot water and bleach. organisms. However, the authors also discussed Wright et al21 reported three cases of postopera- that industrial post-laundering practices may tive Gordonia bronchialis sternal infections after cor- recontaminate attire. onary artery bypass grafting surgery. G bronchialis Some evidence supports home laundering was isolated from the scrub attire, axilla, hands, within specifi c parameters. Lakdawala et al22 con- and purse of a nurse anesthetist and was implicated ducted a nonexperimental investigation of the as the cause of the SSIs. Cultures taken from her effect of low-temperature washing cycles (140° F roommate, who was also a nurse, showed the same [60° C]) by assessing the amount of bioburden on microorganism. After notification of the culture health care workers’ uniforms before and after results, the nurse anesthetist discarded her front- laundering. The researchers concluded that a loading washing machine. During the next year, the washing cycle of 140° F (60° C) for 10 minutes was nurse anesthetist’s and her roommate’s scrub suffi cient to decontaminate hospital uniforms and attire, hands, nares, and scalps tested negative for decrease the bacterial load by at least a 7-log

5 SURGICAL ATTIRE

reduction. The uniforms could become recontami- protect personnel from exposure to potentially nated after laundering, but the organisms could be pathogenic microorganisms. easily removed by ironing. Patel et al23 conducted a study to determine the 1.5.1 Scrub attire contaminated with visible effectiveness of home laundering in removing blood or body fluids must remain at the Staphylococcus aureus from scrub attire. The health care facility for laundering.26 [Regula- researchers cut hospital-laundered scrub attire into tory Requirement] squares, inoculated them with S aureus, and washed them at a typical household laundry temperature of 1.5.2 Contaminated scrub attire must be bagged or 104° F (40° C) and a higher temperature of 140° F containerized at the location where it was (60° C). The researchers concluded that the lower used and not be rinsed or sorted.26 [Regula- temperature did not remove S aureus; however, add- tory Requirement] ing sequential tumble drying or ironing reduced the number of bacteria to an undetectable level. Wash- Rinsing or sorting contaminated reusable attire ing at 140° F (60° C) produced a greater reduction in may expose the health care worker to blood, body total viable organisms compared with washing at ﬂ uids, or other potentially infectious materials. 104° F (40° C). The researchers concluded that scrub attire can be safely washed at 104° F (40° C) if tum- 1.6 Remove surgical attire before leaving the health ble dried for 30 minutes or ironed. care facility. [Recommendation] Al-Benna24 conducted a literature review to The benefits of removing surgical attire before explore home laundering of scrub attire and found leaving the facility outweigh the harms. Moderate- there was little scientific evidence that facility quality evidence supports changing out of surgical laundering was better than home laundering. attire into street clothes when leaving the building to reduce the potential for health care workers to trans- 1.3 Prevent contamination of laundered surgical port pathogenic microorganisms from the facility or attire during transport to the health care facility.25 health care organization into the home or community. [Recommendation] In a systematic review, Goyal et al15 concluded Preventing clean surgical attire from contamina- that provider attire is a potential source of patho- tion during transport from the laundry facility to the genic bacterial transmission in health care settings. health care facility helps prevent physical damage to There is limited data to link provider attire and the surgical attire and minimizes the potential for HAIs. The authors recommended that providers contamination from the external environment.25 wear clean scrub clothes when exiting and return- 1.3.1 Transport laundered surgical attire in ing to the facility. enclosed carts or containers and in vehicles Sanon and Watkins12 conducted a study to that are cleaned and disinfected regularly.25 investigate the pathogens that nurses potentially [Recommendation] take into a public setting outside the work envi- Carts, containers, and vehicles can be a ronment. The 10 nurses who participated in the source of contamination. study were given sterilized scrub attire to wear prior to the beginning of their shift, and the scrubs 1.4 Store laundered surgical attire in enclosed carts, were collected at the end of the shift. Microbial cabinets, or dispensing machines that are cleaned assessment of the scrubs showed that the average and disinfected regularly.25 [Recommendation] bacteria colony growth per square inch was 1,246 Storing laundered surgical attire in clean for the day shift and 5,795 for the night shift. After enclosed carts, cabinets, or dispensing machines 48 hours, methicillin-resistant Staphylococcus helps prevent contamination. Storing clean attire in aureus (MRSA) was present on four of the scrubs a facility locker with personal items from outside of worn during the day shift and three of the scrubs the facility may contaminate the clean scrub attire. worn during the night shift. Other bacteria present 1.5 Scrub attire that has been penetrated by blood, were Bacillus species, Micrococcus luteus, Staphylococ- body ﬂ uids, or other potentially infectious mate- cus aureus, Staphylococcus epidermidis, and Micrococ- rials must be removed immediately or as soon as cus roseus. In light of public health concerns about possible, and replaced with clean attire.26,27 [Regu- antibiotic resistance, the researchers recom- latory Requirement] mended that facilities consider implementing pol- Changing contaminated, soiled, or wet attire icy regarding the wearing of scrub attire outside of may reduce the potential for contamination and the work environment.

6 SURGICAL ATTIRE

1.7 No recommendation can be made regarding per- wide range of variability in study results and several sonal clothing worn under scrub attire. [No studies were performed in the laboratory setting. Recommendation] Six studies support its use as a means to decrease No evidence was found to evaluate the benefi ts bacterial contamination of scrubs,34-39 and four stud- and harms of wearing personal clothing under ies found no difference between standard scrubs scrub attire. and antimicrobial scrubs.40-43 Bearman et al39 conducted a randomized con- 1.7.1 Establish and implement a process for man- trolled trial (RCT) to determine the effectiveness of aging personal clothing that may be worn antimicrobial fabric for reducing the bacterial bur- under scrub attire, including den on the hands and scrub attire of health care • the type of fabrics (eg, nonlinting) that workers in an intensive care unit setting of an aca- may be worn under scrub attire, demic medical center. All study participants (N = 30) • the amount of fabric that may extend were randomly assigned to wear either traditional beyond the scrub attire (eg, a crew neck scrub attire or scrub attire made of antimicrobial collar under V-neck scrub attire), fabric during a clinical shift for a 4-week period. • laundering frequency (eg, daily), and Each health care worker underwent unannounced • laundering method (eg, facility launder- weekly garment and hand cultures. Cultures taken at ing, home laundering). the beginning and end of the shifts included gar- [Conditional Recommendation] ment cultures taken from the abdominal and leg pockets of the scrub attire. The researchers did not 1.7.2 Personal clothing contaminated with blood, specify the length of the clinical shifts. The antimi- body fluids, or other potentially infectious crobial scrubs were associated with a 4 to 7 mean log materials must remain at the health care facil- reduction in MRSA but not in vancomycin-resistant ity for laundering.26 [Regulatory Requirement] Enterococcus or gram-negative rod bacteria. Boutin and colleagues40 conducted a randomized 2. Fabric crossover trial to determine bacterial contamination of antimicrobial scrubs (chitosan/DMDM hydantoin) at the end of a typical 12-hour hospital shift. Stan- 2.1 Select fabrics for scrub attire that are tightly dard untreated scrubs served as the control. A total woven and low linting. [Recommendation] of 110 health care workers participated in the study, Moderate-quality evidence supports wearing and 720 samples were taken. Samples were taken at 4 tightly woven scrub attire. One quasi-experimental28 and 12 hours. The researchers concluded that there and four nonexperimental29-32 studies compared air- was no difference in bacterial contamination borne bacterial contamination levels when perioper- between the antimicrobial scrubs and untreated ative team members wore various types of scrub scrubs and more research is needed before facilities attire. The results of four of the studies indicated invest in antimicrobial scrubs. that tightly woven scrub attire was superior to other Anderson et al43 conducted a three-arm RCT to types of scrub attire in decreasing bacterial contami- test the effi cacy of antimicrobial impregnated scrubs nation of the air.28-31 Tammelin et al28 defi ned conven- compared to standard scrubs. Two antimicrobial tional scrub attire as 50% cotton/50% polyester scrub types were compared with standard cotton/ woven with 270 × 230 threads/10 cm and defined polyester scrubs. Forty nurses were enrolled in the tightly woven scrub attire as 50% cotton/50% polyes- study, and each completed three shifts in the scrub ter woven with 560 × 395 threads/10 cm. However, type that they were randomly assigned to wear. The there was no common defi nition of “tightly woven researchers found that the antimicrobial fabric was fabric” used in the collective evidence. not effective in reducing microbial contamination of Wearing scrub attire that is low linting may help the scrubs; however, the environment was an impor- prevent lint particles from being disseminated into the tant source of contamination of the scrubs. environment where bacteria may attach to the lint Further research is needed to determine the and settle in surgical sites and wounds and increase potential harms to the wearer of wearing surgical the potential for postoperative patient complications.33 attire made from antimicrobial fabric.

2.2 No recommendation can be made for wearing sur- 2.2.1 Follow the health care organization’s pro- gical attire made of antimicrobial fabric. [No cess for the pre-purchase evaluation of Recommendation] products when considering the purchase of Although the evidence regarding the use of anti- antimicrobial surgical attire. [Conditional microbial scrub attire is of high quality, there is a Recommendation]

7 SURGICAL ATTIRE

3. Long Sleeves In an independent cost analysis, Elmously et al46 described implementation of disposable long-sleeve jackets at two facilities in the same hospital system. 3.1 Arms may be covered during performance of pre- The added cost of implementing use of disposable operative patient skin antisepsis. [Conditional jackets was $1,128,078 annually. Recommendation] Although the benefi ts of wearing long sleeves 4. Cover Apparel during performance of preoperative patient skin antisepsis are likely to exceed the harms, further research is needed to confirm the risk-benefit 4.1 If worn, cover apparel (eg, lab coats) should be assessment and the effect on SSI outcomes. clean. [Recommendation] Markel at al44 conducted an experimental study Moderate-quality evidence shows that lab coats to compare air contamination during intraopera- worn as cover apparel can be contaminated with tive patient skin prep with and without arm cover- large numbers of pathogenic microorganisms.47-53 age of the person performing the prep. A mock Researchers have found that cover apparel is not patient skin prep was performed in three hospitals always discarded daily after use or laundered on a with a total of 12 experiments, six with bare arms frequent basis.47,48 and six with arms covered. The researchers used In a systematic review, Haun et al52 examined particle counters to measure airborne particulate bacterial contamination of health care personnel contamination. Active and passive microbial assess- attire and other devices. The researchers found 72 ment was measured using air samplers and settle studies that assessed contamination of a variety of plate analysis. In one operating room (OR), there items including white coats. Pathogens recovered was a decrease in 5.0 μm-sized particles when the from these items included Staphylococcus aureus, arms were covered. In the other two ORs, there was gram-negative rods, and Enterococcus. a decrease in total microbes when the arms were In another systematic review, Goyal et al15 con- covered. Wearing long sleeves specifi cally appeared cluded that provider attire is a potential source of to decrease the amount of Micrococcus in the envi- pathogenic bacterial transmission in health care ronment. The researchers recommended wearing settings. There is limited data to link provider attire with long sleeves when performing the intra- attire and HAIs. The authors recommended increas- operative patient skin prep. ing the frequency of laundering of white coats to at Contamination of the prep by loose-fitting least weekly and when visibly soiled; providing sleeves is a potential harm of wearing long sleeves multiple white coats to allow for laundering; and during preoperative patient skin antisepsis. This providing guidance for laundering at home when risk may be reduced by wearing a tight-fitting required, including the use of hot water, bleach, sleeve, avoiding reaching over the prep area, or and heated drying. wearing a sterile sleeve, which may reduce the In a nonexperimental study, Munoz-Price et al48 potential for introducing pathogens to the prep investigated the laundering practices of 160 health area. Research is needed to evaluate this potential care providers related to scrub attire and lab coats. harm and risk-reduction interventions. Overall, lab coats were washed every 12.4 days and scrub attire every 1.7 days. Ninety percent of 3.2 No recommendation can be made for wearing respondents laundered their lab coats only once long sleeves in the semi-restricted and restricted per month, and four people washed their lab coats areas other than during performance of preoper- only once every 90 days to 12 months. Water tem- ative patient skin antisepsis. [No Recommendation] perature used by health care providers to launder No evidence was found to evaluate the benefi ts their lab coats included cold (11%), warm (21%), and harms of wearing long sleeves in the semi- and hot (52%); 11% did not know the temperature restricted and restricted areas during any activities used; and 6% dry-cleaned their lab coats. Ninety other than preoperative patient skin antisepsis. percent of respondents acknowledged that their lab In an organizational report, Chow et al45 adopted coats were potentially contaminated with hospital a policy requiring all personnel to wear cover jackets pathogens. The researchers recommended that lab in perioperative areas. They compared SSI data from coats be laundered regularly (ie, at least once or before and after implementation and did not fi nd twice per week) and whenever dirty or soiled with any statistically signifi cant differences in SSI out- body fluids. The researchers also recommended comes. The authors noted that laundry costs that the lab coats be laundered in hot water with increased approximately $1,000 per month. bleach to reduce or eliminate potential pathogens.

8 SURGICAL ATTIRE

In a nonexperimental study of contamination beards and by women. The results of the study levels of health care practitioners’ cover apparel, showed that there was signifi cantly more bacterial Treakle et al47 found that cover apparel in inpa- shedding by bearded men than by clean-shaven tient and outpatient areas, intensive care units, men or by women even when a mask was worn. The administrative areas, and the OR was contami- researchers suggested that beards may act as a res- nated with Staphylococcus aureus, including MRSA. ervoir for bacteria and dead organic material. Two-thirds of the health care practitioners per- Wakeam et al69 compared facial bacterial coloni- ceived their cover apparel to be dirty because it zation rates among 408 male health care workers had not been washed in more than 1 week. Nota- with and without facial hair. The results of this bly, health care personnel with contaminated study demonstrated that male hospital workers cover apparel were more likely to have home with facial hair did not harbor more potentially con- laundered their cover apparel. cerning bacteria than clean shaven workers. Clean shaven workers were signifi cantly more likely to be 5. Head Coverings colonized with Staphylococcus aureus, including MRSA. Both groups shed bacteria at high rates. The researchers suggested standard infection preven- 5.1 Cover the scalp and hair when entering the semi- tion practices be followed to prevent contamination restricted and restricted areas. [Recommendation] during the performance of sterile procedures. Wearing a head covering may contain hair and Parry et al67 conducted a study to determine bacteria that is shed by perioperative team mem- whether nonsterile surgical hoods reduce the risk bers, which may prevent contamination of the ster- of bacterial shedding by bearded men. Ten bearded ile field and reduce the patient’s risk for SSI.54-57 and 10 clean-shaven surgeons completed three sets Although there is a potential benefi t to the patient, of standardized facial motions, each lasting 90 sec- research has not demonstrated that covering the onds while unmasked, masked, and masked and hair affects the multifactorial outcome of SSI hooded. The addition of surgical hoods did not rates.55,58-60 Case studies have demonstrated, how- decrease the total number of bacteria as measured ever, that human-to-human transmission of bacte- in colony-forming units (CFU). The unmasked men ria shed from the scalp and hair of perioperative shed a signifi cantly higher number of CFU than the team members can occur and has been directly masked men. The researchers concluded that the attributed to SSI outbreaks.61-64 bearded surgeons did not appear to have an Hair and skin can harbor bacteria that may be increased likelihood of bacterial shedding com- dispersed into the perioperative environment. pared to the non-bearded surgeons while wearing Moderate-quality evidence suggests that hair is a surgical masks, and the addition of surgical hoods reservoir for bacteria.7,54,61,65,66 did not decrease the amount of shedding Mase et al66 conducted a laboratory study to determine whether staphylococci that were pres- 5.3 No recommendation can be made for the type of ent on the hair could be removed by shampooing. head covers worn in the semi-restricted and The results of the study showed that staphylococci restricted areas. [No Recommendation] become fi rmly attached to the human hair surface The evidence does not demonstrate any associa- and the edge of hair cuticles. Extensive treatment tion between the type of surgical head covering with neutral detergents did not remove the organ- material or extent of hair coverage and the out- ism, suggesting that conventional shampooing has come of SSI rates. little effect on removing staphylococci from hair. Markel et al70 compared disposable bouffant Moreover, these neutral detergents had little bacte- style caps and skull caps to newly home-laundered ricidal activity on staphylococci. These results sug- cloth hats to determine permeability, particle gest that hair falling into the sterile fi eld could be a transmission, and pore size. All three types of hats source of multidrug-resistant staphylococci in SSIs. were evaluated twice at two different institutions for a total of four 1-hour-long mock surgeries for 5.2 Cover a beard when entering the restricted each hat. All hat types underwent permeability and areas and while preparing and packaging items porosity testing. The researchers found that dispos- in the clean assembly section of the sterile pro- able bouffant hats were more permeable to bacteria cessing area. [Recommendation] compared to the disposable skull caps and cloth Several studies have demonstrated that beards caps. The researchers acknowledged that cloth hats can be a source of bacterial organisms.67-69 are not always laundered daily, and a dirty, In a nonexperimental study, McLure et al68 exam- unwashed cloth hat could possibly lead to airborne ined dispersal of bacteria by men with and without contamination and transmission of bacteria.

9 SURGICAL ATTIRE

Kothari et al59 conducted a nonexperimental research has not demonstrated any association study to compare SSI rates of patients whose between covering the ears and SSI rates. attending surgeon’s preferred cap style was either Katsuse et al71 conducted a nonexperimental bouffant or skullcap. The data for this study came study of the earlobes and fingers of 200 nurses from a previously published, prospective RCT on working at a university hospital to determine the impact of hair clipping on SSI. A total of 1,543 whether cross transmission could occur between patients were included in the trial, and the preva- bacteria-colonized pierced earring holes and fin- lence of diabetes and tobacco use were similar gers. Staphylococcus aureus was recovered from among both groups. Thirty-nine percent of the sur- the earlobes of 24 nurses (19%) with pierced ears geons preferred wearing bouffant caps and 61% (n = 128) and seven nurses (10%) without pierced preferred wearing skullcaps. Surgical site infections ears (n = 72). Of the nurses who were positive for occurred in 8% of patients whose surgeons pre- S aureus (n = 31), 15 also had S aureus on their fi n- ferred a bouffant cap and 5% of the patients whose gers, which included 12 from the pierced-ear group surgeons preferred a skullcap. When adjusting for and three from the unpierced-ear group. With the the type of surgery, there was no signifi cant differ- exception of one nurse, the susceptibility patterns ence in SSI rates for skullcaps compared to bouffant and genotypes of S aureus were identical for the ear- caps. A limitation of this study design is that it was ring hole and fingers. The researchers concluded a retrospective review of a previous clinical trial that pierced earlobes can be a source of HAIs due to and the head coverings of other team members cross contamination from earring holes to fi ngers. were not documented. The researchers concluded Covering ears may also prevent earrings worn that type of cap worn did not signifi cantly affect SSI by scrubbed team members from falling into the rates after accounting for surgical procedure type. sterile fi eld, which increases the patient’s risk for Haskins et al58 conducted a nonexperimental SSI and a retained item. study to investigate the incidence of postoperative However, covering the ears may have potential wound infections following ventral hernia repair harms such as impairing hearing and potentially and the type of surgical hat worn, using data from impeding team communication, interfering with the Americas Hernia Society Quality Collaborative use of a stethoscope, and hindering the fi t of pro- database. Surgeons were sent a survey asking them tective eyewear or loupes. what type of surgical hair covering they wear in the OR. The association of the type of hat worn, 5.5 Remove head coverings at the end of the shift or operative factors, and patient variables was com- when they are contaminated. [Recommendation] pared with 30-day wound infections using multi- variate logistic regression. A total of 68 surgeons 5.5.1 Reusable head coverings contaminated with responded, resulting in 6,210 cases analyzed. The blood, body fl uids, or other potentially infec- researchers concluded that the type of surgical hat tious materials must remain at the health worn was not associated with an increased risk of care facility for laundering.26 [Regulatory 30-day SSIs or surgical site occurrences requiring Requirement] procedural intervention. A limitation of this study design is that the survey may have introduced 5.5.2 Establish and implement a process for man- response bias. Furthermore, the survey did not cap- aging reusable head coverings, including ture the types of surgical hats worn by other team • the type of fabrics (eg, nonlinting) that members in the OR and may have overgeneralized may be worn, the type of surgical hat worn. • laundering frequency (eg, daily), and • laundering method (eg, facility launder- 5.3.1 An interdisciplinary team, including mem- ing, home laundering). bers of the surgical team and infection pre- [Conditional Recommendation] ventionists, may determine the type of head covers that will be worn at the health care 6. Shoes organization. [Conditional Recommendation]

5.4 No recommendation can be made for covering 6.1 Wear clean shoes when entering the semi- the ears in the semi-restricted and restricted restricted or restricted areas. [Recommendation] areas. [No Recommendation] In a systematic review, Rashid et al72 found that Moderate-quality evidence suggests that ears shoes have the ability to transfer infectious organisms are a potential reservoir for pathogens, although to the ﬂ oor and contribute to ﬂ oor contamination.

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In a nonexperimental study, Amirfeyz et al73 7. Identification Badges examined shoes worn outdoors and shoes worn only in the surgical suite (N = 120). The results of the study demonstrated that 98% of the outdoor shoes 7.1 Clean identification badges with a low-level were contaminated with coagulase-negative staphy- disinfectant when the badge becomes soiled lococci, coliform, and Bacillus species compared with with blood, body fluids, or other potentially 56% of the shoes worn only in the surgical suite. infectious materials. [Recommendation] Bacteria on the perioperative fl oor may contribute Moderate-quality evidence supports that identifi - up to 15% of CFU dispersed into the air by walking. cation badges may be contaminated with pathogens. The researchers concluded that shoes worn only in In a prospective cross-sectional study, Caldwell at the perioperative area may help to reduce contami- al78 cultured employee common access cards and nation of the perioperative environment. identifi cation badges in a burn unit. The overall contamination rate was 75%. There was an 86% bacterial 6.2 Wear protective footwear that meets the health contamination rate on the access cards and a 65% care organization’s safety requirements. bacterial contamination rate on the identifi cation [Recommendation] badges. When the badges and cards were cleaned The OSHA regulations for foot protection74 weekly, the contamination rate dropped to 50%, require the use of protective footwear that meets which indicated that even weekly cleaning appeared ASTM F2414 standards75 in areas where there is a to have an effect on the contamination rate. danger of foot injuries from falling or rolling 7.1.1 objects or objects piercing the sole. The employer is Determine the frequency for routine badge disinfection (eg, daily, weekly). [Conditional responsible for determining whether foot injury Recommendation] hazards exist and what, if any, protective footwear is required. The OSHA regulations mandate that 7.2 Clean lanyards with a low-level disinfectant employers perform a workplace hazard risk assess- when the lanyard becomes soiled with blood, ment and ensure that employees wear footwear body fluids, or other potentially infectious that provides protection from identifi ed potential materials. [Recommendation] hazards (eg, needlesticks, scalpel cuts, splashing Moderate-quality evidence supports that lan- from blood or other potentially infectious materi- yards may be contaminated with pathogens. als).74 The National Institute for Occupational Safety In a cross-sectional study, Kotsanas et al79 exam- and Health recommends wearing slip-resistant ined the pathogenic contamination of identifi cation 76 shoes for prevention of slips, trips, and falls. badges and lanyards and found that the median bac- 77 In a laboratory study, Barr and Siegel examined terial load was tenfold more for lanyards (3.1 CFU/ 15 different types of shoes and tested them with an cm2) than for identifi cation badges (0.3 CFU/cm2). apparatus that measured resistance to penetration by The microorganisms recovered from lanyards and scalpels. The materials of the shoes included leather, identification badges were methicillin-sensitive suede, rubber, and canvas. Sixty percent of the shoes Staphylococcus aureus, MRSA, Enterococcus species, sustained scalpel penetration through the shoe into a and Enterobacteriaceae. The researchers concluded simulated foot. Only six materials prevented com- that identifi cation badges should be clipped on and plete penetration. These materials included sneaker disinfected regularly and that lanyards should be suede, suede with inner mesh lining, leather with changed frequently or should not be worn. inner canvas lining, non-pliable leather, rubber with inner leather lining, and rubber. Wearing shoes made of these materials could potentially prevent harm to 8. Stethoscopes the perioperative team member. 8.1 Clean stethoscopes before each patient use 6.3 Fluid-resistant shoe covers or boots must be worn according to the manufacturer’s instructions for in instances when gross contamination can rea- use. [Recommendation] sonably be anticipated.74 [Regulatory Requirement] Moderate-quality evidence supports that hand hygiene and stethoscope cleaning by health care per- 6.4 Shoe covers worn as PPE must be removed imme- sonnel decreases the risk of transmitting pathogens diately after use. After removal, discard the shoe to patients and environmental surfaces.52,80-90 Stetho- covers and perform hand hygiene.74 [Regulatory scopes come in direct contact with patients’ skin and Requirement] could be a mechanism for transmission of pathogens

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from patient to patient, from patient to health care for use before these items are brought into the OR, worker, or from health care worker to patient. and perform hand hygiene. [Recommendation] In a systematic review, Haun et al52 examined bac- Moderate-quality evidence52,92-100 demonstrates terial contamination of health care personnel attire that cell phones, tablets, and other personal hand- and other personal devices. The review found 72 held devices are highly contaminated with micro- studies that assessed contamination of a variety of organisms, some potentially pathogenic. Research- items including stethoscopes. Pathogens recovered ers recommended regular cleaning of these devices from these items included Staphylococcus aureus, and implementing hand hygiene before and after MRSA, gram-negative rods, and Enterococcus species. use. Reducing the numbers of microorganisms In a comparative study, Denholm et al91 exam- present on the devices may protect patients from ined the microbial contamination levels of the stethoscopes of 155 physicians and medical stu- the risk of HAIs resulting from the transfer of dents and compared personal stethoscopes with microorganisms from the devices or hands of facility-owned stethoscopes. The researchers iso- health care workers to patients. lated signifi cantly more organisms from personal Datta et al92 conducted a nonexperimental study stethoscopes than from facility-owned stetho- to investigate the rate of bacterial contamination of scopes; however, there was no signifi cant relation- the mobile phones of health care workers employed ship between the frequency of stethoscope cleaning in a tertiary health care teaching hospital. Of the and the degree of contamination. The researchers 200 health care workers’ mobile phones sampled, concluded that even regular cleaning of stetho- 144 (72%) were contaminated with bacteria, and scopes may be insuffi cient to prevent colonization 18% of those bacteria were MRSA. The researchers with pathogenic organisms and that stethoscopes concluded that simple measures such as regular used for patients at high risk for HAIs should be cleaning of cell phones and other hand-held elec- restricted to single-patient use. tronic devices and improving hand hygiene may In a nonexperimental cross-sectional study, decrease patients’ risk of acquiring HAIs from Campos-Murguía et al89 examined the number of pathogens carried on personal mobile devices. potentially pathogenic organisms present on stethoscopes by analyzing 112 stethoscopes from 12 hospi- 9.3 No recommendation can be made for whether a tal departments. Forty-eight stethoscopes (43%) had microorganisms that were potentially pathogenic. necklace may be worn in the semi-restricted and The results of this study showed that stethoscopes restricted areas. [No Recommendation] could be significant contributors to MRSA infec- No evidence was found to evaluate the benefi ts and tions and that they should be routinely cleaned and harms of wearing a necklace in the semi-restricted disinfected before and after each patient use. and restricted areas. Wearing a necklace while scrubbed poses a risk that the necklace could fall into 9. Personal Items the sterile fi eld and result in a retained foreign body.

10. Visitor Attire 9.1 Establish a process to prevent contamination of the semi-restricted and restricted areas from personal items (eg, briefcases, backpacks). The 10.1 Visitors entering the semi-restricted or restricted process may include cleaning or containing the areas of the surgical suite (eg, law enforcement item or placing the item in a designated location. offi cers, parents, biomedical engineers) should don [Conditional Recommendation] either clean surgical attire or a single-use jumpsuit Items brought into the semi-restricted and (eg, coveralls, bunny suit) designed to completely restricted areas, such as briefcases, backpacks, and cover personal apparel. [Recommendation] other personal items, may be diffi cult to clean and The benefi ts of wearing clean attire in the semi- may harbor pathogens, dust, and bacteria. Cleaning restricted and restricted areas of the surgical suite these items may help to decrease the transmission of potentially pathogenic microorganisms from for non-emergent situations may outweigh the external surfaces to perioperative surfaces and harms. Donning clean scrub attire or single-use from perioperative surfaces to external surfaces. jumpsuits before entry into the semi-restricted and restricted areas may help to maintain a clean envi- 9.2 Clean cell phones, tablets, and other personal com- ronment and decrease the possibility of transfer- munication or hand-held electronic equipment ring microorganisms from external areas and per- according to the device manufacturer’s instructions sonal attire to perioperative surfaces and patients.

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Glossary 8. Gupta P, Bairagi N, Priyadarshini R, Singh A, Chauhan D, Gupta D. Bacterial contamination of nurses’ white coats after Clean: The absence of visible dust, soil, debris, or blood. ﬁ rst and second shift. Am J Infect Control. 2017;45(1):86-88. [IIC] Fomite: An inanimate object that, when contaminated 9. Gupta P, Bairagi N, Priyadarshini R, Singh A, Chauhan with a viable pathogen (eg, bacterium, virus), can transfer D, Gupta D. Bacterial contamination of nurses’ white coats the pathogen to a host. made from polyester and polyester cotton blend fabrics. J Hosp Health care–accredited laundry facility: An organi- Infect. 2016;94(1):92-94. [IIC] zation that processes health care linens and has successfully 10. Mitchell A, Spencer M, Edmiston Jr C, Edmiston CJ. Role passed an inspection of its facility, policies and procedures, of healthcare apparel and other healthcare textiles in the training programs, and relationships with customers. transmission of pathogens: a review of the literature. J Hosp Low-level disinfectant: An agent that destroys all Infect. 2015;90(4):285-292. [VA] vegetative bacteria, some fungi, and some viruses but not 11. Thom KA, Escobar D, Boutin MA, Zhan M, Harris AD, Johnson JK. Frequent contamination of nursing scrubs is all bacterial spores. associated with specific care activities. Am J Infect Control. Restricted area: Includes the OR and is accessible 2018;46(5):503-506. [IIA] only from a semi-restricted area. 12. Sanon MA, Watkins S. Nurses’ uniforms: how many Scrub attire: Nonsterile apparel designed for the peri- bacteria do they carry after one shift? J Public Health Epidemiol. operative practice setting that includes two-piece pant- 2012;4(10):311-315. [IIC] suits and scrub dresses. 13. Halliwell C. Nurses’ uniforms: off the radar. A review Semi-restricted area: Includes the peripheral sup- of guidelines and laundering practices. Healthc Infect. port areas of the surgical suite and has storage areas for 2012;17(1):18-24. [VA] sterile and clean supplies, work areas for storage and pro- 14. Perry C, Marshall R, Jones E. Bacterial contamination of cessing of instruments, and corridors leading to the uniforms. J Hosp Infect. 2001;48(3):238-241. [IIIB] restricted areas of the surgical suite. 15. Goyal S, Khot SC, Ramachandran V, Shah KP, Musher Surgical attire: Nonsterile apparel designated for the DM. Bacterial contamination of medical providers’ white coats perioperative practice setting that includes scrub attire and surgical scrubs: a systematic review. Am J Infect Control. (eg, two-piece pantsuits, scrub dresses), scrub jackets, and 2019. doi: 10.1016/j.ajic.2019.01.012. [IIIA] head coverings. 16. Munk S, Johansen C, Stahnke LH, Adler-Nissen J. 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Gattlen J, Amberg C, Zinn M, Mauclaire L. Bioﬁ lms isolated 4. Background G. Laundry and bedding. In: Guidelines for from washing machines from three continents and their toler- Environmental Infection Control in Health-Care Facilities (2003). ance to a standard detergent. Biofouling. 2010;26(8):873-882. [IIIB] Centers for Disease Control and Prevention. https://www. 21. Wright SN, Gerry JS, Busowski MT, et al. Gordonia bronchialis cdc.gov/infectioncontrol/guidelines/environmental/back- sternal wound infection in 3 patients following open heart sur- ground/laundry.html. Updated November 5, 2015. Accessed gery: intraoperative transmission from a healthcare worker. April 3, 2019. [IVA] Infect Control Hosp Epidemiol. 2012;33(12):1238-1241. [VA] 5. Abu Radwan M, Ahmad M. The microorganisms on 22. Lakdawala N, Pham J, Shah M, Holton J. Effectiveness of nurses’ and health care workers’ uniforms in the intensive low-temperature domestic laundry on the decontamination care units. 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Association for the Advancement of Medical Instrumentation; 40. Boutin MA, Thom KA, Zhan M, Johnson JK. A random- 2013. [IVC] ized crossover trial to decrease bacterial contamination on 26. 29 CFR 1910.1030: Bloodborne pathogens. Occupational hospital scrubs. Infect Control Hosp Epidemiol. 2014;35(11):1411- Safety and Health Administration. https://www.osha.gov/ 1413. [IA] pls/oshaweb/owadisp.show_document?p_id=10051&p_ 41. Burden M, Keniston A, Frank MG, et al. Bacterial con- table=STANDARDS. Accessed April 3, 2019. tamination of healthcare workers’ uniforms: a random- 27. 29 CFR 1910.132: General requirements. Occupational ized controlled trial of antimicrobial scrubs. J Hosp Med. Safety and Health Administration. https://www.osha.gov/ 2013;8(7):380-385. [IA] laws-regs/regulations/standardnumber/1910/1910.132. 42. Condo C, Messi P, Anacarso I, et al. Antimicrobial activ- Accessed April 3, 2019. ity of silver doped fabrics for the production of hospital uni- 28. Tammelin A, Domicel P, Hambraeus A, Stahle E. Dis- forms. New Microbiol. 2015;38(4):551-558. [IIA] persal of methicillin-resistant Staphylococcus epidermidis by 43. Anderson DJ, Addison R, Lokhnygina Y, et al. The Antimi- staff in an operating suite for thoracic and cardiovascular crobial Scrub Contamination and Transmission (ASCOT) trial: a surgery: relation to skin carriage and clothing. J Hosp Infect. three-arm, blinded, randomized controlled trial with crossover 2000;44(2):119-126. [IIC] design to determine the effi cacy of antimicrobial-impregnated 29. Tammelin A, Hambraeus A, Stahle E. Source and route of scrubs in preventing healthcare provider contamination. Infect methicillin-resistant Staphylococcus epidermidis transmitted to Control Hosp Epidemiol. 2017;38(10):1147-1154. [IA] the surgical wound during cardio-thoracic surgery. Possibility 44. 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Summers MM, Lynch PF, Black T. Hair as a reservoir of of antimicrobial scrubs to reduce methicillin-resistant Staphy- staphylococci. J Clin Pathol. 1965;18:13-15. [IIIB] lococcus aureus burden on healthcare worker apparel. Infect 55. Spruce L. Surgical head coverings: a literature review. Control Hosp Epidemiol. 2012;33(3):268-275. [IA] AORN J. 2017;106(4):306-316. [VA]

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56. Boyce JM. Evidence in support of covering the hair of OR fi ngers in nurses is a potential source of health care-associated personnel. AORN J. 2014;99(1):4-8. [VA] infections. Am J Infect Control. 2019;47(1):78-81. [IIIB] 57. Berrios-Torres SI, Umscheid CA, Bratzler DW, et al; 72. Rashid T, Vonville H, Hasan I, Garey KW. Mechanisms Healthcare Infection Control Practices Advisory Commit- for fl oor surfaces or environmental ground contamination to tee. Centers for Disease Control and Prevention guideline for the cause human infection: a systematic review. Epidemiol Infect. prevention of surgical site infection, 2017 (Supplement). https:// 2017;145(1):347-357. [IIIA] jamanetwork.com/journals/jamasurgery/fullarticle/2623725. 73. Amirfeyz R, Tasker A, Ali S, Bowker K, Blom A. Theatre Accessed April 4, 2019. [IVA] shoes—a link in the common pathway of postoperative wound 58. Haskins IN, Prabhu AS, Krpata DM, et al. Is there an infection? Ann R Coll Surg Engl. 2007;89(6):605-608. [IIB] association between surgeon hat type and 30-day wound 74. 29 CFR 1910.136. Personal protective equipment: foot pro- events following ventral hernia repair? Hernia. 2017;21(4):495- tection. Occupational Safety and Health Administration. https:// 503. [IIIC] www.osha.gov/pls/oshaweb/owadisp.show_document?p_ 59. Kothari SN, Anderson MJ, Borgert AJ, Kallies KJ, Kowal- table=standards&p_id=9786. Accessed April 3, 2019. ski TJ. Bouffant vs skull cap and impact on surgical site infec- 75. ASTM F2412-18a. Standard Test Methods for Foot Protection. tion: does operating room headwear really matter? J Am Coll West Conshohocken, PA: ASTM International; 2018. [IVC] Surg. 2018;227(2):198-202. [IIIA] 76. Bell J, Collins JW, Dalsey E, Sublet V. Slip, Trip, and Fall 60. Rios-Diaz AJ, Chevrollier G, Witmer H, et al. The art and Prevention for Healthcare Workers (DHHS [NIOSH] Publication science of surgery: do the data support the banning of surgical Number 2011-123). 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Pathogenic bacteria on dococcus (Gordona) bronchialis sternal-wound infections after identity badges and lanyards. Med J Aust. 2008;188(1):5-8. [IIIA] coronary-artery bypass surgery. N Engl J Med. 1991;324(2):104- 80. Fafl iora E, Bampalis VG, Lazarou N, et al. Bacterial con- 109. [VB] tamination of medical devices in a Greek emergency depart- 64. Schefl an M, Wixtrom RN. Over troubled water: an out- ment: impact of physicians’ cleaning habits. Am J Infect Control. break of infection due to a new species of Mycobacterium 2014;42(7):807-809. [IIIB] following implant-based breast surgery. Plast Reconstr Surg. 81. Rao DA, Aman A, Muhammad Mubeen S, Shah A. Bacte- 2016;137(1):97-105. [VA] rial contamination and stethoscope disinfection practices: 65. Dineen P, Drusin L. Epidemics of postoperative wound infections associated with hair carriers. Lancet. a cross-sectional survey of healthcare workers in Karachi, 1973;302(7839):1157-1159. [VA] Pakistan. Trop Doct. 2017;47(3):226-230. [IIIB] 82. 66. Mase K, Hasegawa T, Horii T, et al. Firm adherence of Wood MW, Lund RC, Stevenson KB. Bacterial contamina- Staphylococcus aureus and Staphylococcus epidermidis to human tion of stethoscopes with antimicrobial diaphragm covers. Am hair and effect of detergent treatment. Microbiol Immunol. J Infect Control. 2007;35(4):263-266. [IIIB] 2000;44(8):653-656. [IIC] 83. Bernard L, Kereveur A, Durand D, et al. Bacterial con- 67. Parry JA, Karau MJ, Aho JM, Taunton M, Patel R. To tamination of hospital physicians’ stethoscopes. Infect Control beard or not to beard? Bacterial shedding among surgeons. Hosp Epidemiol. 1999;20(9):626-628. [IIIB] Orthopedics. 2016;39(2):e290-e294. [IIA] 84. Uneke CJ, Ogbonna A, Oyibo PG, Onu CM. Bacterial con- 68. McLure HA, Mannam M, Talboys CA, Azadian BS, Yentis tamination of stethoscopes used by health workers: public health SM. The effect of facial hair and sex on the dispersal of bacteria implications. J Infection Dev Ctries. 2010;4(7):436-441. [IIIA] below a masked subject. Anaesthesia. 2000;55(2):173-176. [IIC] 85. Russell A, Secrest J, Schreeder C. Stethoscopes as a 69. Wakeam E, Hernandez RA, Rivera Morales D, Finlayson source of hospital-acquired methicillin-resistant Staphylococ- SRG, Klompas M, Zinner MJ. Bacterial ecology of hospital cus aureus. J Perianesth Nurs. 2012;27(2):82-87. [IIA] workers’ facial hair: a cross-sectional study. J Hosp Infect. 86. Mehta AK, Halvosa JS, Gould CV, Steinberg JP. Effi cacy of 2014;87(1):63-67. [IIIA] alcohol-based hand rubs in the disinfection of stethoscopes. 70. Markel TA, Gormley T, Greeley D, et al. Hats off: a study of Infect Control Hosp Epidemiol. 2010;31(8):870-872. [IIIB] different operating room headgear assessed by environmental 87. Uneke CJ, Ogbonna A, Oyibo PG, Ekuma U. Bacteriologi- quality indicators. J Am Coll Surg. 2017;225(5):573-581. [IIC] cal assessment of stethoscopes used by medical students in 71. Kanayama Katsuse A, Takishima M, Nagano M, et al. 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88. Bhatta DR, Gokhale S, Ansari MT, et al. Stethoscopes: a Evidence Appraisers: Lisa Spruce1; Janice Neil3, PhD, CNE, possible mode for transmission of nosocomial pathogens. J RN, Associate Professor, East Carolina College of Nursing, Clin Diagn Res. 2012;5(6):1173-1176. [IIIB] Greenville, North Carolina; and Amber Wood2 89. Campos-Murguía A, León-Lara X, Muñoz JM, Macías AE, Álvarez JA. Stethoscopes as potential intrahospital carriers of Guidelines Advisory Board Members: pathogenic microorganisms. Am J Infect Control. 2014;42(1):82- • Donna A. Pritchard4, MA, BSN, RN, NE-BC, CNOR, Direc- 83. [IIIB] tor of Perioperative Services, Interfaith Medical Center, 90. Worster A, Tang PH, Srigley JA, Main CL. Examination of Brooklyn, New York staphylococcal stethoscope contamination in the emergency • Bernard C. Camins5, MD, MSc, Medical Director, Infec- department (pilot) study (EXSSCITED pilot study). Can J Emerg tion Prevention, Mount Sinai Health System, New York, Med. 2011;13(4):239-244. [IIIB] New York 91. Denholm JT, Levine A, Kerridge IH, Ashhurst-Smith C, • Heather A. Hohenberger6, MSN, RN, CIC, CNOR, CPHQ, Ferguson J, D’Este C. A microbiological survey of stethoscopes Administrative Director Surgical Services, IU Health in Australian teaching hospitals: potential for nosocomial Arnett Hospital, Lebanon, Indiana infection? Aust Infect Control. 2005;10(3):79. [IIIA] • Mary Fearon7, MSN, RN, CNOR, Service Line Director Neuro- 92. Datta P, Rani H, Chander J, Gupta V. Bacterial contami- science, Overlake Medical Center, Sammamish, Washington nation of mobile phones of health care workers. Indian J Med • Jennifer Butterfi eld8, MBA, RN, CNOR, CASC, Administra- Microbiol. 2009;27(3):279-281. [IB] tor, Lakes Surgery Center, West Bloomfi eld, Michigan 93. Byrns G, Foong YC, Green M, et al. Mobile phones as • Kate McGee9, BSN, RN, CNOR, Staff Nurse, Aurora West a potential vehicle of infection in a hospital setting. J Occup Allis Medical Center, East Troy, Wisconsin Environ Hyg. 2015;12(10):D232-D235. [IIIB] • Mary Anderson10, MS, RN, CNOR, OR RN–II, Parkland 94. Chang C, Chen S, Lu J, Chang C, Chang Y, Hsieh P. Nasal Health & Hospital System, Dallas, Texas colonization and bacterial contamination of mobile phones • Gerald McDonnell11, PhD, BSc, Senior Director, Sterility carried by medical staff in the operating room. Plos One. Assurance, DePuy Synthes, Johnson & Johnson Family 2017;12(5):e0175811. [IIIB] of Companies, Raritan, New Jersey 95. Khan A, Rao A, Reyes-Sacin C, et al. Use of portable elec- • Judith L. Goldberg12, DBA, MSN, RN, CNOR, CSSM, CHL, tronic devices in a hospital setting and their potential for bacte- CRCST, Director Nursing Excellence & Professional rial colonization. Am J Infect Control. 2015;43(3):286-288. [IIIB] Development, Yale New Haven Health, Lawrence + 96. Kirkby S, Biggs C. Cell phones in the neonatal intensive Memorial Hospital, New London, Connecticut care unit: How to eliminate unwanted germs. Adv Neonatal • Brenda G. Larkin13, MS, ACNS-BC, CNS, CNOR, Clinical Care. 2016;16(6):404-409. [VA] Nurse Specialist, Aurora Lakeland Medical Center, Lake 97. Lee YJ, Yoo CG, Lee CT, et al. Contamination rates Geneva, Wisconsin between smart cell phones and non-smart cell phones of • Jay Bowers14, BSN, RN, CNOR, Clinical Coordinator for healthcare workers. J Hosp Med. 2013;8(3):144-147. [IIIB] Trauma, General Surgery, Bariatric, Pediatric and Surgical 98. Martínez-Gonzáles NE, Solorzano-Ibarra F, Cabrera-Díaz Oncology, West Virginia University Hospitals, Morgantown E, et al. Microbial contamination on cell phones used by under- • Elizabeth (Lizz) Pincus15, MSN, RN, CNS-CP, CNOR, Clinical graduate students. Can J Infect Control. 2017;32(4):211-216. [IIIB] Nurse Specialist, St Francis Hospital, Roslyn, New York 99. Murgier J, Coste JF, Cavaignac E, et al. Microbial fl ora on cell-phones in an orthopedic surgery room before and after Guidelines Advisory Board Liaisons: decontamination. Orthop Traumatol Surg Res. 2016;102(8):1093- • Doug Schuerer16, MD, FACS, FCCM, Professor of Surgery, 1096. [IIIB] Trauma Director, Washington University School of 100. Shakir IA, Patel NH, Chamberland RR, Kaar SG. Inves- Medicine, St Louis, Missouri tigation of cell phones as a potential source of bacterial • Cassie Dietrich17, MD, Anesthesiologist, Anesthesia contamination in the operating room. J Bone Joint Surg (Am). Associates of Kansas City, Overland Park, Kansas 2015;97(3):225-231. [IIB] • Leslie Jeter18, MSNA, RN, CRNA, Staff CRNA, Ambulatory Anesthesia of Atlanta, Georgia • Jennifer Hanrahan19, DO, Medical Director of Infection Guideline Development Group Prevention, Metrohealth Medical Center, Cleveland, Ohio • Susan Ruwe20, MSN, RN, CPHQ, CIC, Senior Infection Pre- Lead Author: Lisa Spruce1, DNP, RN, CNS-CP, CNOR, ACNS, ventionist, Carle Foundation Hospital, Argenta, Illinois ACNP, FAAN, Director of Evidence-Based Perioperative Prac- • Susan G. Klacik21, BS, CRCST, FCS, Clinical Educator, tice, AORN, Denver, Colorado International Association of Healthcare Central Service Methodologist: Amber Wood2, MSN, RN, CNOR, CIC, FAPIC, Materiel Management (IAHCSMM), Chicago, Illinois Editor-in-Chief, Guidelines for Perioperative Practice, AORN, • Julie K. Moyle22, MSN, RN, Member Engagement Manager, Denver, Colorado Centura – Avista Adventist Hospital, Golden, Colorado

16 SURGICAL ATTIRE

External Review: Expert review comments were received closures, the Advisory Board concluded that none of the from individual members of the American Association of Nurse potential confl icts related to any content in this guideline. Anesthetists (AANA), American College of Surgeons (ACS), Association for Professionals in Infection Control and Epide- miology (APIC), American Society of Anesthesiologists (ASA), Publication History International Association of Healthcare Central Service Mate- riel Management (IAHCSMM), Practice Greenhealth, and the Originally published March 1975, AORN Journal, as AORN Society for Healthcare Epidemiology of America (SHEA). Their “Standards for proper OR wearing apparel.” responses were used to further refi ne and enhance this guide- Format revision March 1978, July 1982. Revised March 1984, March 1990. Published as proposed line; however, their responses do not imply endorsement. The recommended practices, August 1994. draft was also open for a 52-day public comment period. Revised November 1998; published December 1998. Reformatted July 2000. Financial Disclosure and Revised November 2004; published in Standards, Recom- Conflicts of Interest mended Practices, and Guidelines, 2005 edition. Reprinted February 2005, AORN Journal. This guideline was developed, edited, and approved by the Revised October 2010 for online publication in Periopera- AORN Guidelines Advisory Board without external funding tive Standards and Recommended Practices. being sought or obtained. The Guidelines Advisory Board was Reformatted September 2012 for publication in Periopera- financially supported entirely by AORN and was developed tive Standards and Recommended Practices, 2013 edition. without any involvement of industry. Revised September 2014 for online publication in Periop- Potential confl icts of interest for all Guidelines Advisory erative Standards and Recommended Practices. Board members were reviewed before the annual meeting and Minor editing revisions made in November 2014 for publi- each monthly conference call. Nineteen members of the cation in Guidelines for Perioperative Practice, 2015 edition. Guideline Development Group reported no potential confl ict Revised 2019 for online publication in Guidelines for Peri- of interest.1-5,7-10,12-18,20-22 Three members6,11,19 disclosed potential operative Practice. confl icts of interest. After review and discussion of these dis- Scheduled for review in 2024.