Aorn Attire

s

RECOMMENDED PRACTICES
Implementing AORNRecommended Practicefor Surgical AttireMELANIE L. BRASWELL, DNP, RN, CNS, CNOR;LISA SPRUCE, DNP, RN, ACNS-BC, CNOR
www.aorn.org/CE

3.6

personnel.de periop-g surgical

ure appro-d wearing. The rec-

evidencers to helparios haved practices.011.10.017

el, home

ABSTRACT

Surgical attire is intended to protect both patients and perioperativeAORN published the “Recommended practices for surgical attire” to guierative RNs in establishing protocols for selecting, wearing, and launderinattire. Perioperative RNs should work with vendors and managers to enspriate surgical attire is available, model the correct practices for donning ansurgical attire, and teach team members about evidence-based practicesommendation that surgical attire not be home laundered is supported bythat perioperative nurses can share with their colleagues and managesupport appropriate practices. Hospital and ambulatory surgery center scenbeen included as examples of appropriate execution of these recommendeAORN J 95 (January 2012) 122-137. © AORN, Inc, 2012. doi: 10.1016/j.aorn.2

Key words: AORN recommended practices, surgical attire, cover apparlaundering.

endedmenORN

mended

urpose of

(RP) docu-

urgical at-

es, head cov-

ssories worn

eas of the

.”1(p57) The

document

epresent

vel of prac-

contac

rn the

wing

leting

ation

hours

The revised AORN “Recommtices for surgical attire” docupublished electronically in A

indicates that continuing education

hours are available for this activity. Ea

tact hours by reading this article, revie

purpose/goal and objectives, and comp

online Examination and Learner Evalu

http://www.aorn.org/CE. The contact

this article expire January 31, 2015.

122 AORN Journal ● January 2012 Vol 95

prac-t was’s

Perioperative Standards and Recom

Practices in November 2010. The p

the revised recommended practices

ment is to “provide guidelines for s

tire including jewelry, clothing, sho

erings, masks, jackets, and other acce

in the semirestricted and restricted ar

surgical or invasive procedure setting

practice recommendations in the RP

are intended to be achievable and r

what is believed to be an optimal le

t

con-

the

the

at

for

tice, and these recommendations can be adapted

doi: 10.1016/j.aorn.2011.10.017

No 1 © AORN, Inc, 2012

http://www.aorn.org/CE


nd ot

replas forwere

andge incagainprob

the Rons acons

ntrod, Coloe pubf 201ubmitWhen1 AOia, th

g thehomeativepractenda

gicalattirece abers,not ssurgi04 reof su

trovereithere 200ses wsoile

er ands laun

e last load,er placingg itemsire wash andrms into thelothing, andof the wash-shed surgical

ed since thed AORNering of sur-wever, thee periopera-

e launderingment now

eet the speci-reduction in

l attire,”1(p64)

epth.

te personalicted ands promotesanliness innderstoodsurfaces in

of microbialion. Cleanintroductionlth care per-ment. Al-

n nonsterileical site in-e a patient’ss skin, mu-

dry facilityies followaundry Ac-y accredita-ocess health

RP IMPLEMENTATION GUIDE: ATTIRE www.aornjournal.org

to various settings where surgical avasive procedures are performed.

WHAT’S NEW?The new surgical attire RP document2004 AORN “Recommended practicecal attire.” Some significant changesto the RP document during its reviewquent update. The most notable chanthe stronger stance AORN has takenlaundering of surgical attire, which isthe least popular recommendation inment. Based on the number of questicomments that AORN received fromwhen the recommendation was first ithe 2010 AORN Congress in Denverand when the RP document was in thcomment phase during the summer oRP document was revised and then sfor a second public comment phase.RP document was featured at the 201Congress in Philadelphia, Pennsylvancontinued to be questions surroundinmendation that surgical attire not bedered. This article may help perioperimplement the revised surgical attireommendations, including the recommagainst home laundering.

The previous RP document on surstated, “Home laundering of surgicalrecommended. Without clear evidensafety for patients, health care worktheir family members, AORN doesthe practice of home laundering ofattire.”2(p299-300) Additionally, the 20mendations stated “Home launderingattire that is not visibly soiled is conand there is no concrete evidence toport or refute the practice.”2(p300) Thdocument provided perioperative nursuggestions for how to home laundercal attire, including the type of washtemperature settings to use, as well a
surgical attire in a separate load with no o
her in-

ces thesurgi-madesubse-ludesst homeablyP docu-ndtituentsuced atrado,lic

0, thetedtheRN

ererecom-laun-

nursesice rec-tions

attireis notout the

andupportcalcom-rgicalsial,sup-

4 RPithd surgi-

waterdering

items, laundering surgical attire as thwashing one’s hands immediately aftsurgical attire into the washer, keepincompletely submerged during the entrinse cycles, not placing hands and alaundry or rinse water to submerge cthoroughly cleaning the door and liding machine before removing the waattire.

Research and evidence have evolv2004 RP document was published, anmaintains the statement “Home laundgical attire is not recommended.” Horevised RP document does not providtive nurses with suggestions for homof soiled surgical attire. The RP docustates, “Home laundering may not mfied measures necessary to achieve aantimicrobial levels in soiled surgicaand details those measures in more d

RATIONALEWearing surgical attire and appropriaprotective equipment in the semirestrrestricted areas of health care facilitiepersonnel safety and helps ensure clethe perioperative environment. It is uthat the human body and the variousthe perioperative setting are sourcescontamination and microbe transmisssurgical attire helps to minimize theof microorganisms and lint from heasonnel to clean items and the environthough there is no direct link betweesurgical attire and the impact on surgfections, it seems prudent to minimizexposure to a surgical team member’cous membranes, or hair.

Using a health care-accredited launis preferred because accredited facilitindustry standards. The Healthcare Lcreditation Council provides voluntartion to those laundry facilities that pr

ther care textiles and incorporate Occupational Safety

AORN Journal 123

nd CCDC)ontroindus; monoutines corrater tation

ce recse recects o

stricteludinre andspecinot b

how and, as well asompetencyedures, andogram. Thisenting the

practiceurse’s role inical attire

ive nursesow-lintingis comfort-RN recom-

ly woven,esearchattire is notit is made.3

not r

January 2012 Vol 95 No 1 BRASWELL—SPRUCE

and Health Administration (OSHA) afor Disease Control and Prevention (lines, including establishing quality ctoring and using processes based ondards; regularly testing water qualitywash loads and recording data; and rmonitoring laundry processes, such ameasurement of chemicals, correct wtures, mechanical action, and the durwashing cycle.

DISCUSSIONThere are nine evidence-based practimendations in the RP document. Themendations pertain to the various aspcal attire in the semirestricted and reof the perioperative environment, incommendations about materials that anot acceptable for surgical attire, thetypes of attire that should and should

Figure 1. Attire made of 100% fleece is

in the perioperative practice setting, the clea

124 AORN Journal

entersguide-

l moni-try stan-itoringlyectempera-of the

om-om-f surgi-d areasg rec-

arefice worn

and laundering of surgical attire, andwhen to wear surgical attire correctlyrecommendations for education and cvalidation, creating policies and procestablishing a quality management prarticle offers suggestions for implemrecommendations in the perioperativesetting with a specific focus on the nestablishing safe and appropriate surgpractices.

Recommendation IIn selecting surgical attire, perioperatshould choose attire that is made of lmaterial, catches shed skin squames,able, and looks professional.1(p57) AOmends choosing fabrics that are tightstain resistant, and durable. In fact, rshows that the design of the surgicalas important as the material of which

ecommended for the OR.

nliness Surgical attire should not be highly flammable,

ot ret shedtory df apps canatalogne byess anfferswarmducatide th

retutmenton wecreaioperspectnnelrgicalgical

r facility

facets off the attire,

, what not tosuggestionsof shoes to

ation (ID)items that

ricted or re-ses).1(p57-61)

e personnelareas wearndered, orshoes, headges.1(p57)

ge into sur-reas to de-mination

be de


which is why 100% cotton fleece is nmended4 (Figure 1), and it should noharbor dust, skin squames, or respira

To ensure surgical attire is made omaterials, perioperative staff memberlabels carefully, review health care cinteract with vendors. This can be doing the Exhibit Hall at AORN Congring vendor meetings. If the vendor othat are 100% cotton fleece, such asjackets, perioperative nurses should eabout the misuse of cotton fleece insoperative suite. The vendors can thentheir research and development deparredesign jackets that are made of cot10% to 20% polyester blend, which dshedding component. In addition, perstaff members can work with their reterials management department persoing decisions about obtaining new suThey can also discuss the revised sur

Figure 2. Use of cover apparel should

RP document, which provides detail on fa

com-lint or

roplets.ropriatereads, andvisit-d dur-

items-upe theme peri-rn tots toith ases the

ativeive ma-in mak-

attire.attire

specifications, with vendors and othestaff members.

Recommendation IIRecommendation II deals with manysurgical attire, including cleanliness owhere and how to don surgical attirewear (eg, jewelry, open-toed shoes),for head coverings and the best typeswear, how and why to wear identificbadges, the use of cover apparel, andshould not be taken into the semireststricted areas (eg, backpacks, briefcaIt is recommended that perioperativin the semirestricted and restrictedfacility-approved, clean, freshly laudisposable surgical attire, includingcoverings, masks, jackets, and ID badPerioperative personnel should changical attire in designated dressing acrease the possibility of cross-conta

termined on a facility-by-facility basis.

bric and to assist with traffic control and should

AORN Journal 125

ey nbuildal attironml mayigured toer shacilitys betwxampor fr

nel shng onrrivalsingscrubnal tr

infecave a

d be in-ting from

ar jewelryor braceletssurgical

k of contam-ho wearings as re-Research

mes higherrings than

e nurse’s ori-uss theseuide, the pre-mphasize thatry to thering mayparing surgi-, laceration,

d or confinedorn.


change back into street clothes if thleave the facility or travel betweento prevent contaminating the surgicthrough contact with the external envAdditionally, the use of cover apparedetermined by the practice setting (F

Surgical personnel who are requirefrom one health care facility to anothwear the same surgical scrubs from ffacility. Wearing contaminated scrubfacilities can transfer pathogens, for efrom clothing to the transport vehiclepatient to patient. Health care personchange into street clothes when leaviity and don clean surgical attire on asecond facility. While possibly increatime factor, the benefits of changingweigh the costs; the provider’s persovehicle will not come in contact withmaterials, and the next patient will h

Figure 3. Jewelry, including earrings, nwithin the scrub attire should not be w

vider who is wearing a clean, noncontamin

126 AORN Journal

eed toingsireent.be

2).travelould not

toeenle,omoulde facil-at thethes out-ansporttedpro-

pair of scrubs. Time allotments shoulcluded for providers who are commufacility to facility.

Perioperative nurses should not wesuch as earrings, necklaces, watches,that cannot be contained within theattire5 (Figure 3) because of the risinating the surgical attire. Nurses wjewelry should be aware of the findported in the revised RP document.now shows that bacteria are nine tion the skin beneath finger and noseon the rings themselves.5 During thentation phase is a good time to discfindings. Using safety as his or her gceptor can relay these findings and ewearing rings may, in fact, cause injuwearer or to patients. For example, abecome caught while the nurse is precal equipment and result in an injury

ces, watches, and bracelets, that cannot be containe
eckla
ated or avulsion. The ring may become contaminated

g a suhe rinplac

ry toing itRing

emov

andshoe

nd nohaved. Pe

regar inhazarplashs mat

toes

droppedd or other

h commit-research.l questionacks, ortricted areasthe perioper-ture relatedacteria and, or other

ely usedgh stetho-ire, perioper-r themre inanimate

eg, methicil-

porousbacteria.


with unknown microorganisms durinprocedure, causing the skin beneath tbecome colonized. If nurses prefer toelry in a personal locker or pin jewelclothing, they increase the risk of losmay become dislodged or misplaced.beneath gloves may be accidentally rthe gloves and possibly lost.

Shoe selection also is important,erative personnel should wear cleanclosed toes and backs, low heels, asoles.6 Shoes made of cloth or thator perforations are not recommendeative nurses should adhere to OSHAthat pertain to the choice of footwepractice setting related to potentialas needle sticks, scalpel cuts, and sblood or other potentially infectiouCloth shoes or shoes that have open

Figure 4. Fanny packs, backpacks, briematerials may be difficult to clean or d

backs, for example, increase the wearer’

rgicalg to

e jew-their. Ringss worned with

periop-s withnslipholesrioper-ulationstheds suches fromerials.

or

of sustaining a sharps injury from ainstrument or being exposed to bloobodily fluids.

Perioperative nurses maintain a higment to evidence-based practice andTherefore, when health care personnethe prohibition of fanny packs, backpbriefcases in the semirestricted or resof the perioperative suite (Figure 4),ative nurse must be able to cite literato studies confirming the growth of bmicrobial carriage on fabrics, plasticsporous materials.7-10

Stethoscopes may be the most widmedical device in health care. Althouscopes are not part of the surgical attative health care providers often weaaround their necks (Figure 5). They aobjects that can transmit pathogens (

s, and other personal items that are constructed ofct adequately and may harbor pathogens, dust, and

fcaseisinfe

s risk lin-resistant Staphylococcus aureus) by indirect

AORN Journal 127

withcreaseNursers toationsible fonmeeasurshou

tive ns autFaci

safetys relaalth crrivaleck in. Thiinformph, the per

resented tors must sub-

an additionale into the, the vendorser to retrievefacility-is-e periopera-sure ofear at theuthorizedng these pro-or visitore that nod the appro-out the nec-should notve beenhorized visi-for furthercumentation

oscopesthe ne


contact. Cleaning stethoscopes alongwashing between treating patients depossibility of pathogen transmission.provide antibacterial wipes for providtheir stethoscopes at hand washing st

The perioperative nurse is responsmaintaining a safe and secure envirall times; therefore, as a security mpersonnel in the perioperative settingID badges. This allows the perioperawell as patients, to identify all personto be in the perioperative setting.11,12

can ensure patient and staff memberimplementing policies and procedurevisitors in the OR. For example, a hefacility’s policies may state that on afacility, vendors and visitors must chthrough an automated badge terminalprint a photo/ID badge that containssuch as the date and time, a photograpany represented, and the name of th

Figure 5. Identification badges shouldshould be clean and not worn around

they are visiting. On arrival to the periope

128 AORN Journal

hands the

es canuse on

.ornt ate, allld wearurse, ashorizedlities

byted toareto the

s willatione com-

son

services area, the photo/ID badge is pthe control center. Vendors and visitomit their driver’s licenses to receivebadge that authorizes their admittancOR. On completion of their businessand visitors return to the control centtheir driver’s licenses and return thesued badges. Securing and locking thtive suites will add an additional measafety. Visitors or vendors are to appdoor, ring the bell for help, and be aentrance to the control center. Knowicedures are in place before a vendorarrives at an OR, the nurse can ensurperson enters without having followepriate steps. If someone appears withessary stickers and badges, he or shebe allowed to enter until the steps hacompleted. The nurse can refer unauttors or vendors to the control centerguidance and to complete required do

cured on the surgical attire top and visible, and stethck.

be se

rative before they are permitted to enter.

stionwha

ines fes ofwear,actice

restrireshlred aility o

theriope

ace wgainvivesurg

posetemsf the

ity of

ong deterrente nurses can

s manage-adequateuse by per-f staff mem-onal lockers.rm-up jack-ures. Mem-ve teamsingle-useed closededding skin

. Periopera-ed warm-upere there isets shouldaccommo-

pping thethat thento contact

personal

warm-upown


Recommendation IIIRecommendation III includes suggehow often to change surgical attire,when attire is contaminated, guidelusable and single-use attire, the typthat nonscrubbed personnel shouldwearing personal clothing in the prsetting.1(p61-62)

All individuals who enter the semiand restricted areas should wear fdered surgical attire that is laundehealth care-accredited laundry facposable surgical attire provided byand intended for use within the pesetting.1(p61)

Perioperative personnel should not plsurgical attire in lockers to be worn astudies have shown that microbes surperiods on fabrics.9,10,13 Storing usedattire in one’s personal locker can experioperative nurse’s other personal icrobes that may fall from the fabric oAs previously discussed, the possibil

Figure 6. All nonscrubbed personnel shjacket snapped closed with the cuffs d

transmission of microorganisms to the nur

s fort to door re-attireand

ctedy laun-t ar dis-

facilityrative

ornbecausefor longicaltheto mi-attire.the

individual belongings should be a strfor this type of behavior. Perioperativspeak to their managers and materialment personnel to ensure there is ansupply of surgical attire available forsonnel to help offset the possibility obers retaining used attire in their pers

Surgical attire should include waets with long sleeves and snap closbers of the nonscrubbed perioperatishould wear a freshly laundered orlong-sleeved warm-up jacket snappwith cuffs to the wrist to contain shsquames from bare arms (Figure 6)tive nurses should don a long-sleevjacket before prepping a patient whrisk of skin squames shedding. Jackbe available in a variety of sizes todate every staff member. While prepatient, the nurse should take caresleeves of the jacket do not come iwith the sterile field.

Surgical attire should not include

wear a freshly laundered or single-use long-sleevedto the wrists.

ould

se’s clothing that extends above the top neckline or

AORN Journal 129

al attnd ofes weel winto

to parmfutensivembettire.cate,withted,se maman

tive tr whoe occsoonber

tate t

ly harmfulards.

ad and facialrestricted

over facialneck. Peri-the risk ofhead andames andg onto therecom-etely coverl to coverthe earsFigure 8).ir depart-ment depart-ability of

a variety of

e com


below the sleeve (Figure 7). Surgicshould be changed daily or at the eand should not be worn if it becomcontaminated. Perioperative personnattire becomes soiled should changelaundered attire as soon as possibleprolonged exposure to potentially hteria.14,15 When their bodies are excontaminated, perioperative staff mshould bathe before donning fresh aThe perioperative nurse, as an advoassist other perioperative personnelopportunity for changing contaminaor wet attire. The perioperative nurto contact the charge nurse or floorand request an additional perioperamember to relieve the team membetire becomes soiled while the changthis is not immediately possible, astime permits, the affected team membe relieved. Managers should facili

Figure 7. All personal clothing should b

reliefs to decrease the amount of time a

130 AORN Journal

irea shiftt or

hosefreshly

reventl bac-elyrs14,16

shouldthe

soiled,y need

agereamse at-urs. Ifas

shouldhese

member is exposed to any potentialbacteria as outlined in OSHA stand

Recommendation IVAll personnel should cover their hehair when in the semirestricted andareas.1(p62) Hair coverings should chair, sideburns, and the nape of theoperative nurses can help minimizesurgical site infections by coveringfacial hair, which prevents skin squhair shed from the scalp from fallinsterile field.17,18 Skull caps are notmended because they do not complthe wearer’s hair and skin; they faithe side hair above and in front ofand the hair at the nape of the neck (Perioperative nurses can talk with thement managers and materials management personnel to eliminate the availskull caps. Providing bouffant caps in

pletely covered by the surgical attire.

team sizes will allow perioperative team members

caps

ld pnate

ntamire acwearsableily i

ity.19

at thly labrtme

ceptark wperso

y sewr thatA nohouldr ontpartmcontao thelp prere fary ba

ry bagsr of theesia person-ear personalld have anent marker,me and de-rovideindividual

oiled, per-

a healthhould not beORN haslaunderinge laundering

nded. Thet is that re-me launder-

facility laun-ioburdenniforms atme launder-und on uni-

primary

neck, whenas.


choices when converting to bouffantskull caps.

Perioperative team members shousingle-use head coverings in a desigceptacle after daily use or when coPersonal, reusable head coverings aable for perioperative personnel toare covered with a single-use dispocovering or if they are laundered dahealth care-accredited laundry facilsonal head coverings are launderedty’s laundry, they should be properwith the employee’s name and depaplaced in an appropriate laundry rePerioperative team members can wotheir managers and laundry facilityrecommend labels that can be easilironed into the personal head cap osecurely affixed by another means.ing, nonfading, permanent marker sused to place the name of the ownelabel. Working with the laundry deensure all necessary information isthe label to ensure the caps return tful departments and owners will helost personal items. Many health canow provide individual mesh laund

Figure 8. All personnel should cover hein the semirestricted and restricted are

perioperative personnel to use for person

over

laced re-nated.cept-if theyhead

n aIf per-

e facili-elednt andcle.ithnnel ton orcan be

nbleed-be

o theent toined onright-vent

cilitiesgs for

usable caps. Labels and mesh laundshould be provided to every membeperioperative team, including anesthnel and other team members who whead caps. Mesh laundry bags shouaffixed label, written with a permanthat identifies the staff member’s napartment. A facility may prefer to plarger mesh laundry bags instead ofmesh laundry bags for depositing ssonal caps.

Recommendation VSurgical attire should be laundered incare-accredited laundry facility and slaundered at home (Figure 9).1(p63) Anot changed its position on the homeof surgical attire since 2004, and homof surgical attire is still not recommedifference in the revised RP documensearch now shows definitively that hoing is less effective than health caredering. Studies have shown that the bfound on the health care providers’ uthe beginning of a shift following hoing is the same as the bioburden foforms at the end of their shifts. The

d facial hair, including sideburns and the nape of the
ad an
al, re- reason is that accredited laundry facilities

AORN Journal 131

DC gtion

t surginanpara

pecifires thels in

e lited to tationgers

d ineeti

s as aearchinst herativ

anare teation

ion o

the shift wereith one or

ncomycin-istant Staphy-

fficile.1(p64),21

cottoned with 10that entericrus, and ade-ips after theuded being-minute per-

d areasen sterile

1(p65) Thee periopera-microorgan-

ve team areWearing aoviders from

ttireomme


incorporate numerous OSHA and Clines as well as professional associatice recommendations to ensure thaattire and textiles are free of contamas bacteria and fungi.1(p63-64),20 Comhome laundering may not meet the schanical, thermal, or chemical measunecessary to reduce antimicrobial levsurgical attire.1(p64)

Perioperative nurses should providto perioperative team members relateils of home laundering. This informbe distributed to perioperative manawell. Information may be distributeform of staff bulletin boards, staff meducational venues, or journal clubto share the findings of relevant resAORN has used to recommend agalaundering of surgical attire. Periopnurses can provide staff members, mand all other perioperative health camembers with the following inform

� In a study of bacterial contaminat

Figure 9. Home laundering has been shlaundered by health care facilities or c

laundered uniforms, 39% of uniforms i

132 AORN Journal

uide-prac-icalts suchtively,ed me-at aresoiled

raturehe per-shouldas

thengs,means

omee

gers,am:

f home-

fied as “clean” at the beginning ofactually found to be contaminated wmore microorganisms, including varesistant enterococci, methicillin-reslococcus aureus, and Clostridium di

� A quantitative study performed onstrips of fabric that were inoculatmL of a viral suspension showedviruses such as hepatitis A, rotavinovirus remained on the fabric strhome-laundering process that inclwashed, rinsed, and dried on a 28manent press cycle.22

Recommendation VI“All individuals entering the restricteshould wear a surgical mask when opsupplies and equipment are present.”mask protects both the patient and thtive team members from exposure toisms. All members of the perioperatiat risk for exposure from droplets.surgical mask protects health care pr

to be less effective for cleaning surgical attire than arcial laundries.

own

denti- droplets greater than 5 micrometers in size. Ex-

ropleteptoces.the pacarrie. Wea

careus maretioning at splahe hedy of

of bks ofrevead in ttside

ce the

wear, re-uld cover the1(p65) Theyhead andof transmit-

icroorgan-.1(p66) Con-priately canhing thethrough

surgicalneck or awet (Figure

at a time,iscarded anduld confronting a con-ember’s, the periop-

orn to


amples of diseases where potential dsures may occur include group A Stradenovirus, and Neisseria meningitid

Wearing a surgical mask protectsfrom exposure to infectious materialhealth care provider’s nose or mouthsurgical mask also protects the healthvider from exposure to other infectiofrom patients, such as respiratory secsprays of blood or body fluids. Wearmask decreases the risk of inadvertensplatters of blood or body fluid into tcare provider’s mouth or nose. A stusurgical procedures revealed that 26%exposures were to the heads and necscrubbed personnel. The same studythat 17% of blood exposures occurrenonscrubbed, circulating personnel ousterile field.23

Perioperative nurses can help redu

Figure 10. Surgical masks should be w

fer of microorganisms when they instruct

expo-occus,

tientd in thering apro-terials orsurgicalshes oralth8,500lood

ledhethe

trans-

team members about how to properlyplace, and discard masks. Masks shomouth and nose and prevent venting.should be secured at the back of thebehind the neck to decrease the riskting nasopharyngeal and respiratory misms to patients or to the sterile fieldversely, surgical masks applied approprevent infectious particles from reacwearer’s nose and mouth by passingleaks at the mask-face seal.

Surgical attire should not include amask that is worn hanging from thesurgical mask that becomes soiled or10). Only one mask should be wornand soiled or wet masks should be dreplaced. The perioperative nurse shoany health care provider who is weartaminated surgical mask. If a team msurgical mask becomes wet or soiled

cover the mouth and nose.

other erative nurse should inform the team member and

AORN Journal 133

led m

sk sh

the ti

r her

d per

er tea

sks a

ing th

mber

s pro

ill he

acles

iately

also w

urses

ts, ca

l of a

ment

the e

. As

e foll

rative

ked t

surg

ions

roced

prov

ment

Pers

ucatio

to the

men

nity

nd va

ncies

ive Jo

n Too

lopin

developed,essary, andg. New orpresent anith nurses

s in the facil-cies and pro-d practices.emplates,of 15 sam-

lates basedand Recom-provementient safetydetails on thethat are spe-this article,

document.

RIOulatory sur-w AORNl attire.” Oneubbed per-mirestrictedleeved scrub. The intentmediately.to assist

carpal tunnel

arm up foret and pro-n Nurse Jmoved thee to take offet somethingto be wornspond?

that whileas, all non-ly laundered

ets. The rec-


assist him or her in replacing the soi

After each procedure, the surgical ma

discarded by carefully handling only

the mask.1(p66) After discarding his o

the perioperative team member shoul

proper hand hygiene.24

Perioperative nurses can coach oth

members to discard their surgical ma

form hand hygiene afterward. Provid

propriate receptacles for the team me

deposit used surgical masks as well a

alcohol foam hand wash in the OR w

cilitate compliance. Additional recept

hand hygiene stations located immed

the exit from the perioperative suite

facilitate compliance. Perioperative n

laboration with infection preventionis

velop signage to indicate that remova

gical masks before exiting the depart

required. The signs may be placed at

each OR and at each department exit

to ensure infection control policies ar

any person found outside the periope

wearing a surgical mask should be as

move it.

The Final ThreeIn the “Recommended practices for

attire,” the final three recommendat

education/competency, policies and p

and quality assurance/performance im

These topics are integral to the imple

of AORN practice recommendations.

should receive initial and ongoing ed

competency validation as applicable

Implementing new and updated recom

practices affords an excellent opportu

ate or update competency materials a

tools. AORN’s perioperative compete

has developed the AORN Perioperat

scriptions and Competency Evaluatio

assist perioperative personnel in deve

petency evaluation tools and position desc

134 AORN Journal

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Policies and procedures should bereviewed periodically, revised as necreadily available in the practice settinupdated recommended practices mayopportunity for collaborative efforts wand personnel from other departmentity to develop organization-wide policedures that support the recommendeThe AORN Policy and Procedure T2nd edition,26 provides a collectionple policies and customizable tempon AORN’s Perioperative Standardsmended Practices. Regular quality improjects are necessary to improve patand to ensure safe, quality care. Forfinal three practice recommendationscific to the RP document discussed inplease refer to the full text of the RP

AMBULATORY PATIENT SCENAStaff members at a freestanding ambgery center have implemented the ne“Recommended practices for surgicaof the many changes is that all unscrsonnel working in the restricted or searea are now required to wear long-sjackets that are buttoned up the frontis for everyone to comply starting imHowever, when Nurse J enters OR 1Nurse W in prepping a patient for arelease, she encounters a problem.

While Nurse J holds the patient’sNurse W, Nurse W removes her jackceeds to prep the patient’s arm. Whequestions Nurse W about why she rejacket, Nurse W says, “It is ok for mmy jacket to prep; otherwise I may gon it. AORN doesn’t state that it hasfor the prep.” How should Nurse J re

Nurse J should explain to Nurse Win the semirestricted or restricted arescrubbed personnel should wear freshor single-use long-sleeved scrub jack

riptions. ommended practice is that perioperative nurses

acketof sk

ts shementy turnyer. Aed intactereld aprominfecinterfith ades, or

ital fice isspitallwaysnd plhe baed, dmadany

or sev

nd imthat idingictede can, he btold oI havears,see t

peratcticel invo

olders anden a news an attireicians mayor con-

he changeive person-updating ation earlyenting amade, peri-at barrierses of physi-rtant totients aserioperativee in imple-

ges.xplain theffer to showcles that sup-e presentedgers andfurther dis-uld discussheir buy-in.ion session tod. Withtermine how

nded prac-hallengingtive nurses.ecommenda-nge from

l question thenurse shouldations aree RP docu-dditional


should don a long-sleeved warm-up jprepping a patient where there is risksquames shedding. The jacket prevenof skin squames into the OR environsterile field. Healthy skin is constantlover and forming a new protective laskin cells are shed, they are disseminatenvironment, taking with them viable bcould potentially land on the surgical fipatient. This could contribute to a comsurgical field and potential surgical siteNurse W’s jacket is too large and maythe surgical prep, Nurse J may assist wmeasures such as tucking the front, sidof the jacket to maintain a sterile prep.

HOSPITAL PATIENT SCENARIODr R has been working in Gold Hospyears as an anesthesiologist. His serva large specialty group that Gold Hotracts for anesthesia services. Dr R ahis large bag into the OR with him aon the floor by the anesthesia cart. Textremely worn. It is made of a crackleather-type material. The handles arefabric and are also extremely worn. Minside the bag may have been there fmonths to several years.

Gold Hospital has recently written amented a new policy on surgical attireall of AORN’s recommendations, incluing bags in the semirestricted and restrWhen a colleague informs Dr R that hger bring his bag into the OR with himirate. Nurse G is nearby when Dr R ispractice change. “Nurse G!” he yells. “bringing my bag into the OR for five ynow you tell me that I can’t? I want todence that this causes problems!”

This is a dilemma that many perionurses encounter. How could this prahave been better communicated to al
What should Nurse G do?
beforeinddingand theings these

o theia thatnd theisedtion. Ifere withditionalsleeves

or fivepart ofcon-brings

aces itg isry,e ofitemseral

ple-ncludesprohibit-areas.no lon-ecomesf the

e beenandhe evi-

ivechangelved?

It is important for all key stakehphysician groups to be included whpolicy that will affect them, such apolicy, is being created. Many physfeel that they are being manipulatedtrolled if they are not involved in tprocess. To prevent this, perioperatnel who are involved in creating orfacility policy should provide educaand ask for feedback before implemprocess change. Before a change isoperative nurses must determine whthey may face. What are the attitudcians and staff members? It is impocommunicate the benefits for the pawell as the benefits for personnel. Pnurses should expect some resistancmenting facility-wide practice chan

In this scenario, Nurse G should erationale for the change. She could oDr R the evidence-based practice artiport the change. These articles can bto perioperative and anesthesia manaother perioperative staff members toseminate the information. Nurse G cothe articles with managers to obtain tShe could offer to provide an educatoutline the changes that have occurremanagers’ support, Nurse G could derepeat offenders should be reported.

CONCLUSIONImplementing the AORN “Recommetices for surgical attire”1 presents a cand unique opportunity for perioperaNurses implementing these practice rtions may encounter resistance to chaperioperative staff members who wilupdated practices. The perioperativereiterate that the practice recommendwritten by expert content authors. Thment authors include content from a
expert sources as well, such as the American
AORN Journal 135

e Amocietr Profologyon ofemenove s

in theatingocessr, ricecom

now wce recten, rnteddocu

llingstron

rgicalparty thecommg theortedellingd comd no

y—wtraditphysiatory,t, orperfonityple.

s a “cat is

s Ku

for creating

ire. In: Periop-actices. Denver,

ire. In: Periop-actices. Denver,

ource and routepidermidis

g cardio-thoraciccontamination

fect. 2001;47(4):

g of cottonmaleic acid and

6(4):351-368.annister GC.ounts of operat-8-70.ds 1910.136:nt of Labor.sp.show__id�9786.

tal cleaning inive StandardsO: AORN, Inc;

erioperative. Denver, CO:

rococci andastic. J Clin

e medicallyplastics. J Clin

ronment of care.mended Prac-5-236.rook Terrace,

nurses’ uni-37-42.thogens—235):64004-

Silver LC, Jar-gical site infec-ractices Advi-pidemiol. 1999;

orne pathogens.

r as a reservoir


Association of Nurse Anesthetists, thCollege of Surgeons, the American SAnesthesiologists, the Association foals in Infection Control and EpidemiCDC, and the International Associaticare Central Service Materiel Managintent of all RP documents is to imprmember and patient safety.

As of September 2011, AORN isning stages of putting an “evidence rmentation” phase into the creation preach of its RP documents. As strongeand more robust scientific evidence bavailable, perioperative nurses will kcertainty that each of AORN’s practimendations has been researched, writviewed, revised, and publicly commeFor instance, in the surgical attire RPthe literature review provided compedence that prompted AORN to take astance against home laundering of suAlthough this has not been a popularrevised RP document, as evidenced bber of Congress attendees and publicwho have expressed concern regardinchanges, the recommendation is suppentific research with extremely compTherefore, perioperative nurses shoulwith all parts of any RP document anthe “popular” parts. On any given dait is an inpatient hospital setting in aOR, an ambulatory surgery center, aoffice, a cardiac catheterization labordoscopy suite, a radiology departmenother area where invasive procedures areperioperative nurses have the opportuthemselves apart and to lead by exammenting AORN’s recommendations iaction” for standing up and doing whaccording to the evidence.

Acknowledgement: The author thank

Jones, graphic designer/medical illustrator

136 AORN Journal

ericany ofession-, theHealth-

t. Thetaff

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her,esith

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of thenum-enters

seby sci-results.ply

t justhetherionalcian’san en-

anyrmed—to setImple-all toright—

rt

Creative at AORN, Inc, Denver, CO,

the artwork in this article.

References1. Recommended practices for surgical att

erative Standards and Recommended PrCO: AORN, Inc; 2011:57-72.

2. Recommended practices for surgical atterative Standards and Recommended PrCO: AORN, Inc; 2009:299-306.

3. Tammelin A, Hambraeus A, Stahle E. Sof methicillin-resistant Staphylococcus etransmitted to the surgical wound durinsurgery. Possibility of preventing woundby use of special scrub suits. J Hosp In266-276.

4. Wu X, Yang CQ. Flame retardant finishinfleece fabric: part III—the combination ofsodium hypophosphite. J Fire Sci. 2008;2

5. Bartlett GE, Pollard TC, Bowker KE, BEffect of jewelery on surface bacterial cing theatres. J Hosp Infect. 2002;52(1):6

6. Occupational Safety and Health StandarFoot protection. United States Departmehttp://www.osha.gov/pls/oshaweb/owadidocument?p_table�STANDARDS%26pAccessed September 2, 2011.

7. Recommended practices for environmenthe perioperative setting. In: Perioperatand Recommended Practices. Denver, C2011:237-250.

8. Standards of perioperative nursing. In: PStandards and Recommended PracticesAORN, Inc; 2011:3-52.

9. Neely AN, Maley MP. Survival of entestaphylococci on hospital fabrics and plMicrobiol. 2000;38(2):724-726.

10. Neely AN, Orloff MM. Survival of somimportant fungi on hospital fabrics andMicrobiol. 2001;39(9):3360-3361.

11. Recommended practices for a safe enviIn: Perioperative Standards and Recomtices. Denver, CO: AORN, Inc; 2011:21

12. Hospital Accreditation Standards. OakbIL: The Joint Commission; 2009:47-68.

13. Callaghan I. Bacterial contamination offorms: a study. Nurs Stand. 1998;13(1):

14. Occupational exposure to bloodborne paOSHA. Final rule. Fed Regist. 1991;56(64182.

15. Mangram AJ, Horan TC, Pearson ML,vis WR. Guideline for prevention of surtion, 1999. Hospital Infection Control Psory Committee. Infect Control Hosp E20(4):250-278; quiz 279-280.

16. US Health and Human Services. Bloodb29 CFR §1910.1030.

17. Summers MM, Lynch PF, Black T. Hai
, IKON of staphylococci. J Clin Pathol. 1965;18(13):13-15.
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS%26p_id=9786

http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS%26p_id=9786

perativLancet

. Guidh-carelthcare(HICPA1-42.cil. AcTextilw.hlaessed

contam238-24rvivalinfectiorobiol.

e operInfect

in theand Renc; 201

petency Evalu-n press.OM]. 2nd ed.

NS, CNOR,ai Hospitalno de-

eived ast in the

CNOR, isical services

ussia, PA.that could

nflict of in-.

racticest. Individu-and refer-


18. Dineen P, Drusin L. Epidemics of postoinfections associated with hair carriers.2(7839):1157-1159.

19. Sehulster L, Chinn RY, CDC, HICPACenvironmental infection control in healtRecommendations of CDC and the HeaControl Practices Advisory CommitteeMMWR Recomm Rep. 2003;52(RR-10):

20. Healthcare Laundry Accreditation Countion Standards for Processing Reusablein Healthcare Facilities. 2006. http://wwAccredit%20Standards12.18.08.pdf. Accber 2, 2011.

21. Perry C, Marshall R, Jones E. Bacterialof uniforms. J Hosp Infect. 2001;48(3):

22. Gerba CP, Kennedy D. Enteric virus suhousehold laundering and impact of dissodium hypochlorite. Appl Environ Mic73(14):4425-4428.

23. Romney MG. Surgical face masks in thatre: re-examining the evidence. J Hosp47(4):251-256.

24. Recommended practices for hand hygieneative setting. In: Perioperative Standardsmended Practices. Denver, CO: AORN, I

This RP Implementation Guide is indocument upon which it is based anals who are developing and updatin
ence the full recommended practices doc
e wound. 1973;

elines forfacilities.InfectionC).

credita-es for Usecnet.org/Septem-

ination1.duringn with2007;

ating the-. 2001;

perioper-com-1:73-86.

25. Perioperative Job Descriptions and Comation Tools. Denver, CO: AORN, Inc. I

26. Policy and Procedure Templates [CD-RDenver, CO: AORN, Inc; 2010.

Melanie L. Braswell, DNP, RN, Cis an advanced practice nurse at Sinof Baltimore, MD. Dr Braswell hasclared affiliation that could be percposing a potential conflict of interespublication of this article.

Lisa Spruce, DNP, RN, ACNS-BC,the corporate clinical manager of surgat UHS of Delaware, Inc, King of PrDr Spruce has no declared affiliationbe perceived as posing a potential coterest in the publication of this article

d to be an adjunct to the complete recommended pot intended to be a replacement for that documenanizational policies and procedures should review

tended is ng org

ument.

AORN Journal 137

http://www.hlacnet.org/Accredit%20Standards12.18.08.pdf

http://www.hlacnet.org/Accredit%20Standards12.18.08.pdf

.6.aorn.org/CE

EXAMINATION
CONTINUING EDUCATION PROGRAM
3wwwImplementing AORN Recommended

Practices for Surgical Attire

mmended

al attire.”

ns for surgi-

ur conve-e Exami-

PURPOSE/GOAL

To educate perioperative nurses about how to implement the AORN “Recopractices for surgical attire” in inpatient and ambulatory settings.

OBJECTIVES

1. Identify the purpose of AORN’s “Recommended practices for surgic2. Discuss why home laundering of surgical attire is not recommended.3. Identify appropriate materials for surgical attire.4. Discuss AORN’s practice recommendations for surgical attire.5. Identify methods for implementing AORN’s practice recommendatio

cal attire.

The Examination and Learner Evaluation are printed here for yonience. To receive continuing education credit, you must complete thnation and Learner Evaluation online at http://www.aorn.org/CE.

endede guid_____ictedetting

4, and, 3, 4

the reis the

ative

e OR.e.

s preferable to

ing and usedards.ata.

urement, wa-n, and wash

nd 4

QUESTIONS

1. The purpose of AORN’s “Recommtices for surgical attire” is to providfor surgical attire including ______worn in the semirestricted and restrthe surgical or invasive procedure s1. clothing2. head coverings3. jackets4. jewelry5. masks6. shoes

a. 1, 3, and 5 b. 2,c. 1, 2, 3, 5, and 6 d. 1, 2

2. Perhaps the most notable change tomended practices for surgical attire
stance AORN has taken against

prac-elines

_____areas of.

6, 5, and 6

com-stronger

a. wearing jewelry in the periopersetting.

b. wearing 100% cotton fleece in thc. home laundering of surgical attird. taking briefcases into the OR.

3. Using accredited laundry facilities ihome laundering because they1. establish quality control monitor

processes based on industry stan2. monitor wash loads and record d3. regularly test water quality.4. routinely monitor chemical meas

ter temperature, mechanical actiocycle duration.a. 1 and 2 b. 3 a
c. 1, 2, and 3 d. 1, 2, 3, and 4



f com

nd 42, 3, a

approers shontrol

nd 42, 3, a

ge frohey nbuildi

soilethe a

ludesne-sizingle-

earin

ping to ensurenot come into

’s attire andted, actionsncludebility for.oor managere staff memberd.mber whosethe OR as

f time themember isul bacteria.nd 42, 3, and 4

iscarding ofe thatns two masks

ose and isnd behind the

the neck after

carefully han-

d after the

nd 5, 4, and 5

with consulta-

e Education.

of interest in

CE EXAMINATION www.aornjournal.org

4. Surgical attire should be1. 100% fleece.2. made of low-linting material.3. professional looking regardless o4. stain resistant and durable.

a. 1 and 3 b. 2 ac. 2, 3, and 4 d. 1,

5. To ensure surgical attire is made ofmaterials, perioperative staff memb1. conduct flammability tests in a c

environment.2. consult attire vendors.3. read attire labels carefully.4. review health care catalogs.

a. 1 and 3 b. 2 ac. 2, 3, and 4 d. 1,

6. Perioperative personnel should chansurgical attire into street clothes if tleave the facility or travel betweena. true b. false

7. If worn surgical attire is not visiblyoperative personnel can opt to placea locker to be worn again.a. true b. false

8. Correct use of warm-up jackets inca. ensuring jackets are available in ob. donning a freshly laundered or s

long-sleeved warm-up jacket.c. snapping the jacket closed and w

cuffs to the elbow.

The behavioral objectives and examination fo

tion from Rebecca Holm, MSN, RN, CNOR,

Ms Retzlaff, Ms Holm, and Ms Bakewell hav

the publication of this article.

fort.

nd 4

priateouldled

nd 4

m theireed tongs.

d, peri-ttire in

e-fits-all.use

g the

d. removing the jacket during prepthat the sleeves of the jacket docontact with the sterile field.

9. When a perioperative team memberbody become extensively contaminathe perioperative nurse might take i1. assisting the person with accessi

changing the contaminated attire2. contacting the charge nurse or fl

to request relief personnel for thwhose attire became contaminate

3. ensuring the perioperative staff meattire became contaminated leavessoon as time permits.

4. helping to decrease the amount ocontaminated perioperative staffexposed to any potentially harmfa. 1 and 2 b. 3 ac. 1, 2, and 4 d. 1,

10. Proper wearing, replacement, and dsurgical masks includes making sur1. any team member who is sick do

to prevent disease transmission.2. the mask covers the mouth and n

secured at the back of the head aneck.

3. the mask is worn hanging fromthe procedure is finished.

4. surgical masks are discarded bydling only the ties.

5. proper hand hygiene is performemask is removed and discarded.

a. 1 and 2 b. 2, 4, ac. 1, 3, 4, and 5 d. 1, 2, 3

program were prepared by Kimberly Retzlaff, editor/team lead,

editor, and Susan Bakewell, MS, RN-BC, director, Perioperativ

eclared affiliations that could be perceived as potential conflicts

r this

clinical

e no d

AORN Journal 139

.6.aorn.org/CE

LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM
3wwwImplementing AORN Recommended

Practices for Surgical Attirethe exgramscribe

tives o

ecom

rgical

rgical

dation. 5.

ORNtire.

se yo

objechion fr

esult of read-tion #9A. If

e? (Select all

team regard-

to change/ure.

eeting withand acceptance

valuate theintervals untilest practice.

as a result ofthat apply)t relevant to

teach othersd change.port to make

t we verifythe 3.6 con-16-minute)

This evaluation is used to determinewhich this continuing education prolearning needs. Rate the items as de

OBJECTIVES

To what extent were the following objeccontinuing education program achieved?

1. Identify the purpose of AORN’s “Rpractices for surgical attire.”Low 1. 2. 3. 4. 5. High

2. Discuss why home laundering of sunot recommended.Low 1. 2. 3. 4. 5. High

3. Identify appropriate materials for suLow 1. 2. 3. 4. 5. High

4. Discuss AORN’s practice recommensurgical attire. Low 1. 2. 3. 4

5. Identify methods for implementing Atice recommendations for surgical atLow 1. 2. 3. 4. 5. High

CONTENT

6. To what extent did this article increaknowledge of the subject matter?Low 1. 2. 3. 4. 5. High

7. To what extent were your individualmet? Low 1. 2. 3. 4. 5. Hig

8. Will you be able to use the informat

applicant who successfully completes this program


tent tomet yourd below.

f this

mended

attire is

attire.

s forHigh’s prac-

ur

tives

om this

9. Will you change your practice as a ring this article? (If yes, answer quesno, answer question #9B.)

9A. How will you change your practicthat apply)1. I will provide education to my

ing why change is needed.2. I will work with management

implement a policy and proced3. I will plan an informational m

physicians to seek their inputof the need for change.

4. I will implement change and eeffect of the change at regularthe change is incorporated as b

5. Other:9B. If you will not change your practice

reading this article, why? (Select all1. The content of the article is no

my practice.2. I do not have enough time to

about the purpose of the neede3. I do not have management sup

a change.4. Other:

10. Our accrediting body requires thathe time you needed to completetinuing education contact hour (2

dentialing Center

eptance of this

ers. Each

article in your work setting? 1. Yes 2. No program:

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Creapproves or endorses products mentioned in the activity.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for accactivity for relicensure.

Event: #12503; Session: #0001; Fee: Members $18, Nonmembers $36

The deadline for this program is January 31, 2015.

A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answ
can immediately print a certificate of completion.


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