Implementing AORN Recommended Practices For Surgical Attire
RECOMMENDED PRACTICESImplementing AORNRecommended Practicesfor Surgical Attire3.6MELANIE L. BRASWELL, DNP, RN, CNS, CNOR;LISA SPRUCE, DNP, RN, ACNS-BC, CNORwww.aorn.org/CEABSTRACTSurgical attire is intended to protect both patients and perioperative personnel.AORN published the “Recommended practices for surgical attire” to guide perioperative RNs in establishing protocols for selecting, wearing, and laundering surgicalattire. Perioperative RNs should work with vendors and managers to ensure appropriate surgical attire is available, model the correct practices for donning and wearingsurgical attire, and teach team members about evidence-based practices. The recommendation that surgical attire not be home laundered is supported by evidencethat perioperative nurses can share with their colleagues and managers to helpsupport appropriate practices. Hospital and ambulatory surgery center scenarios havebeen included as examples of appropriate execution of these recommended practices.AORN J 95 (January 2012) 122-137. AORN, Inc, 2012. doi: 10.1016/j.aorn.2011.10.017Key words: AORN recommended practices, surgical attire, cover apparel, homelaundering.The revised AORN “Recommended practices for surgical attire” document waspublished electronically in AORN’sindicates that continuing education contacthours are available for this activity. Earn the contact hours by reading this article, reviewing thepurpose/goal and objectives, and completing theonline Examination and Learner Evaluation athttp://www.aorn.org/CE. The contact hours forthis article expire January 31, 2015.Perioperative Standards and RecommendedPractices in November 2010. The purpose ofthe revised recommended practices (RP) document is to “provide guidelines for surgical attire including jewelry, clothing, shoes, head coverings, masks, jackets, and other accessories wornin the semirestricted and restricted areas of thesurgical or invasive procedure setting.”1(p57) Thepractice recommendations in the RP documentare intended to be achievable and representwhat is believed to be an optimal level of practice, and these recommendations can be adapteddoi: 10.1016/j.aorn.2011.10.017122AORN Journal January 2012Vol 95No 1 AORN, Inc, 2012
RP IMPLEMENTATION GUIDE: ATTIREto various settings where surgical and other invasive procedures are performed.WHAT’S NEW?The new surgical attire RP document replaces the2004 AORN “Recommended practices for surgical attire.” Some significant changes were madeto the RP document during its review and subsequent update. The most notable change includesthe stronger stance AORN has taken against homelaundering of surgical attire, which is probablythe least popular recommendation in the RP document. Based on the number of questions andcomments that AORN received from constituentswhen the recommendation was first introduced atthe 2010 AORN Congress in Denver, Colorado,and when the RP document was in the publiccomment phase during the summer of 2010, theRP document was revised and then submittedfor a second public comment phase. When theRP document was featured at the 2011 AORNCongress in Philadelphia, Pennsylvania, therecontinued to be questions surrounding the recommendation that surgical attire not be home laundered. This article may help perioperative nursesimplement the revised surgical attire practice recommendations, including the recommendationsagainst home laundering.The previous RP document on surgical attirestated, “Home laundering of surgical attire is notrecommended. Without clear evidence about thesafety for patients, health care workers, andtheir family members, AORN does not supportthe practice of home laundering of surgicalattire.”2(p299-300) Additionally, the 2004 recommendations stated “Home laundering of surgicalattire that is not visibly soiled is controversial,and there is no concrete evidence to either support or refute the practice.”2(p300) The 2004 RPdocument provided perioperative nurses withsuggestions for how to home launder soiled surgical attire, including the type of washer and watertemperature settings to use, as well as launderingsurgical attire in a separate load with no otherwww.aornjournal.orgitems, laundering surgical attire as the last load,washing one’s hands immediately after placingsurgical attire into the washer, keeping itemscompletely submerged during the entire wash andrinse cycles, not placing hands and arms into thelaundry or rinse water to submerge clothing, andthoroughly cleaning the door and lid of the washing machine before removing the washed surgicalattire.Research and evidence have evolved since the2004 RP document was published, and AORNmaintains the statement “Home laundering of surgical attire is not recommended.” However, therevised RP document does not provide perioperative nurses with suggestions for home launderingof soiled surgical attire. The RP document nowstates, “Home laundering may not meet the specified measures necessary to achieve a reduction inantimicrobial levels in soiled surgical attire,”1(p64)and details those measures in more depth.RATIONALEWearing surgical attire and appropriate personalprotective equipment in the semirestricted andrestricted areas of health care facilities promotespersonnel safety and helps ensure cleanliness inthe perioperative environment. It is understoodthat the human body and the various surfaces inthe perioperative setting are sources of microbialcontamination and microbe transmission. Cleansurgical attire helps to minimize the introductionof microorganisms and lint from health care personnel to clean items and the environment. Although there is no direct link between nonsterilesurgical attire and the impact on surgical site infections, it seems prudent to minimize a patient’sexposure to a surgical team member’s skin, mucous membranes, or hair.Using a health care-accredited laundry facilityis preferred because accredited facilities followindustry standards. The Healthcare Laundry Accreditation Council provides voluntary accreditation to those laundry facilities that process healthcare textiles and incorporate Occupational SafetyAORN Journal123
January 2012Vol 95BRASWELL—SPRUCENo 1Figure 1. Attire made of 100% fleece is not recommended for the OR.and Health Administration (OSHA) and Centersfor Disease Control and Prevention (CDC) guidelines, including establishing quality control monitoring and using processes based on industry standards; regularly testing water quality; monitoringwash loads and recording data; and routinelymonitoring laundry processes, such as correctmeasurement of chemicals, correct water temperatures, mechanical action, and the duration of thewashing cycle.and laundering of surgical attire, and how andwhen to wear surgical attire correctly, as well asrecommendations for education and competencyvalidation, creating policies and procedures, andestablishing a quality management program. Thisarticle offers suggestions for implementing therecommendations in the perioperative practicesetting with a specific focus on the nurse’s role inestablishing safe and appropriate surgical attirepractices.DISCUSSIONThere are nine evidence-based practice recommendations in the RP document. These recommendations pertain to the various aspects of surgical attire in the semirestricted and restricted areasof the perioperative environment, including recommendations about materials that are and arenot acceptable for surgical attire, the specifictypes of attire that should and should not be wornin the perioperative practice setting, the cleanlinessRecommendation IIn selecting surgical attire, perioperative nursesshould choose attire that is made of low-lintingmaterial, catches shed skin squames, is comfortable, and looks professional.1(p57) AORN recommends choosing fabrics that are tightly woven,stain resistant, and durable. In fact, researchshows that the design of the surgical attire is notas important as the material of which it is made.3Surgical attire should not be highly flammable,124AORN Journal
RP IMPLEMENTATION GUIDE: ATTIREwww.aornjournal.orgFigure 2. Use of cover apparel should be determined on a facility-by-facility basis.which is why 100% cotton fleece is not recommended4 (Figure 1), and it should not shed lint orharbor dust, skin squames, or respiratory droplets.To ensure surgical attire is made of appropriatematerials, perioperative staff members can readlabels carefully, review health care catalogs, andinteract with vendors. This can be done by visiting the Exhibit Hall at AORN Congress and during vendor meetings. If the vendor offers itemsthat are 100% cotton fleece, such as warm-upjackets, perioperative nurses should educate themabout the misuse of cotton fleece inside the perioperative suite. The vendors can then return totheir research and development departments toredesign jackets that are made of cotton with a10% to 20% polyester blend, which decreases theshedding component. In addition, perioperativestaff members can work with their respective materials management department personnel in making decisions about obtaining new surgical attire.They can also discuss the revised surgical attireRP document, which provides detail on fabricspecifications, with vendors and other facilitystaff members.Recommendation IIRecommendation II deals with many facets ofsurgical attire, including cleanliness of the attire,where and how to don surgical attire, what not towear (eg, jewelry, open-toed shoes), suggestionsfor head coverings and the best types of shoes towear, how and why to wear identification (ID)badges, the use of cover apparel, and items thatshould not be taken into the semirestricted or restricted areas (eg, backpacks, briefcases).1(p57-61)It is recommended that perioperative personnelin the semirestricted and restricted areas wearfacility-approved, clean, freshly laundered, ordisposable surgical attire, including shoes, headcoverings, masks, jackets, and ID badges.1(p57)Perioperative personnel should change into surgical attire in designated dressing areas to decrease the possibility of cross-contaminationand to assist with traffic control and shouldAORN Journal125
January 2012Vol 95No 1BRASWELL—SPRUCEFigure 3. Jewelry, including earrings, necklaces, watches, and bracelets, that cannot be contained or confinedwithin the scrub attire should not be worn.change back into street clothes if they need toleave the facility or travel between buildingsto prevent contaminating the surgical attirethrough contact with the external environment.Additionally, the use of cover apparel may bedetermined by the practice setting (Figure 2).Surgical personnel who are required to travelfrom one health care facility to another should notwear the same surgical scrubs from facility tofacility. Wearing contaminated scrubs betweenfacilities can transfer pathogens, for example,from clothing to the transport vehicle or frompatient to patient. Health care personnel shouldchange into street clothes when leaving one facility and don clean surgical attire on arrival at thesecond facility. While possibly increasing thetime factor, the benefits of changing scrubs outweigh the costs; the provider’s personal transportvehicle will not come in contact with infectedmaterials, and the next patient will have a provider who is wearing a clean, noncontaminated126AORN Journalpair of scrubs. Time allotments should be included for providers who are commuting fromfacility to facility.Perioperative nurses should not wear jewelrysuch as earrings, necklaces, watches, or braceletsthat cannot be contained within the surgicalattire5 (Figure 3) because of the risk of contaminating the surgical attire. Nurses who wearjewelry should be aware of the findings as reported in the revised RP document. Researchnow shows that bacteria are nine times higheron the skin beneath finger and nose rings thanon the rings themselves.5 During the nurse’s orientation phase is a good time to discuss thesefindings. Using safety as his or her guide, the preceptor can relay these findings and emphasize thatwearing rings may, in fact, cause injury to thewearer or to patients. For example, a ring maybecome caught while the nurse is preparing surgical equipment and result in an injury, laceration,or avulsion. The ring may become contaminated
RP IMPLEMENTATION GUIDE: ATTIREwww.aornjournal.orgFigure 4. Fanny packs, backpacks, briefcases, and other personal items that are constructed of porousmaterials may be difficult to clean or disinfect adequately and may harbor pathogens, dust, and bacteria.with unknown microorganisms during a surgicalprocedure, causing the skin beneath the ring tobecome colonized. If nurses prefer to place jewelry in a personal locker or pin jewelry to theirclothing, they increase the risk of losing it. Ringsmay become dislodged or misplaced. Rings wornbeneath gloves may be accidentally removed withthe gloves and possibly lost.Shoe selection also is important, and perioperative personnel should wear clean shoes withclosed toes and backs, low heels, and nonslipsoles.6 Shoes made of cloth or that have holesor perforations are not recommended. Perioperative nurses should adhere to OSHA regulationsthat pertain to the choice of footwear in thepractice setting related to potential hazards suchas needle sticks, scalpel cuts, and splashes fromblood or other potentially infectious materials.Cloth shoes or shoes that have open toes orbacks, for example, increase the wearer’s riskof sustaining a sharps injury from a droppedinstrument or being exposed to blood or otherbodily fluids.Perioperative nurses maintain a high commitment to evidence-based practice and research.Therefore, when health care personnel questionthe prohibition of fanny packs, backpacks, orbriefcases in the semirestricted or restricted areasof the perioperative suite (Figure 4), the perioperative nurse must be able to cite literature relatedto studies confirming the growth of bacteria andmicrobial carriage on fabrics, plastics, or otherporous materials.7-10Stethoscopes may be the most widely usedmedical device in health care. Although stethoscopes are not part of the surgical attire, perioperative health care providers often wear themaround their necks (Figure 5). They are inanimateobjects that can transmit pathogens (eg, methicillin-resistant Staphylococcus aureus) by indirectAORN Journal127
January 2012Vol 95No 1BRASWELL—SPRUCEFigure 5. Identification badges should be secured on the surgical attire top and visible, and stethoscopesshould be clean and not worn around the neck.contact. Cleaning stethoscopes along with handwashing between treating patients decreases thepossibility of pathogen transmission. Nurses canprovide antibacterial wipes for providers to use ontheir stethoscopes at hand washing stations.The perioperative nurse is responsible formaintaining a safe and secure environment atall times; therefore, as a security measure, allpersonnel in the perioperative setting should wearID badges. This allows the perioperative nurse, aswell as patients, to identify all persons authorizedto be in the perioperative setting.11,12 Facilitiescan ensure patient and staff member safety byimplementing policies and procedures related tovisitors in the OR. For example, a health carefacility’s policies may state that on arrival to thefacility, vendors and visitors must check inthrough an automated badge terminal. This willprint a photo/ID badge that contains informationsuch as the date and time, a photograph, the company represented, and the name of the personthey are visiting. On arrival to the perioperative128AORN Journalservices area, the photo/ID badge is presented tothe control center. Vendors and visitors must submit their driver’s licenses to receive an additionalbadge that authorizes their admittance into theOR. On completion of their business, the vendorsand visitors return to the control center to retrievetheir driver’s licenses and return the facility-issued badges. Securing and locking the perioperative suites will add an additional measure ofsafety. Visitors or vendors are to appear at thedoor, ring the bell for help, and be authorizedentrance to the control center. Knowing these procedures are in place before a vendor or visitorarrives at an OR, the nurse can ensure that noperson enters without having followed the appropriate steps. If someone appears without the necessary stickers and badges, he or she should notbe allowed to enter until the steps have beencompleted. The nurse can refer unauthorized visitors or vendors to the control center for furtherguidance and to complete required documentationbefore they are permitted to enter.
RP IMPLEMENTATION GUIDE: ATTIREwww.aornjournal.orgFigure 6. All nonscrubbed personnel should wear a freshly laundered or single-use long-sleeved warm-upjacket snapped closed with the cuffs down to the wrists.Recommendation IIIRecommendation III includes suggestions forhow often to change surgical attire, what to dowhen attire is contaminated, guidelines for reusable and single-use attire, the types of attirethat nonscrubbed personnel should wear, andwearing personal clothing in the practicesetting.1(p61-62)All individuals who enter the semirestrictedand restricted areas should wear freshly laundered surgical attire that is laundered at ahealth care-accredited laundry facility or disposable surgical attire provided by the facilityand intended for use within the perioperativesetting.1(p61)Perioperative personnel should not place wornsurgical attire in lockers to be worn again becausestudies have shown that microbes survive for longperiods on fabrics.9,10,13 Storing used surgicalattire in one’s personal locker can expose theperioperative nurse’s other personal items to microbes that may fall from the fabric of the attire.As previously discussed, the possibility of thetransmission of microorganisms to the nurse’sindividual belongings should be a strong deterrentfor this type of behavior. Perioperative nurses canspeak to their managers and materials management personnel to ensure there is an adequatesupply of surgical attire available for use by personnel to help offset the possibility of staff members retaining used attire in their personal lockers.Surgical attire should include warm-up jackets with long sleeves and snap closures. Members of the nonscrubbed perioperative teamshould wear a freshly laundered or single-uselong-sleeved warm-up jacket snapped closedwith cuffs to the wrist to contain shedding skinsquames from bare arms (Figure 6). Perioperative nurses should don a long-sleeved warm-upjacket before prepping a patient where there isrisk of skin squames shedding. Jackets shouldbe available in a variety of sizes to accommodate every staff member. While prepping thepatient, the nurse should take care that thesleeves of the jacket do not come into contactwith the sterile field.Surgical attire should not include personalclothing that extends above the top neckline orAORN Journal129
January 2012Vol 95BRASWELL—SPRUCENo 1Figure 7. All personal clothing should be completely covered by the surgical attire.below the sleeve (Figure 7). Surgical attireshould be changed daily or at the end of a shiftand should not be worn if it becomes wet orcontaminated. Perioperative personnel whoseattire becomes soiled should change into freshlylaundered attire as soon as possible to preventprolonged exposure to potentially harmful bacteria.14,15 When their bodies are extensivelycontaminated, perioperative staff membersshould bathe before donning fresh attire.14,16The perioperative nurse, as an advocate, shouldassist other perioperative personnel with theopportunity for changing contaminated, soiled,or wet attire. The perioperative nurse may needto contact the charge nurse or floor managerand request an additional perioperative teammember to relieve the team member whose attire becomes soiled while the change occurs. Ifthis is not immediately possible, as soon astime permits, the affected
Key words: AORN recommended practices, surgical attire, cover apparel, home laundering. T he revised AORN “Recommended prac-tices for surgical attire” document was published electronically in AORN’s . CNOR, Lisa Spruce, 3.6 Implementing AORN Recommended Practices for Surgical Attire) .
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Key words: recommended practices, retained surgical items, sponge count, sur-gical count, unretrieved device fragments, adjunct technology. T he revised “Recommended practices for prevention of retained surgical items” was published electronically in July 2010 and in the 2011 edition of the AORN Perioperative Standards and Recommended .
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Braswell, M.L., Spruce, L. Implementing AORN Recommended Practices for Surgical Attire, AORN. (January 2012) 122-137. doi: 10.1016/j.aorn.2011.10.017 “It is recommended that perioperative personnel in the semi-restricted and restricted areas wear facility-approved, clean, freshly laundered, or
elections. For 2018 candidates, we have revised the AORN Statement on Campaigning to make you aware of what is and is not acceptable. Please read and return the AORN Revised 2017 Statement on Campaigning Acknowledgment on page 15 of this handbook by September 5, 2017. By mail to: AORN Attention: Hannah Campbell 2170 S Parker Rd, Suite 400
This article focuses on implementing the revised AORN “Recommended practices for hand hygiene in the perioperative setting.” The content of the document has been
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