2013 aorn rp's for surgical attire

7/21/2019 2013 AORN RP's for Surgical Attire

http://slidepdf.com/reader/full/2013-aorn-rps-for-surgical-attire 1/13

2 3 i t i o n ~

Perioperative

Standards

and Recommended

Practices

For Inpatient and

mbulatory Settings



Recommended

Practices

for

Surgical

ttire

T

e following Recommended

Pr

ac

ti

ces for Sur

gica

l Attire were

developed

by

th

e AORN Rec

omme

nd

ed Practices

Com mitt ee a nd ha v e

been

approved

by th e AORN Board

of

Directors. They

were

prese

nted as proposed reco

mm

e

nd

ati

ons

for

commen ts by members and others. They

arc ef

fec

ti

ve

November 1, 2010.

The

se reco

mm

ended practices are

in teuded as ac hi evable recommendation s rep resent

ing what is beli

eved

to be an optimal level of

pra

c

ti

ce

. Po li

cies

and

procedures

will reflect variations in

practice se ttings and

/o

r clinical situations that

dctcr

miue the degree to w hich the rec01nmended practices

l:an be implemented. AORN

recogniz

es the various

se t t in gs in whic h pe riop

era

ti ve nurses p rac ti

ce.

These recommended prac tices are in tended as guide

lines

a

daptabl

e to

var

i

ous practic

e

se

ttin

gs.

Th ese

practi

ce

se tt ings

include

traditional operat ing rooms

(ORs).

am b

u latory surge ry ce

nters,

p h ys i c

ian

s'

offices, card iac catheterization laboratories, endoscopy

suites ,

rad

iology depar

tm en

t

s,

and

all

o

th

er areas

where

surgery and other invasive procedures may be

pe rformed.

Purpose

These recommended practices

provide

guidelines for

s

ur

gi

ca

l a ttire

in

c

ludin

g j

ewelr y

clothing , shoes,

hea d coverings, masks , jackets, and other accessories

worn in th e semires tri cted and restricted areas of th e

surgica l or

inva

s ive procedure se tt ing. The hu man

body a

nd inanima

te surfaces

in

herent to the s

ur

gical

environment are major

sourc

es

of

microbial co ntami

na tion and transmiss ion of microbes; there fore, su rgi

cal

at t

ire

an

d

app

ropriate perso na l

pr

ot

ec

ti ve

eq uip

ment (PPE) are wo rn to p romote

wo

rker safety and a

high leve l of

clea

nlin

ess

and hygiene wi

thin th

e peri

ope

ra

ti

ve tmv i

ro nm

ent. These reco mm

ended

p r

ac

tices arc not intend ed to address steril e s urgical attire

worn

a t th e surgi

ca

l field

or

all PPE.

Recommendation I

Surgical

attire s

hould be

made of low-linting material

contain

shed skin squames

provide comfort

and promote a

profes-

sional

appearance .

In a

pr o

sp

ec

tive

intervent

ional study of surgical att

ir

e

tha t wa s motiva ted by a n increase in endo phthalmitis

a ft er

ca

t

arac

t surgery, researchers co mpared several

t

ype

s of

po

lyester scrub att ire a

nd

c

otton

scrub a

ttir

e.

They found tha t surgical attire made of

100

spun

bond

pol

ypropylene decreased the bac terial load in

th e

air

by 50 co

mp

ared to

co tton

surgi

ca

l a

ttir

e.

R

esea

rchers also

fo

und tha t s

ur

gica l a tti re helps con

tai n

bacte

rial she

dd

ing and promotes environm ental

cont roJ.l In anoth er s

tud

y researchers found that th e

design of

the

s

ur

gical att ire was not as impor tan t as

th e material

of

whi ch it

was

mad c.a

I.a. Surgi

ca

l att ire fab rics sho uld be tight ly woven ,

stai n res istant , a nd du rabl e. S

ur

gica l at t ire

should provide comfort in terms of des ign, fi t,

breathability

and

the we ight

of

the fab ric.

Co

tton

fab r ics with

pore

s grea te r

th

an 80

mi crons may

allow

mi croorga nisms attac hed

to skin squam

es

to pass th rou gh the interstices

of

the material's weave.MTight ly woven

su

rgi

cal atti re (co

tt

on and

pol

yes te r [50/50) with

560 x 395 th read

s/1

0 em)

reduced

th e amount

of

bacte ria

shed

into the a ir by two to five

t

imes

, with th e excep ti on of me

th i

ci ll

in

r

es

is ta

nt

taphylococcus idermidis

(MRSE)

from MR

SE

c r r i e r s

Lb. Surgica l attire ma

de of

100 co tto n fle ece

should not be worn .

Scme fabrics made of co tton fleece materi al

co

ll

ec

t

and

sh

ed

lint. Lint may harbor microbial

l

ad e

n

du

st, ski n s

quam

es , an d res pi ratory

drop lets . In ad d it ion, fleece is made

up

of a

napped

sur

f

ace

w ith low

de

nsity

which

ren

ders t

more

Cotton fiber is one of th e mos t flam mable

fibers, and 10 0 co tton fleece wi th out fire

retard

an

t ch

em

ical treatment docs not m

ee

t the

federal flammability s tandard. z t Cotton blen

ded

wi th 10

to

20

po lyeste r may redu

ce th

e

fla

mm

ability u bu t th is is not alwa

y:;

success

ful. Application

of

a fire-r

etarda

nt chem ical

still may be re

quir

ed.a

Recommendation II

Clean surgical

attire

including shoes

head

covering

masks

jackets and

identification

badges should be worn in the

se

mirestricted and restricted areas

of

the surgical or invasive

procedure setting.

l.

lean a tt ire

minimi

zes t

he

intr

od

uction of

mic

r

oor

ganisms

am

i lint from health care perso nuel to clean

items and th e en

vi

ron men

t. I

Il

.a. Faci lity

-appro

ved, clean, and fres hl y la un

der

ed

or

dispo

sable sur

gica

l a ttire should

be

do n ned daily in a des ignat ed d ressing area

before entry or reentry into the semirest ricted

and res tricte d areas.

Changing from street ap

pa

re l in to fac il ity

approved , clean , and freshly laundered or dis

posa

ble

surgica l att ire in a de signated ar ea

decreases the po ssib ility of cross-contam ination

and assists with tra ffic co ntrol.

20

13 Perioperative Standa

rd

s and Recommended Practic

es

51

La

st rev

ised

: Oct

ober

2010. Copyright

©

2013

ORN

In

c. Al rights r

eser

ved.



_

RP

Surgical

ttire

Il.a.1. When donning surgi cal attire, care s

hould

be taken to avoid contact of the clean attire

with the floor

or

other possibly co

nt

ami

nated surfaces.

II.a.2 . When wearing a two-pie ce scrub suit, th e

top of the scrub suit should be secured at

th e waist , tu cked into the pants, or lit close

to th e

bod

y to

pr e

vent

sk

in sq

uam es from

being dispersed into the environment.

Loos e sc r ub

tops

may a ll o w sk in

squames

to

disperse

into the

en

v

ironment

from

th

e axilla

and

ches

t. Th

e major source

of

bacte ri a dispersed into

th

e

air comes

from hea lth care providers' skin .

IJW.

When

s

kin

s

qu

ames

co

m o off the body s

urfa

ce,

they carry any microorganism that is found

on

the

su r face of

th

e indi vid ua l' s skin.

Every individual loses a complete layer of

s

kin

every four da

ys

(

about

10 ' s kin

s

quam

es every day . With just the move

me

nt of

wa lki ng, this may

cause

a loss

of

10

' s

quame

s

per minute.

u.u

II.a.3. Hea lth care personn el shou ld change into

s tr ee t

clothes

wh enever th ey leave th e

health car e facilit y or when traveling

betw een

building

s located on

separa

te

ca

mpu

ses.a

Surgical attire may become contam inated

by direct

or

indirect contact with the exter

nal environment.

II.b. Jewelry including earrings, necklaces, watches,

and bracelets that cannot be contained or con

fined

within th

e surgical attire s

hould not

be

worn.u Jewelry that cannot be confined within

the

surgica

l

attire

s

hould

be re

mo

ved

befor

e

entry in to th e se mi res tricted and restricted

areas.

Necklaces on the skin may con taminate the

front

of

the steril e gown

if

they are

not

confined

w

ithin the

surgica l attire.

Wea r

in

g fin

ge

r rings,

nose ring

s, a

nd

ear

pierc

in

gs increases bacteri al counts on skin sur

faces

both when th

e jewelry is

in pla

ce

and

a fter

removal.

One

study showed that earrings had

bacterial counts mo re th an 21 times hi gher

benea

th th

e earrings than on

th

e surface

of th

e

earrings. Bacterial co

un t

s w ere nine time s

greater on the skin beneath finger and nose rings

th

an

on

the rings themselves.

The

removal of watches

and

bracelets allows

for

more thorough hand

washing.

llll

Researc

h

ers

sa mp led

100 wristwatch wearers

in

the

hea lth care environment and f

ound

that imme

diatel

y after

th

ey removed

their

watches, 25

of th e wristwa tch wearers' wrists had positive

cultures for

Staphylococcus aureus a

II.b.1. Rings s

hould

be removed before hand

was

h

ing

or

using

hand

rubs.

52

Several studies have shown that wear

in

g

rings may r

esult in

co l

onization of health

care

providers' hand

s

wi th

gram-negative

and gram-positive pathogens .ll.JJ ill Finger

rings

ha

ve been found to increase

skin

sur

face bacteria l co unts. Although hand wash

ing

re

du ces th

ese

co

un ts,

th

ere are

more

bac teria und er rings than on th e adjacent

skin or th e

opposite

hand .

The

pathogens

id e

ntified in

one s

tu d

y were

coag

ulase

negativ

e st

ap

hyl

ococc

i ,

other

sk in flora

,

gram-negativ e cocci, Pseudomonas spp , and

Staphylococcus aureus

u

Removing rings be fore hand washing

may decrease th e potentia l for pathog

ens

to

rema in on

hand

s after hand washing .u

Removing ring s before hand hyg iene may

enh a nce the

effec

ti v ene ss of

th

e hand

hygiene procoss.ll

II.

c. Persons entering

th

e semirestricted or restricted

area s of the surgica l Sllite for a brief time for a

specific

purpo

se (eg, l

aw

enforcement officers,

parents, biomedica l engineers) should cover all

h

ea

d and facia l hair and s

hould

don either freshly

laundered surgical attir

e;

s

in

gle-use attire; or a

single -u se

jumpsuit

(eg, coveralls,

bunn

y suit)

designed to completely cover outside app3rel.

Clean a

nd

freshly laundered surgica l attire,

single-use attire, or single-use jumpsuits

donned

before entry into the se mirestricted and restricted

areas may minimize the potential for contamina

tion

of

the environment and cross-contamination

of

the attire (eg, animal hair, cross-contamination

from other uncontrolled environments, spores in

soil).

ll .d. Shoes worn within the perioperative environ

me

nt

should be clean Y·

Soiled s

ho

es

ha

ve

been found

to

contribute

to en v ironmental co nt

am

in a tion within th e

per

ioper

a tive environment. A s

tudy of shoes

worn outdoors and shoes worn only in the s ur

gi

ca

l sui te showed 98 of th e outdoor s hoes

were contaminated

wi

th coag

ul ase

-n egati ve

staphy lococci, co liform, a

nd

bacillus spec ie s

compared to 56 of the shoes worn only

in

the

sur gical

suite. Bacteria

on

the

periop era ti ve

floor ma y contribute up to 15 of co lo ny

forming

unit

s (CFUs) ,

whic

h are di spersed into

th e

air

by walking. Shoes that are

worn oniy

in

th e perioperative area may he

lp

to reduce con

tamination

of the

perioperative n v r o n m

II.d.l.

Shoes worn w ithin tho periop erative envi

ronment should have closed toes and backs,

low hee ls, non-skid so les, and must

me

et

Occupational Safety Health Administra

tion (OSHA) and

the

health care organiza

tion's safety requirements .u

Shoes that enclose the foot

with

backs,

low hee ls, and non-skid soles may red uce

the risk of

injur

y from slips and falls and

from dropped

it

ems. The OSHA regulations

r e

quir

e th e use of protec tive footwear in

areas where

th

ere is a

dan

ger

of

foot injuries



f

ro

m fa ll i

ng

or ro ll i

ng

obj ec ts or objec ts

piercing the sole. Th e employer is responsi

ble for determining if foo t injury hazard s

ex ist and what, if any, protec ti ve footwear is

required.an The OSHA reg ulations man da te

that employers pe rform a workplace hazard

risk assess ment and ens

ur

e that employees

wea r protec

ti

ve foo

tw

ear to provide protec

tion

fr

om i

dent i

fied po tential hazard s (eg ,

need les ticks, scalpe l cut s, spl as

hin

g from

bl ood or o th er p

oss

ib l y

in

fec tiou s

mat

er

ials).=

Sh

oes th

at h

ave

hol

es or

pe

rf

ora

tion

s

may not protec t the fee t from ex posure to

bl ood,

bo

dy flu ids,

or

o

th

er liquids that may

conta

in

potentially infecti ous agents. Shoes

made of

clo

th , that are open-toed , or th at

have holes on th e top or sides do not o

ff

er

prot

ec

tion against spilled

liquid

s or sharp

items that may bP. dropped or kicked.

In

one

study, 1 5 different types of sh

oes we

re

tes te d with

an ap

p

ara

tu s th a t m eas ur ed

r

es

istan

ce

to penetration by scal

pe

ls. The

materia ls o f

th

e sho

es inclu

de d lea

th

er ,

suede, rubber, and canvas. Sixty pe rcent of

th e sho es sus tained sca lp el p en etra ti on

through the shoe

in t

o a s imuiated foot. Only

six materi als pr eve

nt

ed complete penetra

ti on . These mat

er

i als in c

lu d

ed sn ea ker

su ed e , s u ede w ith inn er m es h lining,

le

ath

er with inn er c

an

vas

linin

g, n on

pl ia

bl

e lea

th

er,

rubber

w

ith inn

er lea

th

er

lining, and rubber.=

I.e.

Id

entificati on badges should be worn by all pe r-

s

on n

el authorized to enter th e perioperative s et

tin g.

;tU,l

Health ca re pers

onn

e l

as

we ll as

patients s hould be able to identify caregivers .

Id

en

ti

fi

cation badges ass ist

in

identifying

per

sons authorized to be in th e perioperative setting

and sup

po r

t security meas

ur

es.:u.u

II. e. 1.

Id

entificati on badges should be secur ed on

th e surgical attire top, be vis ibl e, and be

cl eaned if they beco me soiled .

Badge hold ers suc.;h as lanyards, chains,

or b

ea

ds pose a risk for contamination and

may be very difficult to clean. One study of

identification badges

and

lany

ard

s showed

that th e median bacterial load isolated was

10-fo

ld

grea ter for lanya

rd

s (3.1 CFU

/c

m' )

th

an for identification badges

0.

3 CFU

/c

m' ).

The microorganisms recovered

fr

om lanyards

and

id

entifica ti

on

badges we re methicillin

sens

it i

ve ta ylococcus aureus

M

SSA),

methi cillin-resistant taphylococcus aureus

(MR

SA

), Enteroco

cc

us spp, and enterobacte

riaceae.n As with other personal attire, such

as s tethoscopes, id entification badges become

contamin ated over time.

ll.f.

Th

e use of cover app ar el (eg, lab coat , co

ver

gown) may be det

ermi n

ed at each

indi

vidual

pr

ac ti ce se

ttin g base d on s ta te

reg

ul a

to ry

RP Surgical ttire

requirements and th e culture of the health care

organization.

Wea ri ng cover app arel over surgica l attire

ou ts

id

e of th e p eri

op

era ti

ve

suite may be

required for some health care personne l in some

hea

lth

ca re organi zati ons for a va rie ty of rea

so ns , which may include profess ional ap pear

ance . This may be based on th e belief that cover

a

pp

arel decreases th e risk of

in f

ect ion.

Th

e use

of cover appare l has been

fo

un d to have littl e o r

no effect on reducing con tamination of surgica l

attire.; §

II.f.1 . Cover apparel should be laundered daily in

a health care-a

pp r

oved or -accredit ed laun

dry facility. (Sec Recommendation V.)

Health ca re personnel may carry staphy

lococci and enterococci on their clothin

g,

which may include surgi

ca

l atti re a nd cover

ap p are

t.

u Studi es of

cove

r appa re l have

shown that rath er

th

an pro tecting the cloth

in g

un d

e

rn

ea th th e cover gown,

cove

r

a

pp

arel m

ay

c

on t

aminate th e clo

th

es worn

un d

er th e cover a

ppa

re l. Researchers have

found that cover appa rel is not always di s

carded daily a fter use or laundered on a fre

quent basis.llll

In one s

tu

dy of cov

er

coats worn by 100

physicians,

ta

ylococcus aureus

was iso

lated

fr

om

25

of

th

e cover coats . The cuffs

and pockets of th e

coa

ts

we

re th e most

con taminated.

D

In anoth

er

study of 100 medical students,

mi croorga ni sms were

fo

und on the cuffs

and side po ckets of th e s tu de nt s

cove

r

app are

l.

Contamination was found un their

domin

ant

hand

sleeve cuffs a

nd

th e backs

of the cover apparel 10 em down from th e

co llar. These areas were contaminated with

Staphylococcu s s p on a

ll

cover app arel ,

Ac

in

etobac t

er

sp on seven stude

nts

cove r

ap p

arel, an d diphtheroi ds on 12 s tudents

cover appare

ll

In a st udy of hea lth care prac titioners'

cover appare

l,

researchers

fo

und that cover

app arel in

in

pa tient and

outp

atient areas,

in tensive

care

units, adminis tra tion areas,

a nd th e OR wa s co nt aminate d

with

ta

ylococcus

aureus, which in clud ed

sus cep tible and resistant iso lates . Health

care perso

nn

el

with

colo

ni

zation

we

re more

like ly to have home-laundered

th

eir cover

ap parel. Two-thirds of the h

ea

lth

ca

re

pr

ac

titioners perceived their cover apparel to be

di rty be

ca

use it had not been was hed in

more than a week. JI

Il.g. Ste th oscopes sh o

uld

be cl ean and not wo rn

around the neck.

Ina ni ma te objec ts, such as con taminated

stetho

sco

pe tubing and diaphragms, may trans

mit pa thogens such as MR SA by indi rec t con

tact (eg , by wearing

th

e s te

th

oscope around

th

e

53



~

Surgical

Attire

ne

ck a

nd

co

ntaminating

th e s kin a

nd

surgical

a

ttir

e

).

ill Clea

ning

ste th oscopes in combination

wit

h health care personnel was

hing

th eir hands

b

etween

caring for

patient

s decreases

th

e po

ss

i

bility

of

t

ransmission

of pa th ogens to patients

and environmen tal

su

rfaces.

Steth oscopes ma y be th e mos t wide ly used

medi

cai dev ice in a he a lth ca re fac ility.

11

Although stethoscopes

are

not co ns idered par t

of

the surgical a ttire, health

cam provide

rs often

wear th em around th eir necks as th ough th ey

wer

e part of s urgical attire.

Ste

th oscopes

come

in

di r

ec t con tac t with patien ts skin

and

co uld

prov id e an oppor

tunit

y for tr ansm i

ssio

n

of

microbes from patient to patient, to h

ealth

care

perso

nn

e l, o r from hea lth

ca

re personnel to

patients. One s

tu d

y verified th at ste thoscopes

could be a vect

or

for transmiss ion to

patient

s.n

Anoth

er s

tu dy

condu ct

ed on

ste

th oscope

dia

phrag ms noted that , w h

en

cultured before

cleaning,

79.8

%

of

th e c

ultur

es gr

ew

gram-positive

baci lli ,

74.8 % h ad S t

aphy

l

ococcus spec

i es

non-aureus,

2.5% of baseline c

ultur

es sho we d MSSA , and

group A s treptococcus

wa

s

fo

und in 1%

of

cu ltures.u

A s tu dy showed recontamin ation of stetho

scopes cun occur by th e fifth time th e stetho

scope is used on different patients. The number

of

ba

cteria on a ste

thoscope

increases

with

each

use.u

Cleaning

th e steth oscope daily m

ay not be

adequa

te; clea ning s te

th oscopes

may be

requir

ed

betw

ee

n

ea c

h

pati

e

nt

u

sc

.

Several

s

tudi

es

on

c

ontamination of

ste

th o

scope di a

phragms a

nd

ea

rp i eces have heen c

ondur;t

ed

and

sh

ow

that 66 % to 100%

of

the diaphragms

are co nt

a

mi n

a ted.

11

One

s tu d y

no t

ed

th

a t to

avoid inc reasing e me r

ge nt

s tr ai ns, routin e

cl eaning of stethoscopes may help reduce bacte

rial

colony

coun ts.

II. g.1. Fabric ste

tho

scope

tubin

g covers should not

be used.

Addin

g fabric covers to steth oscope tub

ing may result in th e

cove

rs

ac tin

g as fomi

tes. One study of s tethoscope fa bri c covers

isolated gram-positive

aerob

i c bacteria ,

gram

-nega

tive

aerobic

bacteria,

a

naerob

es,

and yeas t. The

average

l engt h

of

time

between stethoscope cover laundering was

3.7 months, with some fabri c

co vers

that

were neve r laundered. §

II.h.

Fann

y packs, backpacks,

and

briefcases s

hould

not

be taken into the se mirestricted or restricted

areas

of

the peri

opera

tive s

ui te.

Item s

br

ought in to

th

e OR , such as fanny

pa

cks, backpacks, briefcases, and other

pe

rs

on

al

items that are constructed of porous materials,

may be difficult to clean or di sinfect adequately

5

and may harbor pathogens, dust,

and

bacteria. iZ II

Pathogens have been shown to smvive on fabrics

and plastics. i\l.lll Dust is made up of skin par ticles,

ha

ir

, fabr ic fibers, pollens,

mo

ld, fu ngi, in

sec

t

par ts, gl

ove powd

er, and paper fi bers, amo ng

other things . Bacteria may be

transport

ed from

one location to another by carriers such as dust

or

liquid

s,

and

may co

ntaminate

fan ny packs,

backpacks, and briefcases. iJ .mi

Th

e

type

of

envi

r

on

ment al surface an d its

ab ility to support microb ial grow

th

wi ll in flu

en

ce

microbial ca rriage. Gram-positive cocci (eg,

coagulase-negative st

aphy

lococci) may

per

sis t in

dr

y se tt ings. Settings that are moist and so iled

may support

gram-negative bacilli (eg,

fl

oors).

Fungi favo rs moist, fibrous material and are also

found in dus

t.

l

Recommendation ll

All Individuals who enter the semirestricted

and

restricted

areas

should

wear

freshly laundered surgical

attire that

is

aun

-

dered

at

health

care accredited

laundry facility or disposable

surgica

l

attire

provided by the facility

and intended

for use

within

the

perioperative setting.

Surg ica l a

ttir

e he

lp

s con ta in ba cterial sh

ed d

i

ng

and

promotes env ironmenta l cleanliness.

An in d ivid ua l

sheds

mill

ion s o f s

kin

squames daily. Five percent to

10% of sk in squames carry bacteria.a In a study on dis

persal of MRSE, carriers of MRSE were

seen

as possi

ble sources

of air

contam ination in OR

s.

}

Ill.a. Surgical a ttire should be changed dai ly

or

at the

end of the sh i f

t.

u

t

h

as

bee n reported that surgical at t ire may

h

ave bacteri

al

co

lony

co

un t

s

th

at

are hi

gher

when

sc r

ub clothing is remo ved, s tored in a

l

ocker,

and

usud agai

n.

Microbes

have been

s

hown

to survive for long periods

of

time on

fabrics such as surgical attire. ilUll.}}

III.a.1. Reusa ble or single-use

con

t

am

ina ted attire

s

hou

ld be placed in app ropria tely desig

nated

containers

after use. u Worn re

usable

surgical att ire should be left at

th

e he al

th

ca re facility for lau nd

er

ing.

III. <J.2. Surgical attire that h

as been penetra

t

ed

by

blood or ot her po tentially infectious materi

als s hou ld be

removed

im med iate ly or

as

soo

n as possible and

replaced

with

freshly

iaun de red, c l

ean

surgica l a tt i re.

When

ex

tensive contamina tion

of

th e

body occms,

a shower or bath

shou

ld be taken before

donnin

g fresh att ire.=

Changing con tam

in

ated, so iled,

or wet

att ire

reduces

th e

potential

for

contamina

tion

and

protects personnel from prolong

ed

exposure to potentially harmful bacteria.I i.u

III.a.3 . Wet

or

co ntamina ted

surg

ical att ire should

not

be rinsed or sorted in th e loca tion

of



Rinsing or sorting

co

nta

min

ated reusable

a

ttir

e may

ex pose th

e hea lth ca re

worker

to blood , body fluids, or other liquids that

may conta in po tentiall y

in

fecti ous agents

a n d may co nt aminate th e pa t ie nt care

environment .ll

lll. a.4. Surgica l a

ttir

e con t

amina

ted w ith visi bl e

blood

or body

fluid

s

mu

s t r

emain

at

th

e

health care facility for la

un d

ering or be sent

to an accred ited laun

dr

y f

ac

il ity cont r

ac

ted

by th e health care 1 l i . A . l i - ~

Co

nt r

olled la

un d

ering of a ttire contam i

nated by bl

ood or

body flui ds redu

ces

th e

ri

sk

of trans ferring

path

ogenic microorgan

isms from the f

ac

il ity to the home or ge neral

p u b l i

(Sec Recommendation

V.

)

lll.b. When in th e se

mir

estricted or restric ted areas,

all

no n

sc rubb

cd

personn

e l s h ou l

rl

wear

a

fr

es

hl y la

un d

ered or s ingle-u

se

long-s

leeved

warm-up jacket snapp ed closed with the cuffs

d

ow

n to

th

e w

ri

sts.

Wearing the warm-up jacket snap ped cl

osed

pr

event s th e edges of th e front of th e jacket from

con tamina ting a skin prep ar

ea

or th e sterile

s

ur

gical

fi

eld. Long-sleeved attire helps c

ontain

skin s

qu

ames s hed from bare a rms.

ll l.b.l. All personal clothing should be comp letely

cove

r ed by

th

e s

ur

gi

ca

l att

ire

. U

nd

ergar

ments such as T-shirts with a

V-n

eck, w hich

ca

n be contai ned u

nd

erneath

th

e

scru

b

top

,

m

ay

b e

wo rn

; p er

so

na l c lo thin g th

at

ex t

ends

above th e

sc

rub top nec

kline

or

be low th e s leeve of the surgi

ca

l a ttire

sh

ould not be worn.

Personal c lothing is not la

un d

ered by a

health care-accredited la

undr

y faci li t

y.

(See

Recommendation V

)

Recommendation IV

All personnel shouldcover head and facia l hair including side

burns and

the nape

of the neck when in

the

semirestricted

and

restricted areas

Head cove

rin

gs co

ntai

n s

kin

s

qu

am

es

and

hair

shed

fro m th e

scalp

.

t

is impo

rtant

to

pr

event shed skin

sq

uames from

fa

lling o nto

th

e s terile

fi P

Ir

J.

u.» A

lthou

gh

group

A s tre

pt

ococcus is isolated in less

th

an 1 of

s

ur

gical site in fec

ti

ons (SSis)

i

e, 1 pe r 10,000), it is a

se rious

cau

se of SSis a nd can be carried on th e

An outbreak of SS is wa s attribut ed to g roup A

t i c

Streptococcus carried on the scalp

of

peri

op erati ve per

so n

nel.

Th

e report

id

entified group A

St

rep

tococcus in 20 patients w

ith

an SS

I.

In the outb

re

ak investigation, 88

pe r

iopcrative person

nel

we

re c

ultu

red . One was found to h

ave

eryth ema

and scaling o n th e sca

lp

a

nd

ears and under

the br

east.

Th

e

indi

vidual was

tr

ea ted with medica tion a

nd

relo

cated to a non-patie

nt

work area,

and

the o utbreak was

r e s o

RP Surgical Attire

Human ha ir can be a

site

of pa th

ogenic

b

acter

ia

such as MRSA. Routin e shamp ooing of hair

wi

th neu

tral detergents docs not remove

MR

SA

or

have a bacte

ricidal effec t.lill

IV.a. A clea n , low-lin t surgical head cover or hood

that

co

n fi n

es all

ha ir

and covers scalp skin

should he worn.

The

head cover or hood

shou

ld

be des i

gne

d to

min

i

mize

micr

ob

ial

dis

persa

l.

Hair acts as a

fil

ter when it is uncovered and

co lle

ct

s bacter ia

in propor

ti on to its lengt h ,

wa vin ess, and oiliness . Stud ies have shown that

t

p

hy locuccus ureus an

d a p h y

o c o c c u ~ >

epi

der

m

id

is

have a

tende

ncy to co lonize hair,

skin , and the n

asop

h

ary

nx.lill Head

cove

rings

designed

to

contai

n

hair

and

sca

lp

sk

in will

minimize microbial

dis

persaJ.

ll

Skull caps may

fa

il to contain the

side

ha

ir

above

and

in fron t o f

the ca rs and hair at the

nape of

the neck.

IV.

a.

l .

Us

ed

single-

usc

h

ead cove

r ings sho

uld

be

removed an d

disca

r

ded in

a des i

gnate

d

r

ecep

tacle dai ly

or

when co

nt

aminated.

Placing con tamina ted h

ead

coverings

in

a des ignated receptacle assists in mainta in

ing a clean and orderly area and

dec

reases

the possibi

li

ty

of

cross-contamination.

lV.a.2. Reusab le head cover

in

gs shou ld be

laun

de

red in a hea lth ca re-accred

ited

lau ndry

fa

cility a fter eac h

da

ily u

se

.ll (See

Re

com

mendation V.)

Recommendation

V

Surgical

attire

should be laundered in a health care-accredited

laundry

facility.

Surgica l a

ttir

e; street clothing; PPE; and other hospital

textiles (eg, bed linens, towels, privacy

cur

ta

in

s, wash

clo

th

s ) m

ay

b

ecome

contami

n

ated

by

bac

ter

ia

a nd

fu ng i during

wea

r or use. In

one

st udy, researchers

foun

d that mi crob

es

can survive on hosp ital textiles for

extende d periods of time. These text iles included

• 100 cotton cloth ing;

• 60 co tton and

40

polyes ter blend (eg, scrub

suits, lab coats);

• 100 polyes t

er

cloth in

g;

a

nd

• pol

ye th

yl

P

ne plastic

aprons

.

Researchers inoculated these tex tiles with stap hylo

cocc

i under laboratory

co

ndit ions.

Th

e textiles

we

re

a llowed to remain in ambient air with

ou

t any launder

ing for vari ous periods

of

time. Results showed that th e

s taphylococci s

ur

vived one to 56 days on po lyester

and

up

to 90 days on polyethylene plasti

c.

The larger

th e mi crobial inoculum of staphy lococci on polyes ter

a

nd

pol

ye th

ylen

e, th

e longe r th e sta

ph

yl

ococc

i sur

vived. Even if only a few hundred staph ylococci sur

vived, th

ey

were viable for clays on most textiles. The

shor tes t time fo r enterococci survival on tex tiles was

11 days.

Wll

Researchers in another stu dy tes ted fungal s

ur

vival

unde

r laboratory

conditions

on

• 100 cotton cloth in

g;



RP

Surgical

ttire

•

60 co tton and 40 polyes t

er

blend (eg,

scrub

suits, lab coats, clothes);

• 100

polyes ter c

lothin

g; a

nd

• polyethylene plastic aprons.

The microorganisms

used

as the

in oc

ulum were

Candida albicans Candida tropicalis Candida krusei

Candida parapsilosis Aspergillu s flavus Aspergillus

fumigatu s Aspergiilus niger

As

pergillu s terreus

Fu

sa rium

sp ,

Mucor

s

p,

a

nd Paec

ilomyces s p.

These

pathogens were isolated in the researchers ' hea lth care

facility. The

da ta

co

llect

ed

showe

d

th

at

ca

ndid

a,

aspergi llu s, mucor,

and fu

sarium, which are known to

be hea lth care-associa ted

in f

ec tious agents, s

ur

vived

on fabrics and plastics

fo

r at least one day a

nd

often f

or

weeks.

Th

e survival

of the

se microorganisms

on

these

textiles and plastics shows that they may serve as rese r-

voirs or vectors for f u n g Another study showed that

Staphy lococcus aureus

and

P

seudom

onas aeruginosa

bind to polyester and acry lic fib ers. tl

Hea lth care-a

ccredited

l

aundry

fa c ilities are

pr

e

fe rred because th ey fo ll

ow

indus

tr

y st;mdards. The

H

ea lt hcare

La

un d

ry

Accreditation

Co

un

r.i

l (HLAl.)

offers voluntary accreditation for those la

undry

fac ili

ties that

process

reusable

h

ea lth

c

ar

e t

ex

ti l

es and

which incorporate OSHA

and

th e Centers for

Di

sease

Control and Preven ti

on CD

C) guideli nes and

prof

es

s ional association

recommended

practices.

Th

e HLAC

stand ard s for accred itation include,

but

are not limited

to,

• Tex ti le

quality cont ro

l

procedure

s

are defin

ed

and impleme nted.

•

The in vs ntor

y

sy stem

is ad e

qu

ate to ens

ur

e

supply.

•

So

il ed a

nd

cont

am inat

ed tex tile areas are

se

pa

rated by a

ph y

sica l barr ier.

•

Th

e ventilation is

controll

ed

with

negative

pr

es

sure in the so iled area, pos itive

pr

ess

ur

e from the

clean

textil e area through th fl

so

iled textile area, 6

to 10

air exc

hanges

per

hour, a

nd

a ir vented to

the outside.

• Clean textiles are stored

in

an area

fr

ee of vermin,

dust, and lint and at room te

mp

eratures of

68°

F to

78

° F (20° C

to

25.6° C).

• Storage shel ves are in ch to 2 inches from th e

wa ll,

th

e bottom s

helf

is 6

in

ches to 8 inches

fr

om

th

e floor, and

th

e top shelf is 12

inches

to

18

in

ches below the

ce

ilin

g.

• Hanel washing faci lities arc located in a ll areas with

soiled t i l e J and washing or antiseptic dispens

ers are in the clean textile area; and employees per

form ha

nd

was

hin

g a

ft

er

glove removal a

nd

rest

roo m use, b

efore eating,

a

nd when hand

s

are

contaminated with blood or other poten tially infec

tious materials.

• Working s

ur f

aces are clean and are disinfected if

they become contaminated with blood or other

potentially infectious material s.

•

The

OSHA Exposure Control Plan is in place and

PPE is s

uppli

ed and ava ilable.

• Personn el tra ining is provided and docum ented.

• Quality control monitoring a

nd

processes arc in

place.

56

• Material Safety Data Shee ts are avai lable for eac h

ch

em

ical used .

• Water quality is tested

on

a regular basis for hard

ness, alkalinity, iron content , and pH.

• So iled health care textil es are hand led, collected,

and

transported according to loca l , state,

and

fed

eral regulations.

• Each wash load is monitored and a

ppli

cab le data

f

or

each wash are recorded, inclu ding cycle, pre

wa

sh , wash , rinse , and final rinse times; wa ter

l

eve

ls

and

usage; tem

pe ratur

es; a

nd

chemi cal

usage.

• Water extraction a

nd

drying are perfo

rm

ed using

methods that preserve th e integrity of the tex ti les

and

minimi

ze bacterial growth.

• Cleaned texti les are packaged and stored in fluid

resistant

bundle

s

or

fluid-resistant carts

or

ham

pers

and

are h

and

led as little as po

ss

ible.

• Carts used for transport or storage are kept clean

a

nd

arc well maintain ed.

• Clean text iles nre stored

and

trnns ported se pn

rately from soiled textil es.

• Vehicles used to transport textil es provide sepa

ration

of

cl ean

and

soiled textiles, a

nd

the vehicle

in teriors are cleaned on a regular bas is.n

R

ou

tine monitoring

of laundry

processes,

including

cl

ea ning of work areas, e

qu ipmen

t , and good

hand

hygiene

pr a

ctices, is

imp

or tant to

minimi

ze cross-

contamin

ation of clean textiles. An acc re

di

t

ed

hea lth

care fa cility lau nd

er

ing process includes monito ring

correc

t

measurem

ent

of

c

hemica

ls, s

ufficient wa

ter,

correct temp erature, mechani cal action, and the dura·

tion of th e washing cyc le. Cleaning and d isi

nfec

ting

th

e work area incl

ud

es, but is not limited to, the wash

ers,

ex

trac tors, d ryers,

and

conveyor belts.

The pre

s

e

nc

e

of

skin

b

ac

teria on

processed

textiles

and

envi

ronmen tal s

urf

aces

in

one study di rec ted attenti on to

ha

nd

hygiene

of

th e lnu

nd r

y facility workers, a

ir

con

tamination, inadequate separation of so iled and clean

work areas, and the cleaning a

nd

disinfecting

of

a ll o t

th e e

qu i

pm ent and work s urfaces. li Water

can

be a

sour ce of

bacterial transmi

ss ion

,

which

makes

th

or

ough

drying

of textil es vitaJ. u Staphylococci ,

Sa

lmo

nella, and Mycobacterium are fairl y res istan t to heat

and may su rvive

Home laun dering is not monitored for quality, consi

s-

tency, or safet

y.

Exposure

of

health care pers

onn

el and

their family members to blood and

other po

tenti ally

infectious ma

tcrh1

ls may rosult

fro

m improper hanrlling

a

nd

decontamination

of

s

ur

gi

ca

l attire. Home washers

may have a lower temperature (ie,

< 160°

F

[71.1o

C])

or

washing parameters and temperatu res may not be adjust

able. Home washers may have limited capacity for c hem

ical

add

iti ves and may

not

have directions for using

alkalis

and

acids.

Home laundering may not meet

th

e speci

fied

mea

s

ure

s necessary to achieve a red uc t ion

in

mi

crob

ial

levels in

so

iled s

ur

gical attire. These measures involve

mechanical,

thermal , and c he mi

ca

l com ponent

s,

includin

g

•

diluting

and agitating the water to remove micr

o-

organisms and bioburdcn;



•

se

lecting suitable

che

mica ls.

if

low-te

mper

a

tur

e

cycles(< 160° F [< 71.1°

C))

are used;

• using

prope

r chemical

concentrat

i

ons

if

lo

w

temperature cycles are used ;

• using water te

mp

era

tu r

es

>

160° F

(>

71.1

o C)

for

more than 25 minutes for hot-water cycles;

• using c

hlorin

e bleach,

which

gives

added

mi cr

o

bicidal benefit: a

nd

•

addin

g chemicals

known

as sour to the water to

neutralize alkali n

it

y

in

th e

water,

soa p , or

detergent.

These measures cause a shift

in pH fr

om 12 to 5,

in

ac tiva

tin

g some mi croorgani sms. Low

temperatur

es

(ie , < 160° F [< 71.1°

C])

may be

us

ed so

lon

g

as

the

dr

y

in

g temperatures and ironing temperatu res provide

th e additional microbicidal benefits to

ensure

surgical

att ire is clean.

ll-lil

A stu d y

on

bac t

er

ial co ntamination of h ome

la

under

ed uniforms beg

an

by c

ulturin

g

uniform

s

worn

at the beginning o f the shift. Thirty-nine percent

of th

e

uniforms identified as clean had one or more micro

organisms

(eg,

va

ncom

yc in-

resis tant

en

t

erococc

i ,

MRSA,

lostridium

diffici/e) identified. Uni f

orms

were

tes ted again at the e

nd

of th e s hift and 54 had one or

mor

e microorganisms; some that were po sitive at the

beginning of the shift were negative at the end of th e

shift. ln o

ne

demonstration, bac

illus

spores

we

re trans

ferred from health ca re

pro

vid er

s'

aprons

and

cotton

uniforms to a mock patient. lill

A s tudy of home

-laund

ered uniforms involved tak

ing

surveill ance

cu

ltur

es from five patie

nt

s . Results

showed

th

at th ree of the patients were

co

lonized wi

th

th e s ame s train of microorgani sm as th at cultured from

th e hea lth care proviclers'

uniform

s . With uniforms

co

ntamin

ated

with

microorganisms a t

the

beg

innin

g of

a s

hift

,

th

e researchers suggested

that inappropriat

e

launder

ing practices may be the cause. lli

Home la

un d

er

in

g has been shown to be less effec

tiv

e for

cleaning surgical

a

ttir

e

than launder

in g

by

hea lth care

fa

cilities

or

commerc

iallaundri

es.lll

A quantitative stu dy was perfo

rm

ed in 20

diff

erent

geog

raphi

ca l areas.

lll

Eight lau n

dering

me

th ods we

re

s

tu

died:

• reusable clean scrubs

laundered

at the facility

in

which

th ey were used;

• reusable

worn

scrubs la

undered

at

th

e facility

in

which

the

y were us

P.d;

• reusable clean scrubs that wore homo laundered;

•

re

u

sa

ble wo

rn scrub

s

th

at

were hom

e

laund

ered;

•

reusable

clean

scrubs laund

er

ed

by

an out

si

de

la

undr

y f

ac

ilit

y;

•

reusab

le

worn

sc

rub

s la

un dered

by an

ou

ts

id

e

laundry facility;

• packaged , clean, s

in

gle-use,

non-woven sc

rubs;

and

• packaged, worn, s

in

gle-use, non-woven scrubs.

Re

sults of the s tudy showed that th e bioburden on

hom

e-l a

und

ered surgical attire was significantly greater

than

on

s

ur

gical attire that was faci lity-laundered; laun

dered by a third-part

y;

or single-use, disposable.

Hom

e

la

un d

ered clean scrubs at the beginning of the day had

RP Surgical

Attire

th e sa me amount of organisms as

did

worn scrubs at the

end of the work day.lll

A quantitative study was performed on cotton strips

of

fabric that were inoculated with 10 mL

of

a viral sus

pension

to discover

if enteric

viruses

i

e, ade

no

virus,

rotavirus, hepatitis A viru s) survive d a home-laundering

pr

ocess

. The

inoculated

fabric s

trip

s

were was

h

ed,

rin

sed,

and dried

on

a 28- minute permanent p ress

cycle in home

w

as

h

ers.

lt

was found th

at

enteric

viruses remained on th e fabric str ips after th ey were

washed.n

V.a

. La

un d

ered surg ica l at ti re sh

ou

ld be pro t

ected

during

trans

port

to the

pr

ac tice

se

tti ng to

pre

vent contamination.

:m

PropP.r

tm n

sfer and storage

of

s

ur

gica l attire

protec ts s urgical attire from contamination by

preventing any

ph

ysical d amage to la

undr

y,

minimi

z

in

g

mi

c

robial

c

ontamination

from

environmenta l surfaces. and

preventing

an

y deposits from airborne sources

such as dust to settle

on

laundry.

Jtu

V.a.l. S

ur

gical attire should be tra nsported in a

cl

ea

n vehicle and e n c losed

ca r

ts or

con

tainers

JMu

La

undr

y vehicles can be a source of con

tamination. Cleaniug and disinfection on a

regular basis are required.

V.b. Clean s

ur

gical attire should be s tored

in

a clean,

enclosed cart or cabine

t. 2-M

V.b.1.

S

torin

g clean surgica l a

ttir

e

in

a l

ocker

with

personal items from outside of th e hosp i tal may

cont aminate th e clean surg ica l a ttire. Ent

er

ic

viruses

have b

ee

n detected

in

lo ckers w here

contaminated attire

ca

n ac t as r

ese

rvo

ir

s f

or

viral

tr

ansmi

ss

ion J

Lll

Surgical attire may be stored

in

a d ispens

ing mac

hin

e. Di

spe

nsing

machin

es s

hould

be routinely emptied and cleaned according

to

th

e ma

nu f

ac

tu rer

's d irections.

Attire-di

spens

ing mac

hin

es m3y

be used

to

in

crease

individu

al acco

unt

abilit

y,

pro

mote cost

conta inment

, facilitate an ade

qu

ate sup pl

y,

and provide clean storage for

s

ur

gical attire. l Zf

Recommendation VI

All

individuals

entering

the

restricted

areas

should wear sur-

gica l mask when open sterile supplies and equipment re

present

A s

ur

gical mask protects both the s

ur

gical team

and

the

pat ient from transfer of microorganisms.H The surgical

m

as

k

prote

cts hea

lth care providers

from

droplet

s

greater than 5 mi cromet

ers

in siz e. Examples of

di

seases th at

produce dropl

ets include group A

streptococcus, adenovirus, and Neisseria me

nin

gitides

.Z->

A s

in

gle surgical mask is worn to protect the health care

provider from contact with infectious mat

er

ial from the

patient (eg,

respiratory

secretions, sprays of blood or

bod y fluids) and

to

protect the patient from expos

ur

e to

7



RP Surgical ttire

in fectiou

s age

nt

s ca rri ed in

the

provider'

s

mouth

or

nose. Surgi

ca

l

ma

sks

protec

t s

ur

gical te

am

memb er

s'

noses a

nd

mo

uth

s from inadverte

nt

splashes

or

splat

ters

of

blood

and oth

er bod y fluids.ll A s

tudy

involving

8,500 surgica l proce

du r

es showed that 26 of ex

po

sur

es to blood

wer

e to

th

e h

ea

ds

and

necks

of scrubb

ed

personn

el, a

nd that 1 7 of blood ex

pos

ures

were to

circula

tin

g pers

on n

el outs

id

e the

st

eril e

fi

e

ld

.

lli

Vl. a.

Th

e mask should cover the mouth and nose and

be sec

ur

ed in a ma

nn

er to prevent ve

ntin

g.

A mask that is s ec

ur

ely tied at

th

e back of the

head a

nd

be

hind

th e neck dec reases

th

e risk

of

health care personnel transmitting naso

ph

aryn

geal a

nd

res

pir

atory

mi

croorganis

ms

to pa

tient

s

or th e s terile field. Infectious particles can r

eac

h

th

e wearer's nose

and

mo

uth

by pa

ss

ing

thr

ough

leaks at the mask-face seal.

VI.b. A fresh, clean surgical mask sho

uld

be wo

rn

for

e

ver

y proce

du r

e.

Th

e mask

sh

o

uld

be replaced

and disc ard

ed

when

e

ver

it bec

om

es wet

or

soiled .

Th

e filtering capacity of a mas k is

co

mpro

mis

ed

when

it be

com

es wet. In a s

tud

y to dete

r-

mi ne

micr

o

bi

al b

ar

ri er e ffi cacy

of

s

urgi

c

al

ma

sks

with

9

5

bac teria l filt ra

tion

a t one-,

two-, three-, a

nd

four-hour

in t

e rvals showed

that

after four

hour

s, the masks had dec reased

efficacy. Avoiding un n

ece

ssa ry sp P-aking and

ke

e

pin

g

in mind the

patie

nt '

s

po

ss ible

immuno

logical s

tatu

s are important.

This

res

ea r

ch s

tud

y

s

how

ed that all c

ount

s of CFUs

we

re

low

er

than

4 x

10

2

,

which c

ould

cau

se an SS

I

in

patie

nt

s

with po

or

immunity, tho

se

with surgical

wound

c

ompli

ca

tion

s (eg, isc hemia , he

matom

a), or

those

under

going s

ur

gery

with

an implant. u

VLb .l. Masks s

hould

not be

worn hangin

g

down

from the neck.

Th

e

fi

lter portion of a s

ur

gical mask har

bors bacteria collec ted from the nasopharyn

gea l

airw

ay.

Th

e

contam

inated m

as

k

ma

y

cross-

co

ntaminate

th

e s

ur

gica l att ire top.

VL

c. Surgi

ca

l

ma

sks s

hould

be di

scard

ed after each

proce

du

re. Masks

shou

ld be removed carefully

by

handling

only th e mas k ties.

Hand

hygiene

should

be performed after removal of mas ks.ll

Removing masks by the ties preve

nt

s possible

c

ont

amination of

th

e ha

nd

s.

Th

e filter

portion

of

the

ma

sk

harbor

s

ba

cte

ria

co

lle

c

ted fr

om

th

e

na

s

op h

aryngeal airwa

y.

VI.d.

Onl

y

on

e s

ur

gic

al ma

sk s

hould

be w

orn

at

a

tim

e.

M

as

ks are

in t

e

nd

e d to c

on t

a

in and

filter

dropl ets

of

mic roorga

nism

s expelled from

th

e

mouth

and nasop

ha r

ynx

durin

g talking, sneez

ing, a

nd cou

ghing.

LI

Use

of

a double ma

sk

cre

a tes an impediment to brea thing and

do

es not

incr ease filtr

a

tion

;

th

ere fo r

e, th i

s is

not

reco

mm

e

nd

ed.

Zll

8

Recommend

ation

VII

Health care

personnel

should

receive

initial and ongoing

educa

-

tion and

demonstrate competency on

appropriate surgical

attire .

Comp eten

cy

assessment verifies that health c

ar

e pe

r-

s

onn

el have an

under

sta

nding

of the arti cles a

nd

pur

pose of surgical a ttir

e.

This knowledge is essential for

re

du

c

in

g

th

e risk of health

ca

re-associated

in f

e

ction

s.

VILa. Health care perso

nn

el should receive e

du

cation

a

nd

gui da n

ce

on a

pp

r

op

ria te a rticles

of

s

ur

gical

attire worn in

th

e periopera ti ve environment at

ori ent ati on and a ft er cha nges are mad e.ull.

Hea lth ca re

pe rso nn

el s

ho

u ld be informed of

a

nd

be compliant with the hea lth care organi za

tion s

s

ur

gi

ca

l a ttire polic

y, includin

g l

aund

e

r-

ing policies.

On

going e

du

ca tion of perioperative perso n

nel f

ac

ilita t

es th

e dev

elopm

ent

of kno

wledge,

skills , and

attitud

es

th

at a ffec t pa

ti

e

nt

a nd

wo

rk

er safet

y.

VII.a.1. He

alth

c

ar

e pers

on n

el should

under

sta

nd

th

e

ri

sk

of

beco

min

g co

loni

zed or

in f

ected

with microorganisms from patie

nt

s

or

th e

enviro

nm

e

nt

when s

ur

gical

attir

e is cleaned

improperly.

RecommendationVIII

Policies

and procedures for surgical attire should

be

developed

reviewed period

ically and be

readily

available within

the prac

-

tice

setting.

Policies a

nd pr ocedu res

serve as

op

era

tiona

l

guid

e

li n

es and es ta

bl i

s h a

uthorit

y, res po ns

ibility,

a nd

a

ccountabilit

y

within th

e organi za

tion

.

Policie

s and

proce

du r

es

al

so ass ist in the deve

lopm

ent

of

pati e

nt

s

af

ety, quali ty assessment , and im provement ac tivities.

VIlL

a. Surgical a ttire polices

and

pr

oc

edures shou

ld

in

c lu de, but not be limited to , requirem ent s

related to

o fac ili ty-a

pp r

oved and sta

nd

ardi zed s

ur

gical

attire,

o areas wh ere s urgical attire is worn ,

o

inf

ection

pr

evention

and

c

ontr

o

l,

o use

of

PPE,

o laundering,

o

transport a

nd

storage

of

clean atti re, a

nd

o compliance monitoring.

An un ders

tandin

g of su

rg

ical

attir

e policies

a

nd

pro

cedu r

es assists hea

lth

c

ar

e pers

onn

el in

pr otecting the pati ent, th emse lves , and th e ir

family members.

VIII.b. Policies and procedures sho

uld

be introduced

a

nd

reviewed

in

th e

initi

al o

rient

a

tion

,

wh

en

now surgi

ca

l

attir

e is

intr

o

du ce

d , a

nd durin

g

on

going e

du

cation of health care personne

l.

Re

vi

ew of

poli

ci

es

a

nd

proc

e

du res ass

ists

health ca

re pers

onn

el in be

in

g kn owl edgeable



about

and

compli

ant

with th e health care orga

nization s policies and procedures.

Recommendation

IX

The hea

th care

organization s

qua ity management

program

should

evaluate compliance with

surgical

attire

policies

and

identify

and respond to

opportunities for improvement.

Quality management programs that enhance personal

performance a

nd

monitor surgica l attire

practices

are

established to promote patient

and

health care personnel

safety. Health care l

aundry

processing requires special

ized

equ

ip

ment

,

adequate

space, qualified

personnel

with ongoing

tr

a ining, and continuous

monitoring

for

quality

s s u r n c e

IX

.a. S

tru

cture, process,

and

perfo

rman

ce

measures

should

be identified.

Structure, process,

and

performance mea

sures can

be used to improve

surgical at t

ire

quality and monitor compliance with

facility

policies and procedures, national

s t

andards,

and regulatory

requirements.

IX.a.1 .

Quality

indicators

for

surgical attire may

include, but are not limited to,

• h

ead

coverin

gs completely cover th e hair

and

sca lp ;

•

warm-up

jackets wi th wrist- l

ength

sleeves are worn

and

are snapped;

• identification badges are worn, visible,

and clean;

• shoes are clean

and

protect heal th care

personnel's feet;

•

visibly soi

l ed or we t surgica l at t ir e is

removed and

cleaned

at

an accredited

health care la

undr

y facility;

• masks,

when

worn, are ti

ed

securely

and

are discarded after each procedure;

and

• cover apparel, if worn, is l

aunde

red daily

at th e organization

or

an accredited laun

dry facility.

IX.b.

Quality assurance monitoring

of

laundry

pro

cesses should be ongoing.

A study of the risk of

Clostridium

diffici e

cross-contaminati on in the

l

aundry

process

illnstrates th at cross-contamination occurs with

the

use of

nonsporicidal disinfectants,

but

that

the use of sporicida l disinfectant cloths showed

significantly

reduced

CFUs.

The researcher

con

cluded that cleaning Clostridium difficile-

contaminated

surfaces

wit

h

nonsporicidal

dis

infectants

crea tes a vector for cross

contamination to

ot h er

textiles via the

laundering process. Cleaning contaminated sur

faces with sporicidal disinfectant may not com

pletely e

limin

ate this vector,

but

does signifi

cantly reduce associat

ed

risk.

lll

A rare outbreak

of

zygomycosis in a hospital

was investigated by the CDC using standard out

break protocols. Zygomycosis

is

an invasive

fungal in f

ection caused

by mucormycetes,

RP

Surgi.cal Attire

which includes a Rhizopus species (ie, a group

of molds

that is commonly f

ound

in

the

envi

ronment) . Infections wi th this microorganism

are rare and usually

occur

in people who have

underlying medical conditions. A cluster

of

six

cases occurred from August 2008 to July 2009.

Of

the six cases, five patients died (ie, prema

tu r

e

children up

to age 13). All five

children

h

ad

risk

factors

for

zygomycos

i

s, which

included

acidosis (ie, four children)

and

bone

marrow transplant (ie, one ch ild). Hospital lin

ens were the on ly items common to these cases.

Environmental cu ltures taken

at

the hosp

ita l

revea

led

Rhizopus

species

on

26

out

of 65

swabs (40%) of clean linens

and

areas

in

con

tact w

ith

clean linens,

and on

1

out of 25

sam

ples

(4%) of items not

in

contact

with

linens.

Cl

ean

linen closets were

cultured,

including

those in the OR, where two items were found to

be Rhizopus-positive. Researchers

determined

th

e h

osp

ital linens to be

th

e most likely vehicle

of

transmission to

patients

skin. Co

nt

am

in

ation

of

linens may have occurred during laundering,

en

route

to

the

hospital,

or during

delivery to

the hospital. The hospital changed commercial

l

aundry

facilities, replaced a ll of its linens, dis

infected all lin

en

storage closets, and used a dif

ferent delivery area for its linens

in

an effort to

prevent reoccurrence of this type of u t b r e k

Glossary

Restricted

area: Incl

ud

es the OR

and

procedure

room,

the

clean core,

and

scrub

sink

areas. People in

this area are required to wear full surgical atti re

and

cover

all

head

and facial

hair, including sideburns,

beards, a

nd

necklines.

Sem irestricted area:

Includes

th

e peripheral

support

areas of the surgical su

it

e

and

has storage areas for ster

ile

and

clean

supp

lies, work areas for storage

and

pro

cessing in

s

trum

en ts,

and corrid ors

l

eading

to

the

restricted areas of the surgical suite.

Surgical attire:

No

nsterile

appare

l designated for

the

OR practice setting that includes two-piece pantsuit s,

cover jackets, head coverings, shoes, masks, protective

eyewear,

and

other protective barriers.

FEREN ES

1. Andersen

BM,

Solheim

N.

Occlusive scrub suits

in

operating theaters

during

cataract surgery: effect on

airborne contamination. Infect Control Hasp Epidemio l

2002;23 4) :218-220.

2.

Tammelin A, Hambraeus

A,

Stahle E Source and

route of methicillin-res istant Staphylococcus epidermidis

transmitted

to

the surgical wound during cardia-thoracic

s

ur

gery. Possibility of preventing wound contamina

tion by use of special scrub suits.

f Hasp Infect

2001;47

(4):266-276.

3. Whyte

W,

Hamblen

DL,

Kelly

IG,

Hambraeus A,

Laurel G. An investigation of occlusive polyester surgical

clothing. Hasp Infect 1990;15(4):363-374.

4.

Barrie

D.

How hospital linen and laundry services

are provided. f Hasp Infect 1994;27(3):21 9-235.

9



RP Surgical

ttire

5. Tamme

li

n A, Domice l P,

Hambra

eus A, Stahle E.

Di

spersa l of me

thicillin

-res ista nt

Staph

ylococcus epider

midi

s by s t

aff in

an

operatin

g s

uite

for

th

oracic a

nd

car

diovascul

ar

surgery: rel

atio

n to s

kin carr

iage

and

clothing.

JHa sp In fect

2000;44(2):119-126.

6. Wu

X,

Yang CQ. Fl

am

e retardant fin is

hin

g of cotton

fleece fabric: part

III

- the

combina

tion of ma leic acid a

nd

sodium

h

ypophosphi te. J

Fire Sci 2008;26(4):351-368.

7.

US De

pa

r

tm

e

nt

of

Health

a

nd Human

Serv

i

ces.

Standard

for the flammability of

clothin

g tex tiles. 16 CFR

§1610.

8. Yang CQ,

Qiu X.

Fl

am

e-reta

rdan

t finishing of

co

t

ton

fl

eece fa

br ic:

Part

I. Th

e usc of a hy

droxy

-func

tiona

l

org

an

op

ho

sp

horus ol igo me r a n

cl

d imethy lo l

ei

ihydr ox

ylethylene

urea

. Fire

and Ma

terials 2007;31(1):67-81.

9. AAMI. ST79:

Co

mprehensive Guide to Steam Ster-

ilization and Sterility ssurance in Health Ca re

Fa

cilities

2009.

10

. Mi t

che ll NJ,

Evans DS, Kerr A. Re

du

ction of

skin

bacter ia in thea tre air

with

co

f

ortable, non-woven dis

po

sa

bl

e cluthing for

operating-t

he

at r

e s taff. Br Med f

1978;1(6114):696

-698

.

11

.

Woodh

ead K, Taylor EW, Bannis ter G, Ch

esworth

T, Hoffman

P,

Humphr

eys H. Behaviours

and

rituals

in

the

opera

ting

th

ea tre. A r

ep ort

from

th

e Hos

pital

Infec

tion

Society Working Party on I

nfec

ti

on

Control

in

Operating

Theatres.

JHosp In fec t

2002;51(4):241-25 5.

12. Nob le WC.

Di

s

persa

l of

sk

in microorganisms. Br

J

Dennatul 1975

;93

(4):477-485.

1

3. Nob

le WC, Ha

bbema JD

,

van

Furth R,

S

mith

I,

de

Raay C. Qucmtitative stu

di

es on the

di

sper

sa

l of skin

bacteria

into

th

e a ir.

f Med Microbial 19

/6

;9(1):53-61.

14. Bartlett GE , Po

llard

TC, Bowker

KE

, Bannis ter

GC.

Effect f j

ew e

llery on

su rface

bacterial

counts

of

ope

r

ating

th

ea

tr

es.

f

Hosp Infect 2002;52(1):68-70.

15. Graves

PB

,

Twomey

CL. Su rgical

hand antiseps

is:

an

ev

idence-based

revie

w. Perioperative Nursing Clinics

2006;1 (3):235-246.

16. Fie

ld

EA, McGowan P, Pear

ce

PK, Martin MV. Rings

and watche

s: s

hou

ld th

ey

be removed prior to

op

era tiv e

dental

pro

ce

du r

es?

J

Dent 1996

;2

4(1-2):65-69.

17. Recommend e d pr

ac ti

ces fo r hand h

yg

ie ne

in

th

e

perioperative

se

tting.

In: Pe riopera

ti

ve Standards

and Recomme

nded

Practices

Denv e

r,

CO: AORN,

In

c ;

2010

:75-90.

18. J

ea

ns AR,

Moore

J,

Nico

l C,

Bates

C, Read RC.

Wris

twatch

usc and a c q u i n ~ d infection. f Hosp

In fect 2010;74(1 ):16-21 .

·J

9.

Bo

yce

JM,

Pittet

D,

Health

c

ar

e Infec

tion

Co

ntrol

Pra

c ti

ces Advisory

C

ommittee

, HICPAC

/S

HEA

/A PI

C

IIDSA Hand Hygi

e n e

Ta

s k Fo r

ce

.

Guide

li

ne for

Hand

Hy

gie

ne

in Health-Care Settings. Reco

m

mendat ions

o f

th

e

Healthcare

In f

ec tion Con

trol

Practi ces

Adv

i

so ry Committee and

the HI

CPAC/

SHEA/APIC/IDSA

Hand

Hygi

e

ne

T

as

k

Force.

Soci

ety for

H

ea

lthcar e

Epid

e

mio

l

ogy

of Am e

ri ca

Assoc ia t ion fo r

Prof

es s

io n

a ls in In fec tio n

Co ntrol

/ I

nfectiou

s Diseases Society of America. MMWR Reco

mm

Rep 2002;51(RR-16):1-45,

quiz

CE1-4.

20.

Sa

li s

bury

DM , Hutfi lz P,

Tree

n LM ,

Bollin

GE,

Gautam S.

Th

e effect of r ings

on

microb ial load of health

care worke

r

s' hand

s .

m f In f

ec

t Control 199

7;25(1):

24-2

7.

21. Kels

all

NKR, Griggs RKL,

Bowk

e r

KE

,

Banni

s ter

GC. S

hould

finger rings be removed prior to scrubbing for

th

ea

tr

e?

JHasp Infec

t 2006;62(4):450-452.

60

22. lhck

WE

, Ve

rnon

MO, Hayes RA, et a l.

Impa

ct of

ring

wearing

on hand

co

ntamination

and comp

ari

son

of

ha

nd

hyg ie

ne

agents in a

ho

s

pi t

a

l. Clin Infect Dis

2

00

3;

36(11):1 383-1390.

23. Amirfeyz R,

Ta

sk

er

A. Ali S,

Bowk

er K,

Blom

A.

Th

ea tre

shoes-a

link in th e co mmon

pa t

h way of

postop

era

ti v

e

wound in

f

ec tion? nn R Co li

Surg

Eng

l

2007;89(6):605-608.

24.

Occ

up ationa

l

Safety

and Healt

h

St a nd

ar

d s

1910

.136:

Foot pr

o

tecti

on .

United

S

tates

De

partm

e

nt

of

Labo

r http: / /

www.o

s ha.

gov/pl

s/ oshaweb/o

wadi

sp

.show document?p t

ab l

e=S

TANDARDS

p id =9786 .

Accessed September 29, 2010.

25.

Fairfax

RE. We

arin

g

Crocs brand

sh

oes with

a

partia

lly

op

en h

ee

l

and

a c

ov

ered t

oe

in a

pharmacy

se ttin

g [letter]. Ju ly 16 , 2

00

6.

http :/ /ww w

.os

ha.gov/p

ls

/os

haweb/owadisp.show documen t?p

tab

lc- INTERPRE

TATIONS p id=25439 . Accessed October 4, 2010.

26. O

ccupati

onal

exposure

to blo

odborn

e

pathogen

OS

HA. Final ru le. Fed R

eg

is/ 1991 ;5ti

(2

35):64004-64182.

27. US H

ea

lth and H

uman

Services. Bloodborne pa

tl

lo

gens. 29 CFR §1910.1 030.

28. 29 CFR 1

910.132:

Gen

era

l requirement s. U

ni t

ed

S

ta tes

De

partment

of

La

bor

.

http

:/ /

ww w

.o s

ha.gov/pl

s

/o

s

ha w

eb /o wadisp .

sh ow

docum e n t

?p

t abl e =STAN

DARDS p id=9777. Accessed September 29, 2010.

29. B

ar

r J,

Siege

l D. Da n

gers of

rl e

rmatologi

c sur

gery: prote

c t

your fe

et. Dermatol Sur

g 2004;3

0(1 2

Pt

1):1495-1497.

30. Watt AM, Patkin M, Sinnott MJ, Black RJ , Maddern

GJ. S

ca

lpe l sa fety

in th

e

operative se tting:

a

sys

tematic

rev iew. Sur

ge1y

2010;147(1) :98 -106.

31.

AORN

p

os ition state

ment

on th

e

ro

le

of th

e

h

ea

lth

ca

re i

ndust

ry represe

ntative in th

e p

er ioperativ

e

/invasive

procedure sett

ing.

http:/ /www

.

ao

rn

.

org/Prac

ticeRe

sources/

AORNPos iti o

nStat

eme

nts/

. Accessed

Se

p

tember 29, 2010 .

32. R

ecommend

ed p r

actices

for a

safe

e

nvironment

of

care. In :

Perioperative S

tandard

s

and

R

eco

mmend

ed

Practices Denver, CO: AORN, Inc; 2010 : 217-240.

33.

Developing

and i

mp

le

mentin

g a workp l

ace

vio

lence prevention program and policy. In: Violence in the

Workplace: Risk Factors and Prevention Strategies

Wash

in

g

ton

, DC: National In

stitu

te for

Occupational

Safety a

nd

Hea lth ; 1996.

34. Hos

pital

ccreditation

Stand

ards

Oakbrook

Ter

race, IL : Th e Joint Com miss io

n;

2009:47-68.

3S. Kot sflnas D. Sr.ott C, r ~ p i P EE,

Korman TM,

Stuart

RL. What's

hangin

g ar

ound your

neck?

Pathog

enic

bac

t

eria

on

identity badges an

d l

anyards.

Med J A us/

2008;188(1):5-8.

36. K

ap lan

C, Me

ndiol

a R, Ndjat

ou

V, Chap

ni

ck E,

Mi n

koff H.

Th

e role

of cove

ring

gow

ns

in

re

ducin

g rates

of

ba

c

terial contamination

of

sc rub

s

ui t

s.

m

J

Obstet

Gynecol 2003;188(5):1154-1155.

37.

Trea kl

e AM,

Th o

m KA,

Furun

o JP,

Strauss

SM,

Ha rri s AD,

Per

en

cev

ich EN.

Ba

cteria l c

ont

a

mination

of

h

ea lth ca

re

work

ers'

whit

e coa ts.

m J

Infect Control

2009;3 7(2):101-105.

38. Wong

D,

N

yc K,

Hollis

P.

Microbia l flora

on doctors'

wh

ite

coa

ts.

BMJ

1991;303[6817):1602-1604.

39. Loh W. Ng VV, Holt

on

J. Bacteria l flora

on

the

wh

ite

coa ts of medical s

tud

ents.

f

Hosp

In fec

t 2000;45[1):65-68.

40.

Durai

R, Ng PC,

Hoqu

e H. Methici

ll in-res

is t

an

t

Staphylococcus aureus: an update. ORN f 2010;91(5):

599-609.



41. Wood MW,

Lund

RC, St

evenson

KB.

Bacterial

con

taminat ion of ste

tho

scop

es

w

ith

a

ntim

icrobial di

aphragm

cove

rs.

Am I

Infect

Co

ntrol 2007;35 4):263-266.

42. Be

rn

ard L,

Kerevcu

r A, Durand D, e t al.

Bact

e

ria l

contam in

ation

of h

osp

ital

physic

i

ans'

st

et ho scopes

.

Infect Control Hasp Epidemiol

1999;20 9):626-628.

43 . L

ecat

P, C

ropp

E, McCord

G,

Hall

er

NA.

Ethano l-

based

cleanser

ve

r

sus

i

so p

ropyl

a

lcohol to

d

eco nt

a m

in

ate

s t

et

h

oscopes.

Am

Inf

ec

t Co

nt r

o l

2009;37

3

):

241-243.

44.

Lep

ra t

R,

Minary P, Devaux V, d e

Waz

ie re B,

Dupond

JL

,

Ta

l

on

D.

Why, when a

nd how

to

clea

n

stet

ho

scope

s.

I Ha

sp

Iu fect

1998:39 1):80-82.

45.

Sood

P,

Mishra

B,

Mandai

A.

Po

te

nti

a l

in fection

haza

rds

of stet hoscopes. I Indian Med Assoc 2000;98 7):

368-370.

46. Mi lam MW, Hall M, Pringle

T,

Buchan an

K.

Bac

te r

i

al co

ntamination

of fabric

s t

et

h

oscope covers:

the

velvetee

n r

abb

it o f h

ea

lt h

ca

r

e?

Infec t

Contro

l H

asp

Epidemiol 2001 ;22 10):653-655.

47.

Recommended

p

rac

ti

ces

for

environmenta

l clea n

ing in

the perioperative setting. In: Periopera

ti

ve Stan-

dards

and

Reco

mm

d

ed

Practices Denver, CO: AORN,

Inc; 2010: 241-256.

48.

Stan

d

ards of perioperative nurs

ing. In :

Periopera-

tive Standards and

Recomm

ended Practices Denver, CO:

AORN, Iuc; 2010: 9-62.

49

. Nee ly AN, Maley

MP. Surviva

l

of enterococci and

s taph

ylococc

i

on

hospital fabrics and plastic. Clin Micro-

bioi 2000;38

2):724-726.

50.

Neely AN, Orloff MM. S

ur

viva l

of so

me

medi

ca

ll

y

important

f

ung

i on

ho

s

pi t

al fabrics

and

pl

astics. I Clin

Microbial 2001 ;39 9):3360-3361.

51.

Sehul

st

er

L, C

hinn RY,

CDC, HICPAC. G

uid

e

lines

fo

r

environmen

ta l in fect ion co

ntro

l

in health-ca

re faci li

ties. R

ecommend

at

ions

of

CDC

and th

e Hea

lthcare Inf

ec

ti on

Co n

tr ol Practices

Adviso

ry C

ommittee

HICPAC).

MMWR Reco

mm

Rep 2003;52 RR-10):1-42.

52. L

co

n

as

KK

.

Ef

f

ec

t

of

launderin

g on

th

e barri

er

prop

erti

es of

reu

sab

le

surgica

l

gow

n fabrics.

Am I

I

nfec

t Con-

trol 1998;26 5):495-501 .

53.

Scal tril

i

S, Cence tti S,

Ro

ve s ti S, Marc

h

es

i I,

Bargell

ini

A, Borella P.

Ri

sk

factors for

parti

c

ul

ate

and

mi c

robi

a l con tamination of air

in

ope

rating

th

ea tres.

I

Hasp

In

fect 2007;66

4 )

:320-326.

54.

Mang

ram A}. H

oran

TC,

Pearso

n ML,

Silver

LC,

Jarvis WR.

Gu

ide line for preventi

on

of

surg

i

ca

l s ite infec

tio n,

1999.

Hospi tal

Inf

ection Con trol Practices

Advisory

Co

mmittee. In f

ect Control Hasp Epidem iol

1999;20

4):

250-278;

quiz

279-80.

55.

Callaghan I

Bacterial

contamina

tion of

nurses' uni

forms: a

st

udy. Nurs Stand 1998;13 1 ):37-42.

56. National I

nstitute

for OccuJ,Ja

tion

a l Safety an d

Health.

Protecting Workers Families: A Rese

ar

ch

Agenda.

DHHS NIOSH)

Pub

No. 2002-113.

http

:/ /w ww

. cdc .gov/

niosh

/ docs/2002-113 / 200 2-

113.html.

Accessed

Septembe

r 29, 201 0.

57.

Summers

MM, L

ynch

PF, Black T. Hair

as

a reser

voir

of staphy lococci.

I

Clin Path 1965;18 13):13-15.

58 . Din een P,

Drusin L. Ep

id emi cs of po stoperative

wo

und

infec

tions associated w ith

hair

carriers. Lancet

1973;2 7839):1157-1159.

59.

Mas

tro TO, Farley TA, Elliott

JA,

et a

l. An

outbreak

of surg

i

ca

l

-wound

infections

due

to gr

oup

A

stre

ptoco

cc

us

ca

rri

ed on the

sca

lp

. N Eng/ Med 1990;323 14):968-972.

60. Mase K, Hasegawa

T,

Horii T,

et

a

l.

Firm

ad

her

ence

of

Staphylococcus au reus

and

Staphylococcus epidermidis

_____

:

Surgical

ttire

to human h

air and

effect of detergent treatment. Microbial

l

mmuno

l 2000;44 8):653-656.

61. Friberg

S, Ardnor

B. Lundholm R, Friberg

B.

The

addition of

a mobile u

lt

ra-clean

expone

ntial

laminar

air

fl ow

screen to

conve

ntional

operating room venti

lat ion

reduces

ba

cte

ri

al

co

nt

a

minatio

n to operating

box

l

eve

ls.

I

Ha sp In fec t 2003;55 2):92-97.

62. Takas

hi m

a

M, Shirai F Sageshima M,

Ikeda

N.

Okamoto

Y,

Dohi

Y.

Di

s t

in

c

tiv

e b

acteria-binding

prop

erty

of cloth mat

erials. Am

I

In fect Control 2004;32 1):

27-30.

63. Health

care La un

dry Accreditat ion Co

un

ci

l.

Accredi

tat ion Sta

udar

ds for P

ro

cessing Reusable Textiles for Usc

in

H

ea

lth

ca

rc Fac

iliti

es.

2006. http:/ /

w ww.

hl ac

n et.org

I

Accre

dit%2

0Sta

nd

a

rd

s12.18.08.pdf. Accessed

Oc

tober 6,

201 0.

64.

Fija

n

S, Sostar-Turk S, Ccncic

A.

Impl

eme

ntin

g

hygiene

moni

toring systems in hospital laundries in

order

to

re d

u

ce

mi

cro

bial

cont aminat

i

on of

hosp

ita l

te

x

tile

s.

I Ha sp In fec t 2005;61 1 ): 30-38.

65. ANSI/ A AMI. ST65:

Process

ing

of

reusable

su

rgical

t

ex

t

iles

for u

se in

he

alth care

faci lit ies . 2008.

66. G

er

b

CP.

Applica ti

on

of

qu

an tit ative risk assess

men

t for formula ting h

yg

ie

ne

policy

in the domest

ic

se

t

ti ng.

I Infect

2001 ;43 1):92-98.

67. Associat ion

for

Linen Managemen t. Clinical Ta lking

Point s: Healthcare T

ex

tiles Biob urden

e

du

cational mate

riall . Ri

ch

mond,

KY:

Associat

ion

for Linen Manageme

nt

;

2009.

68. Perry

C,

Marsha

ll R,

J

ones

E. Bacterial

contam

ina

ti

on

of un iforms. Ha sp

In f

ect 2001 ;48 3):238-241.

69.

Hedin

G.

St

ap

hy

lococcus epiderm

id i

hosp ital

e

pid

emiology and the

detectio

n of

me

th ici ll in resista

nc

e.

Scand

I

Infect Dis

Supp l.

1993;90:1-59.

70.

Twomey

CL, Be

itz

H,

Johnson

BJ.

Bact

e

ri

a l

co

n

t

am in

at

i

on

of surg

i

ca

l

scrub

s

and

laundering mecha

nisms

:

in f

ec

tion control imp

l

ications.

Infection Control Today

2

009.

http

:/

www.i nfectioncontrol

od

ay .com/ articl es

/ b

ac

te ria I-c on a

mi

na

lion-

of-surgi

ca l- sc

ru b s .h tm

I

.

Accessed

September

29, 2010.

71. Gerba CP, Kenne

dy D. En

t

er

ic vi

rus survival

d

ur

ing

hou

se

ho ld laundering a nd

impac

t of disinfe cti

on

wi

th so

dium

hypochlorit e .

Appl

Environ Microbial.

2007;73 14):4425-4428.

72.

Boon

e SA,

Gerba

CP.

Sig

nifi

cance

of fo

mites in

the

sp

read

of respi ratory

an

d ent eric viral

di

sease.

Appl

Environ Microbiol 2007;73 6):1667-1696.

73. Scheuer R.

Dispensing

of excess

sc rub expenses.

Ma ter Manag Heaith Ca re ~ 0 0 6 ; 1 f : J l ) : 2 4 - ~ 7 .

74.

Akridge

J. No

blanket strateg

i

es in

tex ti le manage

ment. Healthc Purchasing News 2007;31 1 2):46, 48-49.

75. 2007

Guide

l

ine fo

r I

so

lat i

on

Precautions: preve

nt

ing tra nsmiss i

on

of

in fec ti ous agents

in hP.fl ith

r.a

re

se

t

tings.

Cen

ters for Dis

ease

Control a

nd

Prevent ion. http

://

ww

w.c

dc.gov

/

hi

c

pac/ 2007IP

/2

00

7is

ol

a

tionPrecaution

s

.html. Accessed September 29, 2010

76.

Romney

MG. S

urgic

al f

ace mask

s

in th

e

operat

ing th

eat

re: re-

exam

in in g th e evidence. I Hasp In fec t

2001 ;4

7

4):251-256.

77. Barbosa MH ,

Graz

i

ano

KU. Influence of wearing

tim

e on efficacy

of

di

sposabl

e s

ur

gica l masks as microbial

barrier. Braz I Microbial 2006;37 3):216-21

7.

78. McCluskey

F.

Docs wearing a

fac

e mas k

reduce

bac

terial

wound

in f

ection? A literature review.

Br Theatre

Nurs 1996;6 5):18-20, 29.

79. Carbone HL, He

ll

ickson L

A,

Thomass e

r AL,

Vu

LK

.

Cl

os tridium

difficile cr

oss cont

a

mination

in

th

e t

ex

t ile

61



RP Surgical ttire

laundering process: the importance of

se

lecting an ap pro

priate hard surface disinfectant. Paper prese nted at: Inte

r-

national Conference on Healthcare-Associated Infections;

March 19, 2010; At lanta GA.

80. Duffy J Harr is J Newhouse

EN

et al. Zygomycosis

outbreak s ~ o c

t e d

with hospital linens. Paper presented

at:

In

ternatiOnal Conference on Hea lthca re-Assoc iat ed

Infections; March 19, 2010; Atlanta, GA.

Acknowledgments

L t:AD UTHORS

Joan Blan

chard , MSS, BSN, RN, CNOR, CIC

Perioperati ve Nursing

Specialist

AORN Center for

Nursin

g Practice

Denver

, Col

orado

Melanie

Braswell,

DNP, MS, RN, CNS, CNOR

Fu ll -T

im

e Faculty School of Nursing

Purdue University

Lafayette , hH.Iiana

CONTRIBUTING UTHORS

George All

en,

PhD, MS, RN, CNOR

Director of

Inf

ection Control

Down

state Medica l Center

Brooklyn , New York

Nancy Bjerke, MPH, RN, CIC

Consultant

Association

for Profess ionals in Infec tion Control and

Epidemiology, Inc (APIC)

Sa

n Antonio, T

exas

Sorin Brull, MD

American

Socie

ty o f

Anesthe

siology

Professor of Anesth esiology

Mayo Clinic College of

Medicin

e

Roches ter,

Minn

eso ta

PUBIJC TION HISTORY

Originally pu blished M

ar c

h 1975, AORN Journal as

AORN S tand ard s fo r p r

oper

OR wea ring

appare l.

Format revision March 1978, July 1982.

Rev ised March 1984, March 1990. Publis hed as pro

posed recommended practices, August 1994.

Rev ised November 1998; published December 1998.

Refo

rmatted

July 2000.

Rev ise d November 2004; pub lished

in S ta

nd

ards

Recommen ded Pmct i

ces

and Guidelines 200 5 ed i-

tion. Reprinted Feb

ru

ary 2005, AORN

Journal

Revised October 2010 for o

nlin

e publicat ion in

Peri-

operative Standards and Recommended Practices.

Reformatted Sep tember 2012 for publication

in

Peri-

operat

i ve

Standards and Recommended

Prac

ti

c

es

2

01

3 e dition.

2013 aorn rp's for surgical attire

Documents