Download Guideline for Surgical Attire

Surgical Attire:
Are We Doing this Right?
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Developed and originally presented by
Patricia C. Seifert, MSN, RN, CNOR, CRNFA, FAAN
Antonia B. Hughes, RN, BSN, MA, CNOR
Claire Everson, RN, CNOR
Deena Young Guren, MSN, RN, CNOR, CNS-CP
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Objectives
• Describe four challenges related to implementing
evidence-based practices for surgical attire.
• Discuss four ways to implement a change in
practice related to surgical attire.
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Challenge
The Skull Cap … we stopped
ordering them, but we keep
finding them on the shelves
Why do we need to replace them?
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Reasons
• Bare skin (ie, baldness) contains skin squames and
microorganisms.
• Skin organisms may be dispersed in air.
• No convincing evidence that head coverings reduce
surgical site infection (SSI) rates.
• Hair can carry microorganisms and bacterial
contaminants.
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Recommendation and Rationale
• Cover the head, hair, ears, facial hair, and nape of neck when
entering the semi-restricted and restricted areas.
• Non-disposable head coverings should be covered with a
disposable head cover.
• Non-disposable head coverings should be laundered in a health
care-accredited laundry facility.
Rationale: Reduction of patients’ exposure to potentially
pathogenic organisms from clinicians’ hair and bare skin (ie, bald
head); a skull cap does not cover all areas recommended.
Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:97-120.
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Ideas for Success
• Engage surgeon and anesthesia champions to support
changes in head coverings.
• Provide available research on OR head covering to
medical and nursing staff.
• Have the most current AORN Guideline for Surgical
Attire readily available.
• Offer interactive inservice programs for staff and
ensure adequate time for discussion, Q&A, and “push
back.”
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Head Covering
Head covering should cover the
head, hair, ears, facial hair, and
nape of neck when personnel
enter the semi-restricted and
restricted areas.
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Challenge
I am hot and I’m NOT the patient …
why do I need to cover my arms with
a scrub jacket if I’m not scrubbed !!??
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Reasons
• Skin contains skin squames.
• Skin is the source of multiple organisms.
• Skin organisms may be dispersed in air.
• Tightly woven attire can reduce dispersal.
• No direct connection between squames and SSI.
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Recommendations and Rationale
Wear scrub attire that covers arms when:
─ prepping the patient
─ preparing and packaging sterile items in the
clean assembly area of sterile processing
Rationale: minimize dispersal of material
and/or organisms on the skin
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Ideas for Success
• Create a notebook of supporting research on OR attire for
managers, OR staff, and sterile processing professionals.
• Ensure an adequate supply of disposable and/or nondisposable jackets.
• Have most current AORN Guideline for Surgical Attire
readily available.
• Offer interactive education for staff and ensure adequate
time for discussion, Q&A, and “push back.”
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Surgical Attire
Surgical attire and personal
protective equipment are
worn to provide a high
level of cleanliness.
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Questions
and Answers
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Challenge
I am COLD and I am not the patient!
Why can’t I wear a fleece jacket or turtleneck?
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Good Question!
Suggestions:
– have the jacket laundered at the facility
– wear undershirts that are V-neck or wear camisoles
• Fleece can be worn if it is tightly woven without
holes.
• Don’t forget: Clothing that comes from home should
not be in contact with the surgical environment.
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Challenge
Why can’t I launder the scrub clothes at
home?
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Concerns
Home laundry
─ does not have parameters for hot/cold water
temperature.
─ does not have standards for detergent or water
treatments.
There is a potential for contamination from patients to
home or home to patients when home laundering is
used.
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
More about home laundering
Some facilities may not offer a laundry service.
If home laundering is done;
─ the scrubs should be isolated from the other laundry.
─ scrubs should be thoroughly dried and isolated for the
return to the point of use.
─ the use of bleach is recommended.
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Questions
and Answers
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Challenge
Wow, you are wearing a matching ring-set, watch,
earrings, and necklace! Can you please remove it?
I know you are a medical student/MD/experienced
RN/surgical technologist/anesthesia provider, but you
are not following the policy about surgical attire….
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Reasons
• Patient safety and considerations
comes first.
• Wearing jewelry was found to
increase bacterial counts on skin
surfaces when the jewelry is in
place.
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Recommendations and Rationale
• “Jewelry that cannot be contained or confined within
the scrub attire should not be worn in the semirestricted or restricted areas.”
• Ring wearing associated with a 10-fold higher median
skin organism count on the hands.
• Hand hygiene reduces bacterial skin count but more
bacteria is found under the rings than on adjacent
skin or on the opposite hand.
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Ideas for Success
• Involve the team to brainstorm creative ways to confine and
contain jewelry
– rings, bracelets on a long chain that can be worn under scrub
top
– watch confined under scrub jacket
• Hand hygiene demonstrations using reactive gel or powder
– volunteer willing to wash hands while wearing a plain ring
– examine under black light for residual materials
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Ideas for Success
Emphasis always on patient safety
• Risk of SSI
• Risk of scratches from elevated settings
• Risk of tubes and catheters becoming entangled in
jewelry with associated risks
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Challenge
We wrote a new policy
So why isn’t anyone following it?
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Reasons
• Perceptions
– written in the Ivory Tower
– meant for everyone else but ___(me)
– my jewelry could get lost if I left it in my locker
• Education and orientation with little emphasis on
attire, changes in policy
• Leaders not leading by example
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Recommendations and Rationale
• Commitment from leaders
– at the beginning to support change
– hold each other accountable
• Leaders hold staff accountable
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Ideas for Success
• Involve a multi-disciplinary team
– researching and writing policy
– reflective of all roles in the perioperative environment
• Involve that same multi-disciplinary team
– sharing the information
– formal and informal education
– multiple times
– multiple formats
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Challenge
How to sustain the change?
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Ideas for Success
• Recognition patrol
• Acknowledgment for change in personal practice
• Periodic reminders
─ What is happening around us?
─ How it could apply to these recommendations?
• What should health workers do with jewelry worn while caring
for a patient with an infectious disease?
• What would you do with your jewelry if you discovered, after
caring for someone, they had a previously unknown infectious
disease?
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Questions
and Answers
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Challenge
We have four sites and four different surgical
attire policies: now what?
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Reasons
• Impetus for change
• Consistent standard of practice
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Recommendations and Rationale
• The guidelines are intended to be achievable
recommendations.
• Policies and procedures will reflect variations in
practice settings.
• Ensuring and monitoring personnel compliance
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Ideas for Success
• Implementing change is challenging!
• Consider Change or Process
Improvement Models
• Don’t forget data:
before and after change
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Ideas for Success
• Group meeting of OR directors from all 4 institutions
• Directors asked Standardization Committee for help
• Draft of a Surgical Attire Policy
– consolidating four different ones
• Identification of the groups it would affect
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Ideas for Success
•
•
•
•
Directors met again
Plan for change
Make the case for change!
Rolling out means:
– Start early!
– Say it often!
– Say it to everyone!
– Seek informal leaders/colleagues in other departments
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Challenge
Technology is in the OR:
We’re seeing more cell phones, tablets, laptops,
briefcases in the OR. Is this okay? What should
we do?
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Reasons
• Briefcases/backpacks/personal items
– difficult to clean
– potentially may bring pathogens into the OR environment
– should not be placed on the OR floor
• Cell phones/tablets/hand-held devices
– should be cleaned before entering and leaving the
perioperative setting
• Department of Health regulations
• Issue of distraction
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Recommendations and Rationale
• Briefcases, backpacks, personal items taken into the semirestricted or restricted areas
– should be cleaned (moderate evidence)
• OR and procedure floors are considered contaminated
– items should not be placed there (moderate evidence)
• Evidence does not suggest prohibiting items
– but evidence emphasizes the need for thorough
cleaning and disinfection (moderate evidence)
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Recommendations and Rationale
• Evidence demonstrates that cell phones, tablets, and other
devices are highly contaminated with microorganisms.
• Other considerations concerning cell phones, pagers, or handheld communication devices
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Ideas for Success
• Institutional policies restricting/prohibiting
– laptops/bags/backpacks
– cell phones/pagers/devices
• Cleaning stations
– laptops/bags/backpacks
– cleaning products
– hand hygiene
– other technologies
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
Questions
and Answers
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
References
•
American Association of Nurse Anesthetists Position Statement: Mobile Device Use. Formerly Position Statement Number
2.18.
http://www.aana.com/resources2/professionalpractice/Documents/PPM%20PS%202.18%20Mobile%20Device%20Use.pdf.
Accessed October 21, 2014.
•
Andersen BM, Solheim N. Occlusive scrub suits in operating theaters during cataract surgery: effect on airborne
contamination. Infect Control Hosp Epidemiol. 2002;23(4):218-220. doi:10.1086/502040. [IIIC]
•
Krueger CA, Murray CK, Mende K, Guymon CH, Gerlinger TL. The bacterial contamination of surgical scrubs. Am J Orthop.
2012;41(5): E69-E73. [IIIA]
•
Noble WC. Dispersal of skin microorganisms. Br J Dermatol. 1975;93(4):477-485. [VA]
•
Noble WC, Habbema JD, van Furth R, Smith I, de Raay C. Quantitative studies on the dispersal of skin bacteria into the air. J
Med Microbiol. 1976;9(1):53-61.
•
Guideline for environmental cleaning. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:9-30.
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
References
•
Guideline for sterile technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2014:67-96.
•
Guideline for surgical attire. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:97-120.
•
Guideline for prevention of transmissible infections. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc;
2015:419-451. [IVA]
•
Robb W. Distractions in the operating room threaten patient safety. AAOS Now. American Association of Orthopaedic
Surgeons/American Academy of Orthopaedic Surgeons. 2012. http://www.aaos.org/news/aaosnow/may12/clinical5.asp.
Accessed October 21, 2014.
•
Saver C. Patient safety: cell phones are everywhere, but do they belong in the OR?” Reprinted from OR Manager.
2011:27(2):1-3. ECRI.
https://www.ecri.org/Documents/Reprints/Cell_Phones_are_Everywhere,_but_do_they%20Belong_in_the_OR(OR_Manager)
.pdf. Accessed October 21, 2014.
•
Sivanandan I, Bowker KE, Bannister GC, Soar J. Reducing the risk of surgical site infection: a case controlled study of
contamination of theatre clothing. J Perioper Pract. 2011;21(2): 69-72. [IIIB]
Copyright © 2015 AORN, Inc. All rights reserved. Used or adapted with permission.
References
•
Tammelin A, Domicel P, Hambraeus A, Stahle E. Dispersal of methicillin-resistant Staphylococcus epidermidis by staff in an
operating suite for thoracic and cardiovascular surgery: relation to skin carriage and clothing. J Hosp Infect. 2000;44(2):119126. doi:10.1053/jhin.1999.0665. [IIC]
•
Tammelin A, Ljungqvist B, Reinmüller B. Comparison of three distinct surgical clothing systems for protection from air-borne
bacteria: a prospective observational study. Patient Saf Surg. 2012;6(1). [IIIC]
•
Tammelin A, Ljungqvist B, Reinmuller B. Single-use surgical clothing system for reduction of airborne bacteria in the operating
room. J Hosp Infect. 2013;84(3):245-247. doi:10.1016/j.jhin.2013.03.007; 10.1016/j.jhin.2013.03.007. [IIIC]
•
Trick WE, Vernon MO, Hayes RA, et al. Impact of ring wearing on hand contamination and comparison of hand hygiene agents
in a hospital. Clin Infect Dis. 2003;36(11):1383-1390. [IIA]
•
Wiener-Well Y, Galuty M, Rudensky B, Schlesinger Y, Attias D, Yinnon AM. Nursing and physician attire as possible source of
nosocomial infections. Am J Infect Control. 2011;39(7): 555-559. [IIIA]
•
Images on slides 36,38,42 accessed from Office.com Clip Art Royalty-free photos and illustrations.
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