Thinking about safe surgical attireExperts suggest quality, consistency, awareness are key themes to keep in mind as all perioperative professionals think about what they are wearing and how this supports safety
By Carina Stanton
Senior News Editor
It happens every day. A perioperative health care professional heads to work wearing scrub attire. On the way she takes her child to school, drops the dog at the groomer, and stops for gas, picking up infectious organisms along the way that her patients may be exposed to. After her shift, she leaves the facility without changing out of her scrub attire. She gets the dog, grabs her dry cleaning, picks up her child from day care, and heads home, leaving her work day scrubs in the laundry room for washing. By wearing her surgical scrubs outside of the facility and making routine stops on her way, she has just put herself, her family and her community at risk by possibly carrying dangerous pathogens from her health care facility, including methicillin-resistant Staphylococcus aureus, Clostridium difficile and other infectious organisms.
“What professionals wear in a health care setting can become so automatic that they forget to think about what they may be carrying on their clothing and their hands. Awareness about safe practices for surgical attire is so important to reinforce,” said Joan Blanchard, RN, BSN, MSS, CNOR, CIC, an AORN perioperative nursing specialist responsible for overseeing AORN’s recommended practices for surgical attire.
Blanchard, Melanie Braswell, RN, MS, CNS, DNP, CNOR, Nancy Bjerke, RN, MPH, CIC, and other members of AORN’s Recommended Practices Committee have been working with infection control experts, laundering specialists, and others to update AORN’s Recommended Practices for Surgical Attire.
“The key regarding surgical attire is to keep in mind patient and personal safety. Because surgical attire is something perioperative nurses “do” every day, it’s important for perioperative leaders to regularly remind their teams about the safety hazards that can occur if nurses don’t follow appropriate guidelines for surgical attire,” Blanchard stressed. “This is a message that can’t be repeated enough.”
The root of the problem
When it comes to safe practices for surgical attire, Blanchard said there should be a focus on quality, consistency and awareness that starts with facility administration and is followed through with every staff member entering the perioperative suite. Health care leaders should provide their perioperative personnel with policies, procedures, regular education and policy review, and adequate clean attire inventory as part of their daily work flow, Blanchard said.
The health care organization should provide freshly laundered or disposable surgical attire for all personnel entering the perioperative suite. The surgical attire should be made of low-linting material and should minimize bacterial shedding. The surgical attire should be donned in a designated dressing area of the perioperative suite before entry or reentry into semi restricted and restricted areas.
What’s in the wash
Blanchard said, when looking at attire from a safety perspective, it becomes important for a facility to review how it handles the laundry process. “There needs to be a focus on quality, consistency and documentation. When you look at the laundry process in an accredited, certified laundry facility, what you see is a monitored process with very definitive steps that are followed and documented,” she stressed.
Kathy Tinker agrees. She is the executive director of the Healthcare Laundry Accreditation Council (HLAC), an independent accreditation organization that certifies laundry facilities practicing safe laundering according to HLAC standards. These standards include best safety practices established in the ANSI/AAMI ST65:2000 guidance for Processing of Reusable Surgical Textiles for Use in Health Care Facilities, as well as regulations established by the Occupational Safety and Health Administration, Tinker explained. “HLAC-certified laundries must demonstrate established and regulated processes for every step of the laundering process, from transferring soiled laundry, to sorting it, washing with specified wash formulas, time and temperature according to manufacturer guidelines, drying, pressing, packing and transferring clean laundry. As part of this process, all employees must demonstrate knowledge of safe practices to protect themselves and prevent the spread of infectious diseases, blood borne pathogens and other harmful pathogens that may be embedded in soiled laundry from health care facilities.”
HLAC surveyors inspect laundry facilities seeking to gain or renew voluntary certification to ensure adherence to these standards. “Certification shows clients and consumers that a laundering facility is walking the talk,” Tinker added.
Staff members at an accredited commercial health care
laundry facility sort soiled linens, including surgical scrub
attire, to be washed according to a standardized process.
Staff members wear personal protective equipment and
are educated to safely handle soiled linens that may harbor
infectious organisms.
Used with permission. Source: HLS Linen Services
Currently 100 health care laundering facilities located in metropolitan cities across the United States are HLAC certified, including Health Systems Cooperative Laundries (HSCL) in St. Paul, Minn. HSCL is a not-for-profit cooperative laundry located in a free-standing facility that services several major hospital systems in the Minneapolis/St. Paul metropolitan region. HSCL safety director Tom Smith explained that every aspect of the laundering facility, from building layout and ventilation system to staff training and the laundering process, is designed to ensure that health care textiles, including surgical scrub attire, are laundered in a way that removes harmful soiling and provides health care facilities with clean laundry free of any infectious agents that can be transferred to health care professionals or their patients.
“Much of our laundering system is automated, which enables us to easily test and track each step of the laundering process and to set parameters for things like chemical formulas, and temperature and time settings for wash loads that are tailored to specific textiles, whether its surgical scrubs, surgical drapes or other health care textiles,” he explained. This automation also prevents excessive handling of the textiles by laundry staff members. And, staff members who do come in contact with the laundry are trained to follow universal precautions and must wear personal protective equipment, including gowns, gloves and head and face coverings, he added.
In addition to these safety steps for the laundering process, HSCL also works closely with health care facilities to educate staff members, including central sterile staff members and OR managers about new textile products, and washing technologies and to establish regular quality checks and documentation review in efforts to maintain safety and quality.
Having this direct line of communication with the laundry facility is invaluable because I feel comfortable that the laundering process is being monitored and I know my staff members always have a supply of clean surgical attire available to them, according to Jenny Rover, RN, CNOR, clinical manager of surgery at St. Joseph’s Hospital in St. Paul, which is part of the HealthEast Care System that uses Health Systems Cooperative Laundries.
Rover works with HSCL’s surgical pack room director Barb Fordyce to educate hospital staff members and packroom staff on safe laundering practices, new laundering products and regular review of monitoring and documentation of laundering. “By establishing this connection with our laundry facility, we have the processes in place to track any outbreaks if we were to suspect the outbreak was linked to the surgical textiles—that’s something you can’t do if surgical scrubs are laundered at home,” Rover said.
Looking at the evidence
Individual home laundering practices cannot be monitored to ensure the same level of quality and standardized practices that can be achieved in certified commercial laundry facilities, said Blanchard. She stressed that certified laundering facilities have the technology and tools in place to meet manufacturer instructions designed to reduce infectious diseases and harmful pathogens harbored in soiled laundry—infectious organisms that can easily be transmitted to patients, health care personnel and their families.
Blanchard noted the research of Charles Gerba. In his 2007 study with co-author Stephanie Boone, the researchers found a correlation between presence of infectious diseases on fomites—inanimate objects, such as clothing, hands and other surfaces—and infectious disease transmission among patients. For example, one hospital study demonstrated that rotavirus-contaminated surfaces increased simultaneously as the number of ill children increased.
Gerba’s research is referenced in AORN’s proposed Recommended Practices for Surgical Attire and can serve as an evidence-based reminder to perioperative professionals that infectious diseases are easily transmitted to patients from surfaces, hands and clothing.
Raising awareness
All perioperative professionals need to always be thinking about the risks of transmitting infectious diseases as they move throughout their work day. “Practicing appropriate hand hygiene is absolutely critical,” Blanchard stressed. Recommendations for appropriate hand hygiene are included in the proposed Recommended Practices for Surgical Attire, as well as AORN’s Recommended Practices for Hand Hygiene in the Perioperative Setting. She said regular campaigns, innovative reminders and educational activities help to reinforce this thinking.
She noted an article in the May 2010 issue of AORN Journal, “’Managing Up’ Can Improve Teamwork in the OR,” where visual reminders of correct and incorrect surgical attire are posted in perioperative areas to serve as visual reminders. Another visual teaching tool Blanchard noted is AORN’s annual “What’s Wrong with this Picture” cartoon, which demonstrates breaks in recommended technique, including breaks is safe practices for surgical attire. The cartoon serves as a reminder for how to get it right. The 2010 cartoon is currently available for purchase through the AORN Foundation.
Blanchard also said the release of the updated AORN Recommended Practices for Surgical Attire, expected this summer, will provide a good opportunity for perioperative staff members and leaders to review their own practices for safe surgical attire.
“Attire is something that may not always be on a perioperative professionals’ radar, but it should be. Taking the time to ensure adherence to recommended practices for surgical attire is an important way for all perioperative nurses to promote safety for their patients and for themselves,” she said.
Additional resources
Healthcare Laundry Accreditation Council
www.hlacnet.org/laundries.php
AORN Recommended Practices for Hand Hygiene in the Perioperative Setting (currently available) and AORN Recommended Practices for Surgical Attire (forthcoming) in Perioperative Standards and Recommended Practices, 2010 edition
aorn.org/PracticeResources/AORNStandardsAndRecommendedPractices
Significance of Fomites in the Spread of Respiratory and Enteric Viral Disease
Stephanie A. Boone and Charles P. Gerba
Appl Environ Microbiol. 2007 March; 73(6): 1687–1696.
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