include "_nav_tab.php";Hand hygiene and patient prepping are generally considered the first line of defense in preventing nosocomial infections. However, because the surgical team represents the greatest potential source of contamination, wearing the proper surgical attire - everything from gloves to goggles to gowns - is arguably the most important way to ensure a sterile field around the patient.

While some experts have debated the necessity of certain pieces of attire as an SSI-prevention measures, no one doubts the importance of protecting OR staff from contact with splashed bodily fluids. This 15-question quiz will test your knowledge of the known and presumed preventative benefits of surgical attire - from head to toe.

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1. OR staff members with active infections pose no threat to the patient as long as they are wearing PPE.
Answer: B) FALSE
Many studies have linked OR workers with active infections to SSI outbreaks, according to infection control expert Alicia Mangram, MD, of the University of Texas at Houston's Department of Surgery. For example, outbreaks of Serratia marcesans have been traced to transmissions of the bacteria from contaminated OR staff to patients.

Of particular concern is the wearing of artificial nails in the OR. Bacteria such as Serratia can colonize artificial nails, whereas they do not typically colonize human skin. Wearing jewelry also poses a threat, as some studies suggest that bacteria can colonize more heavily underneath jewelry. Scrubbing may not remove these extraneous organisms.

This raises the problematic question of whether staff and docs should be permitted to wear a wedding band in the OR. There is no consensus on this issue, but experts on both sides agree that there should be a consistent policy applied to hold to the same standard of care (in other words, you can't make a policy that says simple gold bands are ok but staffers with larger, more elaborate rings must remove them).

There have also been reported nosocomial infections from nurses with infections underneath their fingernails. The bacteria can make their way to the surgical site even when the staffer wears latex gloves without easily noticeable damage. Although there is little evidence to link SSI to long (natural) fingernails, long nails pose the threat of puncturing surgical gloves.

2. What surgical attire does OSHA classify as personal protective equipment (PPE)?
Answer: D) BOTH A & B
In the 1991 Bloodborne Pathogens Standard, The Occupational Safety & Health Administration (OSHA) defines personal protective equipment as "specialized clothing or equipment worn by an employee for protection against a hazard." This may include hair coverings, eye protection, gloves, gowns and booties, but does not explicitly include surgical scrubs or general work clothes.

According to OSHA, personal protective equipment must be able to prevent blood or other potentially infectious materials from passing through and reaching an employee's work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions.

Here's a quick review of the PPE regulations mandated by OSHA. Your facility must:

• Provide all PPE at no cost to the employee and it PPE must be readily accessible.
• Ensure the adequacy, maintenance and sanitation of any PPE a staff member brings from outside the facility.
• Formally educate staff on the following: 1) when to wear PPE; 2) what PPE is necessary; 3) how to put on, take off, adjust and wear each piece of PPE; 4) limitations of PPE; and 5) care, maintenance, life expectancy (disposable or re-usable) and proper disposal of PPE.
• Investigate reported incidences of non-PPE compliance and take corrective measures, if necessary.
• Clean, launder, repair, replace and dispose of the PPE at facility, not worker, expense. (Note: Because surgical scrubs are not explicitly included in PPE, home laundering of scrubs falls into a gray area. See question 11 for a discussion of this topic).
• Store the PPE properly and have it ready for the next working period.

3. What is the primary purpose of wearing personal protective equipment in the OR?
Answer: B) TO PROTECT THE PATIENT FROM CONTAMINANTS FROM THE SURGICAL TEAM (SKIN CELLS, BACTERIA, ETC.)
The primary purpose of gowns, masks, caps, gowns, gloves and drapes is to provide a sterile field around the patient, according to infection control expert Dan Mayworm. Protecting the surgical team from bloodborne pathogens, while also critical, is secondary.

4. In procedures where there is a high probability of splashing of blood and body fluids, which of the following constitutes adequate eye protection?
Answer: D) BOTH A & B
In these cases, wear goggles, face shields, masks with attached face shields, or at the very least, eyeglasses with attached side-shields, says Nancy Bjerke, RN, MPH, CIC, a consultant for San Antonio-based Infection Control Associates. Even sports goggles are okay, says Ms. Bjerke, as long as they are form fitting and provide adequate clarity of vision. Institute a cleaning policy for visibly contaminated items; usually, washing with soap and water is adequate.

5. Surgical masks are capable of filtering:
Answer: A) BACTERIA
Even the least porous surgical masks cannot filter viruses, which are typically 1/100 the size of a bacterium. The FDA mandates that standard surgery masks be able to filter particles of 0.3 microns and larger, and laser surgery masks be able to filter particles of 0.1 microns and larger.

The wearing of masks in the OR is somewhat controversial. AORN guidelines state that "all persons entering the restricted area of the surgical suite should wear a mask when open sterile items and equipment are present." OSHA mandates that masks (as well as goggles and other appropriate PPEs) be worn whenever there's a chance that blood or other infectious material can spray or splatter.

However, some recent studies suggest that requiring nonscrubbed personnel to wear masks may be unnecessary. Nevertheless, few are willing yet to go out on the limb of saying masks can be eliminated.

We do know this much, however. If masks are not worn properly, they are useless. Thus, if you require masks, make sure everyone knows the right way to put them on, advises New York-based infection control expert Robert Garcia. If the mask has an aluminum nose strip, make sure it is molded tightly to the nose, and ensure that the mask is pulled tightly under the chin.

AORN recommends changing masks between uses and whenever they become moist. Masks should not be reused, hung around the neck or tucked into a pocket for later use. Tie the strings tightly with the upper string around the back of the head and lower string around the neck. A tightly worn mask can help reduce - although not eliminate - the microorganisms expelled into the air when one talks, sneezes, or coughs. Do not cross the strings, lest you create a gap around the cheeks. Lastly, when removing the mask, do not touch the filter in order to prevent contaminating your hands.

6. Which of the following hand lotion ingredients are compatible with latex gloves?
Answer: E) NONE OF THE ABOVE
Mineral oil, petrolatum and lanolin may cause latex gloves to break down within minutes of exposure. Also beware of highly fragranced hand care products, as they can cause irritation when gloves are worn. Experts recommend using only lotions that are water soluble and approved for use in a healthcare environment.

7. "Low-powder" gloves are defined as gloves containing:
Answer: D) NONE OF THE ABOVE
There are no regulations or guidelines defining a "low-powder" glove, so experts suggest switching to "powder-free" varieties. Note that even powder-free does not mean completely powderless - FDA defines it as being no more than 2 mg trace powder per glove. This is because residual powder is often left on gloves during the manufacturing process.

8. Wearing two pairs of gloves (double-gloving) helps reduce contact with blood and body fluids when compared to wearing a single pair.
Answer: A) TRUE
Although double-gloving isn't an OSHA requirement, science supports the practice and some professional organizations recommended it. Double-gloving may be particularly useful in orthopedic procedures, where gloves have a higher incidence of being punctured by an instrument or bone fragment. Some companies make brightly colored gloves that can be worn under neutral gloves - if the top glove is punctured, the lower glove is immediately apparent, signaling the surgeon to change.

9. What parts of a surgical gown are most susceptible to contamination?
Answer: E) BOTH B & C
The highest level of contamination occurs from elbow to wrist and the neck to the waist. Some surgical gowns are reinforced with greater protection in these areas, which may be advisable for some orthopedic and GYN procedures, where the chance of fluid contamination is high, says Ms. Bjerke. Note, however, that some "liquid-proof" gowns can be uncomfortably warm, especially during longer procedures and when the team is working under powerful lights.

10. Facilities that reprocess surgical gowns are held to the same sterility standards as surgical gown manufacturers.
Answer: A) TRUE
Because surgical gowns are sterile, the reprocessing regulations are the same as those governing the reprocessing of medical devices, says Ms. Bjerke.

11. OSHA mandates on-site laundering of surgical scrubs and prohibits home-laundering.
Answer: B) FALSE
Although there is no regulation mandating surgical scrub laundering, the issue is highly controversial. Some experts, including Ms. Bjerke, recommend against it, pointing out that a facility that allows home laundering may as well allow employees to wear street clothes under their surgical gowns. The AORN also discourages this practice, recommending that "all reusable surgical attire be laundered in a facility-approved and monitored laundry."

Experts agree, however, that there are no studies linking home-laundered scrubs to an increase in nosocomial infections. About 30 percent of healthcare facilities have instituted home-laundering policies. If you do decide to launder scrubs at home, Mr. Garcia recommends the following:

• Launder scrubs separately from other clothing.
• Use a detergent with a bleach additive. Mr. Garcia says it's not necessary to use hot water, as most detergents are formulated to work well in cold water.
• Dry scrubs at a high temperature to kill any remaining bacteria.
• Don't don scrubs at home after laundering. Pack them away and put them on only after entering the facility.

12. The practice of wearing a cover gown, such as a lab coat or a jacket, over scrubs when the employee is outside the OR has been proven to be effective in reducing scrub contamination.
Answer: B) FALSE
A 1994 American Journal of Infection Control study testing the use and non-use of cover gowns in a neonatal unit showed no significant difference in infection rates. AORN states that the use of cover gowns depends on a facility's culture and "the perioperative manager's assessment of priorities and state regulatory laws."

13. Wearing shoe covers always decreases the risk of surgical site infection.
Answer: B) FALSE
Wearing shoe covers (booties) has never been shown to decrease the risk of surgical site infections or even to decrease bacteria counts on the operating room floor, according to the CDC's 1999 Guideline for Prevention of Surgical Site Infection. OSHA mandates wearing booties only during procedures where gross contamination is anticipated.

14. At the end of a procedure, all personal protective equipment should be red-bagged.
Answer: B) FALSE
Red bags are completely overused, adding thousands of dollars to disposal costs, according to Bob Sharbaugh, PhD, International Director for Infection Control for Hill-Rom. Use red bags only for infectious waste, which OSHA defines as items visibly contaminated with liquid to semi-liquid non-absorbed blood or body fluids. You can dispose of anything else in the regular trash.

15. Central service employees should wear the following PPE when initially removing bioburden from medical instruments (cleaning endoscopes, for example).
Answer: F) ALL OF THE ABOVE
Healthcare workers usually remember to wear gloves and masks when cleaning instruments, but neglect eye protection and gowns, according to Ms. Bjerke. But because these workers are susceptible to splashes of contaminated fluids, they need to be fully protected. Workers should also protect themselves when transporting canisters of contaminated fluids to disposal areas.