Selecting and buying surgical drapes, gowns and masks can become rote, like driving a car. The trouble is, just as with driving, real danger can rear its ugly head if you let your guard down too long.

"I have observed that barrier properties take a back seat to cost," says Edward J. Quebbeman, MD, professor and general surgeon with the Medical College of Wisconsin in Milwaukee. "But I am still hopeful that, some day, science will win out."

But how does a manager consider the science when manufacturers' testing statistics are often unavailable and clinical evidence is inconclusive? Here are some practical ideas for breaking out of the box and selecting the items that will provide the level of barrier protection you need.

Pay attention
Foremost, say experts, stay mindful of the fact that barrier protection practices are crucial. Recently, some have questioned the role of surgical drapes, gowns and masks because current evidence doesn't clearly show that any one of these measures reduces surgical site infection rates. However, these measures do help prevent cross-contamination, and few argue their necessity. Even a single SSI can result in very real suffering and significant cost. One report estimates that SSIs cost $1.6 billion a year and happen in 2.5 per 100 operations.

"SSIs create a tremendous societal burden and affect an institution's bottom line," says Charles E. Edmiston Jr., PhD, professor of surgery, pathology and otolaryngology and hospital epidemiologist with the University of Wisconsin, Milwaukee. "They are a high-priority issue."

Don't let factors like cost and relationships with sales reps rule the product decision, say experts.

"I think it's very hard - I'd even say impossible - for facility managers to select these products by sitting at a computer and having discussions with manufacturers, because they have such a large number of choices and pressures, and because few manufacturers provide useful data," says Dr. Quebbeman. Rather, he says, focus on function first.

Apply AAMI standards
The first step experts recommend is to apply the recent AAMI barrier performance standards to determine what categories of drapes and gowns you need for each member of your surgical team. The standards stratify strikethrough properties of the most critical zones of drapes and gowns (including seams and attachments). Infection control expert Fran Koch, RN, administrative director of surgical services at Presbyterian Hospital in Dallas and co-chair of the Association for the Advancement of Medical Instrumentation Protective Barriers Committee, explains the levels like this:

• Level one. Procedures involving little fluid or pressure (some dermatology, ophthalmology and simple ENT surgeries, for example).
• Level two. Hernias, orthopedic procedures with tourniquets and tonsillectomy/adenoidectomies.
• Level three. Procedures such as mastectomies, arthroscopies and general surgeries.
• Level four. Highest protection, equivalent to FDA-labeled impervious gowns, for large abdominal cases, orthopedic cases without tourniquets, trauma, C-sections and cardiovascular procedures.

"When evaluating your needs for gowns and drapes, look at the amount of fluid on the field and how vulnerable the field is to splashes or sprays, as well as how much pressure is anticipated," advises Ms. Koch.

The surgeon and first assistant require the most protection, while others in the OR can typically use lower-level, more comfortable and less expensive gowns.

"I pushed for these standards, and I certainly think they are helpful, but only if they are applied," adds Dr. Quebbeman, noting that many facilities simply aren't asking manufacturers for the information.

Judging gowns and drapes
The second step, and by far the best way to find out if your gowns and drapes are going to provide the protection you need, is to perform an in-use evaluation, says Dr. Quebbeman. Many facilities don't even think about doing this, he says, but it's fairly simple to create a systematic way of recording contamination rates. And, he adds, this kind of evaluation can make for an excellent QA study. Here are some of the factors Dr. Quebbeman suggests you assess:

• Find out if and when patients are getting wet from irrigation fluids soaking through the drapes.
• Check to see if surgeons are getting any blood on their skin after they de-gown.
• Note the location of contamination (such as, but not limited to, forearms, abdomen and face).

Record, analyze and report this information, then use it to compare products, says Dr. Quebbeman.

"Evaluate what's going on in your OR. If fluids are penetrating the drapes and gowns, they're not good barriers even if they are cheap," he says. "Surgeons comment that they get blood on their forearms all the time, but most don't think of it as a big deal. And while blood on intact skin is not a big risk, I know few people who scrub every day who also have intact skin."

Data like this, says Dr. Quebbeman, not only reveals the rate of contamination but also points out where you'll need extra reinforcements in your gowns. And, he says, it's the only way to really know how the products will perform, because even the most thorough lab test can't predict factors like the amount of moisture, stretching and shearing that will occur during surgery.

For example, Dr. Quebbeman and his colleagues performed formalized studies of surgical gowns and found that gynecologic surgeons were at the greatest risk of contamination. Both they and general surgeons were most likely to experience forearm contamination, while orthopedic surgeons had more widespread contamination over their bodies than any other specialty because blood and irrigation fluids tended to run down the side of the OR table. They also found that, while surgeons and first assistants were more likely than other members of the surgical team to become contaminated, circulators' forearms became contaminated with blood splashes while handling and counting sponges.

Mask considerations
To evaluate masks, Dr. Edmiston says it's critical to assess fit, because the tighter the fit around the face, the more effective the filtration. However, comfort is important, too, because discomfort will cause personnel to loosen the masks. And while this may seem like old news, Dr. Edmiston's very recent research is showing that an effective mask may be more important than previously thought. Using an innovative air sampling system, he and his colleagues have illustrated that airborne transmission is a pathway for bacterial contamination in the OR - namely, nasopharyngeal shedding. This, he says, is nothing short of a significant paradigm shift in infection control (see "A New Pathway for OR Contamination: Airborne Pathogens" on page 32).

"Historically, we were taught that bacterial infection resulted from our own and the patient's flora, and infection control practices for preventing dissemination of bacteria relied on contact issues," explains Dr. Edmiston. "These new data are very important in the context of improving our infection control practices."

Once you identify which personal protection items pass your in-use evaluation, you can focus on cost, say experts. If you find several gowns, for example, that provide the level of protection you need, then by all means, buy the cheaper product. Just don't let cost be the driving factor, they warn.

Keep looking
The in-use evaluation shouldn't be the last step you take. Dr. Edmiston recommends letting it mark the beginning of a new way to think about infection control in the OR.

"Let it begin a discussion," he says. "Take a look at your practices. Are your surgeons walking around with masks on their chins or masks hanging around their necks and then re-using them? Masks certainly are not so cost-prohibitive that surgeons can't replace them between procedures."

Finally, he advises, let this process lead you even further outside of the box.

"Now that we know nasopharyngeal shedding occurs, think about other strategies we can adopt. In our center, we now cover prosthetic devices with a small sterile drape while we are sizing graphs so it doesn't lie out in the open. This could reduce the risk of casual contamination," he says.

Other examples include requiring pre-op antiseptic showers, ensuring properly timed and properly dosed antibiotic prophylaxis, evaluating state-of-the-art surgical skin preps, enacting a policy to ensure glycemic control in all patients and using antiseptic-impregnated surgical sutures.

"While infection rates may seem low, if you get one, the statistics just don't matter. If you are the patient, then you are 100 percent infected," says Dr. Edmiston. "Many infections take months or years to manage, and with the rise of implantable devices, whatever we can do to reduce the risk is worthy of our consideration."