The OR nurses in Florida who are up in arms over a new policy requiring them to buy and home-launder their scrubs have nothing to worry about when it comes to the risks of potential infection, according to a 2004 pilot study conducted by Priscilla Jurkovich, MSN, RN.1

Ms. Jurkovich sought to determine the presence of pathogens on scrub attire that had been either laundered at home or in the hospital. She cultured the left front shoulders of home-laundered scrubs (n=30) and hospital-laundered scrubs (n=20) during the first two hours of a single workday. For the home-laundered scrubs, she collected data concerning home-washing procedures, water temperature, pets in the home and donning procedures.

She found no pathogenic growth on either the hospital- or home-laundered scrubs. In addition, she found no relationships between home-washing procedures, water temperature, pets in the home and donning procedures. The results of Ms. Jurkovich's study suggest that scrubs laundered both at home and in the hospital were free of pathogens and that differing home-washing procedures made no difference.

In 1986, Stanford University Hospital found that unprotected scrub attire worn outside the OR was not significantly more contaminated than scrub suits that weren't worn outside the OR.2 In 1997, researchers concluded that home-laundered scrub clothing could be worn safely in labor and delivery units, including ORs contained in those units.3 Another study concluded that low-temperature washing was as effective as high-temperature washing in eliminating bacteria from hospital laundry.4 In addition, an electric clothes dryer played the most significant role in eliminating bacteria from linen.

Pushback at two hospitals
Health First, which owns and operates three Florida hospitals, now requires its OR nurses to buy their own scrubs and wash them at home. Some of the surgeons and nurses at two of the hospitals, Holmes Regional Medical Center in Melbourne and Palm Bay Community Hospital, are less than thrilled with the new policy for fear that wearing home-laundered scrubs into the OR could increase the risk of surgical infections while also posing a reverse risk to nurses, who might take a hospital-acquired infection home with them.5

Hogwash, says Jan McCoy, MSN, RN, CNAA, BC, vice president of patient care services at Health First's Cape Canaveral Hospital, where OR nurses have home-laundered their scrubs for six years.

"I am absolutely certain that laundering scrubs at home will not increase your infections rates," says Ms. McCoy. "This is a non-issue. No studies have shown any correlation between infection and laundering scrubs at home as opposed to hospital-laundering. We did an extensive literature search to see if there were any studies that showed any problems. There were zero. None."

Ms. McCoy notes that surgeons routinely arrive at the OR from home dressed in scrubs. They do surgery, go to their office and see patients, do more surgery, go to the cafeteria and then maybe drive to another facility to do more surgery - all in scrubs and all without changing clothes.

"They've done it for years," she says. "A lot of this uproar is because hospital laundering of scrubs is a sacred cow that nobody wants to challenge. But when you really start to look into it, there's no basis for not having nurses wash their own scrubs. Nurses in the operating room cover their bodies with sterile cover gowns, so they're actually more protected than nurses on the floor."

What's more, there's an economic advantage to home laundering. With 150 beds, Cape Canaveral Hospital saves up to $30,000 a year in scrub costs and commercial laundry fees, says Ms. McCoy. Health First's new policy is expected to save an additional $75,000 to $100,000 annually, according to officials' estimates. "It's not just the cost of the scrubs, but also the per-pound cost of laundering the scrubs," says Ms. McCoy.

In the beginning, her nurses complained of having to pay for their own scrubs, says Ms. McCoy. Now, however, she says scrubs have become an identifying factor for the nurses, as they get to choose their own styles and colors.

The CDC makes no recommendation because there are no well-controlled studies that evaluate scrub laundering as a surgical site infection risk. AORN, on the other hand, opposes home laundering of scrubs, while conceding limited research exists to dispute or support the organization's stance. However, AORN notes that such environmental bacteria as methicillin-resistant Staphylococcus aureus or Clostridium difficile can remain on fabrics a long time unless water temperatures reach 110'F or chlorine bleach is used. Home laundering of contaminated scrubs, whether privately owned or provided by the facility, is not acceptable under OSHA regulations.

"Use common sense," says infection control expert Dan Mayworm. "If you buy your own scrubs and take them home to launder, then you shouldn't wear them en route or at home either before or after they are laundered."

Mr. Mayworm offers these practical tips:

• Bag scrubs at the hospital and launder them at home, making certain that the wash cycle reaches the appropriate temperature - no cold washes.
• Wear street clothes to the hospital and change into the scrubs when you get to the hospital. Never wear scrubs when going home. And never wear them from home to the hospital.

"Nurses don't like to have to change clothes, and the rationale they use is that they're covered by sterile gowns during surgery," says Mr. Mayworm. "But this ignores that all the places they go in the hospital while wearing scrubs is carried home with them. Not a good idea." What about bacteria from hands? When introduced into the operative wound, bacteria from the hands of a surgeon or other staff member can cause infections.2 Here's a look at what studies have shown regarding jewelry and fingernails. Studies have found that the skin underneath a ring is colonized more heavily than skin without rings.6 In a study by Salisbury, et al., of 100 healthcare workers (50 wearing rings, 50 without rings) who washed with antimicrobial soap and water, the colony counts were significantly higher in the ring-wearing group.7 Jacobson and colleagues also reported that skin under rings was more heavily colonized than skin on those that didn't wear rings during antisepsis.8 AORN guidelines recommend that you remove rings, watches and bracelets before you start surgical hand antisepsis and keep them off until the procedure is completed. Rings can also tear gloves, increasing the potential for the transmission of pathogenic microorganisms to the patient. Studies have shown that wearing artificial nails increases bacterial and fungal contamination of hands.6 However, there is a lack of well-characterized studies that show that SSIs are directly attributable to nail length and cleaning.9 The CDC and AORN recommend that artificial nails not be worn in the clinical perioperative environment.

References
1. Jurkovich P. "Home- versus hospital-laundered scrubs: a pilot study." American Journal of Maternal Child Nursing. 29(2):106-110, March/April 2004.
2. Copp G, et al. "Covergowns and the control of operating room contamination." Nursing Research. 35 (Sept./Oct. 1986) 263-268.
3. Kiehl E, Wallace R, Warren C. "Tracking perinatal infection: Is it safe to launder your scrubs at home?" MCN, American Journal of Maternal Child Nursing. 22:195-197, July/Aug. 1997.
4. Blaser MJ et al. "Killing of fabric-associated bacteria in hospital laundry by low-temperature washing." Journal of Infectious Disease. 149:48-57, January 1984.
5. Jenks S. "Scrubs policy raises concerns." Florida Today. 6 April 2007.
6. Boyce JM, Pittet D. "Guidelines for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America." MMWR Recomm Rep. 2002;51:1.
7. Salisbury DM, Hutfiltz P, Treen LM, et al. "The effect of rings on microbial load of health care workers' hands." Am J Infect Control. 1997;25:24.
8. Jaconson G, Thiele JE, McCune JH, et al. "Handwashing: ring-wearing and a number of microorganisms." Nurs Res. 1985;34;186.
9. Graves, PB, Twomey, CL. "Surgical hand antisepsis: an evidence-based review." Periop Nursing Clinics. 1 (2006) 235-249.