Infection prevention is a two-way street — both the patient and the surgical team are at risk of contamination when the sterile field is compromised. Here are 5 head-to-toe precautions you can share with your staff and use to fortify your barrier-protection policies.

1. Scrub cap

• Why it's important. Loose hairs or dandruff may contain microorganisms or microbes that can contaminate the sterile field. AORN recommends that all surgical team members serving in semi-restricted and restricted areas of the OR wear a head cover that encloses all head and facial hair. Even personnel with bald or shaved heads should cover up "to prevent shedding of squamous cells."[1]
• Challenges. "Some staff members do not find it fashionable to contain all hair within a scrub hat," says Lisa Waters-Davis, RN, clinical director of Parkridge Surgery Center in Columbia, S.C. Wisps of hair protruding from the front areas of scrub hats or the temple area can either shed and contaminate the sterile field or "provide an opportunity for bloodborne pathogens to come in contact with the hair and surrounding skin," says Ms. Waters-Davis.
• Getting it right. AORN recommends that surgical personnel wear low-lint, disposable bouffant and hood-style caps, and discourages wearing skullcaps that fail to cover hair around the ears and neck or net caps that don't prevent stray hairs and dandruff from falling out. "Provide head attire appropriate for the environment and place it in a common area where all staff have access," says Ms. Waters-Davis.

2. Protective eyewear

• Why it's important. Infectious diseases, including viruses and bacteria that cause conjunctivitis and such bloodborne pathogens as HIV and hepatitis B and C, can be transmitted through the mucous membranes of the eye.[2] In a 2007 study, a surgeon performed 384 operations wearing protective masks and glasses over the course of a year. Post-op, the protective gear showed a 45 percent rate of blood or body fluid splash on the protective lens; half of laparoscopic procedures resulted in body fluid splashes.[3]
• Challenges. Many surgical team members neglect to don protective eyewear before cases. "It's not something as routine as putting on the mask," says Linda Cunningham, RN, BSN, CNOR, infection control liaison to the OR at New England Baptist Hospital in Boston. A 1998 study of blood exposures among OR personnel found that "barrier protection for the nose and mouth is more consistently worn by OR personnel than eye protection," thereby resulting in a higher volume of reported exposures to the mucosa of the eye rather than to the nose or mouth.[4] Ms. Cunningham says a common misconception is that regular eyeglasses are enough to protect the eyes during surgery, or that protective eyewear in general is not necessary for every procedure or every surgical team member. In the 1998 study, "circulating nurses had nearly the same number of eye exposures as scrub persons despite the generally held belief that circulating nurses are at negligible risk of eye exposure."
• Getting it right. According to AORN, "masks should be worn, along with protective eyewear (goggles, glasses with solid side shields and chin-length face shields, for example) whenever eye, nose or mouth contamination reasonably can be anticipated as a result of splashes, spray or splatter of blood droplets or other potentially infectious materials." Splashing is particularly a concern in procedures where power tools are used. New England Baptist Hospital gives surgeons and staff the option of 3 different types of protective eyewear, including disposable eye shields that sit on the ears (ideal for people who wear glasses) and others that sit on surgical masks. Jane Perry, associate director of the International Healthcare Worker Safety Center in Charlottesville, Va., recommends goggles that have a seal above the eye line to prevent fluids from running into the eyes. Make protective eye shields as routine and mandatory as masks, says Ms. Cunningham: If you're not wearing one, you can't set foot in the OR.

3. Mask

• Why it's important. In a similar fashion, surgical masks keep bloodborne pathogens from infecting personnel via the mucous membranes of the nose and mouth. They also filter droplets expelled from the mouth and nasopharynx while talking, breathing, sneezing or coughing, says Ms. Waters-Davis.
• Challenges. Surgical personnel are generally accustomed to donning a mask before entering the OR. A more pressing issue, according to Ms. Cunningham, is duration of wear. A surgical mask's effectiveness as a barrier against airborne microorganisms diminishes with time, but many personnel will wear one mask for several hours, letting it hang down in between procedures and then tying it back up before stepping into the OR.
• Getting it right. Educate your staff on the surgical mask's role in preventing contamination of the patient and the surgical team, and "create an internal practice for everyone to remove masks at the end of each case," advises Ms. Waters-Davis. She also suggests you "provide a variety of masks above scrub sinks and in close proximity to all OR suites and sterile environments."

4. Gown

• Why it's important. Disposable gowns changed with each procedure prevent blood and other potentially hazardous materials from contaminating the skin or the freshly laundered surgical scrubs your staff wear throughout the day and throughout your facility, says Ms. Waters-Davis. Gowns also prevent intercontamination and microbial migration between staff members and the patient's blood and body substances.
• Challenges. Especially in an ambulatory facility, Ms. Waters-Davis says, staff may not be aware of the importance of covering up with protective gowns during quick, minor procedures. Ms. Cunningham adds that another common problem is "glove creep": When worn properly, sterile gloves should fully cover the cuff of the surgical gown, but sometimes the glove will slide off the cuff, increasing the risk of contamination to the sterile field. According to AORN, gown sleeve cuffs are "not considered effective microbial barriers" because, along with the neckline, shoulders and underarms, they are "areas of friction."[5]
• Getting it right. AORN recommends that scrubbed personnel "don sterile gowns and gloves from a sterile area other than the main instrument table." To prevent glove creep, consider gowns that feature a grip on the cuff to help keep the glove in place, says Ms. Cunningham. Encourage your staff to be wary of this problem, speak up when they notice cuff slippage and take the time to carefully readjust if necessary.

Make sure sterile gowns are readily available — if not in your procedure packs then somewhere else in the OR, counsels Ms. Waters-Davis. Purchase gowns that have the appropriate level of barrier protection for the cases you host. According to AORN, a gown with minimal barrier protection may be appropriate for short procedures where staff anticipates little or no risk of exposure to blood or bodily fluids, but "as the complexity and length of the planned procedure increases, there may be increased potential for exposure to bloodborne pathogens, and it would be prudent to select a gown with greater barrier capability."[6] The Association for the Advancement of Medical Instrumentation classifies the barrier protection capability of surgical gowns and drapes on a scale of 1 to 4, with Level 1 signifying minimal protection (OK for low-risk procedures such as ENT and ophthalmic surgery) and Level 4 indicating protection when a high level of fluid volume is anticipated (for example, during major orthopedic surgery).[7]

5. Footwear

• Why it's important. The floors of your ORs may be contaminated with bloodborne pathogens, hazardous and potentially hazardous fluids and cleaning agents. Protective footwear protects your surgical personnel from these hazards and prevents infectious agents from spreading to other areas of your facility when personnel move in and out of the OR. Shoe covers can also "decrease microbes that are stirred in the air when traffic through the sterile environment occurs," says Ms. Waters-Davis.
• Challenges. When your surgical personnel don't cover up their shoes for surgery or fail to change shoe covers between cases, they may carry microorganisms with them when they exit the OR. Ms. Waters-Davis notes that staff may also fail to don more sturdy footwear, such as boots, "during procedures when copious amounts of fluids will be used, such as arthroscopic cases." In the warmer weather, staff may be tempted to wear open-toe or open-back shoes — another no-no, according to AORN.
• Getting it right. Create and enforce a policy of removing shoe covers and boots and putting on new ones between each case so as not to spread infectious waste throughout your facility. Appropriate shoe coverings should be made available and housed in areas where they're accessible to the staff members who'll need them, says Ms. Waters-Davis.