The correct use of personal protective equipment is vitally important for shielding staff and patients from cross-contamination, so I can't help but spot the oft-overlooked bad habits that surgical teams need to stop perpetuating (maybe that's why I became an infection control coordinator). Barrier protection may seem like a bland topic so, to liven things up, let's examine some real-life photos published in Outpatient Surgery Magazine. Many of these oversights are common in surgical facilities — likely even yours — so look at them as practical reminders for gaining compliance with PPE-related protocols instead of pointing the finger of blame at the staff and docs in the pictures who may or may not have known they were doing anything wrong.

ANESTHESIA AWARENESS No one's wearing goggles; the anesthesiologist has bare hands and is wearing a watch; and the assistant is wearing a scrub gown as a robe.

Staff and physicians must wear gloves for all patient-care activities during which there's any chance of contact with bodily fluids. Intubation fits that description — if the patient coughs or bucks, you're going to be exposed to microbes. That's also why the anesthesiologist should be wearing goggles — he's standing right over the airway.

Then there's that watch. Do you want to swab it and find out what microbes it's harboring? In addition, watches without elastic bands are a pain to take off every time hand hygiene is performed, which means he probably missed some spots while trying to avoid waterlogging his timepiece. Don't let anyone say to you, "I need to be able to just look down and know what time it is." That's nonsense — there are clocks everywhere in critical care areas.

Finally, a scrub gown should be worn as a scrub gown only, not for keeping warm. If it's cold in the OR, put on a scrub jacket. That gown is (a) not protecting the front of her body and (b) is too flowing and bulky for her to know whether bodily fluids, bioburden or another substance have gotten on it and are being transported around the facility.

COVER-UP SCANDAL She's wearing a hoodie or sweater over her scrubs, and she's removed the shield from her mask.

Scrubs are made of a combination of fabrics that prevent lint and shedding. Whatever she's wearing, whether it's made of fleece or woven materials, is a prime candidate for getting lint in the surgical field or for harboring microbes. And where is the cover-up laundered? I doubt the facility is ensuring her jacket was washed at the appropriate temperatures. That's why there are warm-up jackets made specifically for health care — personnel who get chilly in the OR should wear one of those instead.

She made a good choice, picking a mask that accommodates a shield. But not actually attaching the shield? That's a bad choice. Shield or goggles, you've got to have one of them in that situation.

TWO STRIKES The anesthesiologist's not wearing eye protection and his pocket is overstuffed.

This is the last time I'll remind you about eye protection. And no, eyeglasses don't count, unless they're big enough to cover the entire eye area and have side shields. Sometimes it's hard for surgeons who wear glasses to comply with eye shield requirements because they'll say the field of vision isn't as good or crisp when looking through 2 lenses. So, for them, purchase prescription glasses that will fit the bill as eye protection. But for intubation, there's no reason to not be wearing eye protection in addition to those glasses.

What's in the right pocket of his scrub jacket? It's good to see he's wearing the right kind of cover-up in the OR, but those packets of syringes or medications are inches away from patient, in the sterile field no less. He's going to take them everywhere he goes, from patient to patient to patient. Don't give microbes a free ride around the facility. Use pockets to keep pens or stethoscopes handy, and some antibacterial wipes for cleaning them between uses.

If you hear the excuse that staff needs supplies nearby, point out that there are plenty of storage carts in the OR. And if supplies genuinely aren't readily available, take it as an opportunity to make sure everything they need is within arm's reach.

'EAR ME OUT This photo depicts a laser-safety drill, so I'll forgive the lack of gloves this time. Kudos to everyone for appropriate eye protection, but there are other worrisome issues here: The tech in the foreground is wearing a long-sleeved shirt under her scrubs, everyone's wearing cloth hats with ears exposed, and the nurse in the middle is wearing dangly earrings.

Remember what I said about not wearing hoody sweatshirts? The same goes for layers underneath scrubs, for all the reasons previously listed. If you're cold, grab a scrub jacket. Cloth surgical hats are a no-no unless they're facility laundered. Home washing machines usually aren't able to reach the correct temperature, and you can't monitor what staff actually do with their hats. Are they changing to a new one every day? Are they even washing them between uses?

Bouffant caps are the only acceptable headgear, really. If staff want to wear colorful cloth caps in your facility, they can — so long as there's a bouffant cap over top. These disposable hats are also easier to get over the ears, which should be fully covered in the OR. Ears contain squames that shed and can fall out and onto or into the patient. If the thought of getting sprinkled with earwax makes you squirm, then so should wearing hats above the ears. (Similarly, staff who shave their heads still must wear caps, because head skin sheds, too.)

Ban dangly earrings from patient care areas. It's surgery, not a fashion show. If earrings are to be worn, they should be studs that fit neatly under the bouffant cap, which then goes over the ears, of course.

HANGMAN The physician's stethoscope is hung around his neck.

The stethoscope is a sort of hub for every person you come into contact with. It's picking up microbes left and right and is a prime candidate for spreading them from patient to patient. As such, there are only 2 acceptable modes for the stethoscope: in use, or wiped down with disinfectant and stowed in the pocket of your scrubs.

DOUBLE TROUBLE The nurses' masks are dangling around their necks.

This far-too-common practice means everything you've been breathing out, for who knows how long, is now exposed to the open air and can go anywhere and everywhere. The rule for masks is hard and fast: either down and off, or up and on. Or, as one of our wittier nurses put it, "Think of your mask as your bra. You wouldn't let it just hang there."

NEW HABITS
5 Tips for Improving PPE Compliance

1. Back yourself up. Don't hesitate to go to key sources — OSHA, AORN, APIC, the CDC, AAMI — anytime someone wants to dispute a policy. Also rely on those sources when developing staff education for a monthly newsletter or regular staff education in-services. Have fun at those sessions: Get physicians and staff to use a certain colorless lotion before performing hand hygiene. After scrubbing, the lotion will be activated, and missed spots will be readily visible. It's a good reminder about why PPEs matter, even on body parts you get "clean.

2. Reiterate the message. Sometimes, the gentle approach is best. Other times, after a torturous half-hour citing statistics, the PPE offender says, "Well, I still don't think that's true." That's when it's time to be firm: "That may be your opinion, but this is the way we're going to do it." Support your infection preventionist and actively promote proper infection control policies.

3. Be a friend. Alerting staff to barrier protection issues doesn't have to be confrontational. If Jane has already scrubbed in and you haven't, and her hair's sticking out from under her bouffant, let her know. Then tuck it up there for her so she doesn't have to re-scrub. It's just common courtesy to help ameliorate, rather than ignore, when you see a problem. Encourage the whole staff to become advocates, challenge them to spot, then politely stop, bad practices.

4. Make the E stand for "easy." Keep utility gloves in 3 areas in the OR and in all sub-sterile rooms. Place hand sanitizer dispensers next to the trash bins where gloves are most likely to be thrown out. Launder scrubs for staff (you really shouldn't be allowing home-laundered scrubs anymore). Look around, see how you can help aid the ways people work on a daily basis.

5. Conduct ongoing reviews. As soon as you think you've got everyone doing right, that's the day you catch the anesthesiologist not wearing gloves. So observation should be ongoing, if not a formally counted measure in your SSI tracking. Not much is going to change in barrier protection at this point; it's staff behavior that needs to change.

— Patricia Castellano, RN