When your surgeons and staff don't follow correct attire practices, such as completely covering the hair and not wearing scrubs outside the OR, they're endangering patients by putting them at risk for an infection. Needlessly so.

We may not have all the answers when it comes to keeping our patients safe from infections, but thanks to careful research and high-level evidence collected over many years, there's plenty we do know. And yet, every day, in surgical facilities all over the United States, clinicians who should know better disregard some of the most basic dictates and principles of infection prevention.

What can you do about it? At the very least, you can set a good example by resolving to never let personal preference or convenience override what you know to be right. The choices you make can send a powerful message to your surgeons and staff and help motivate them to make the same choices. Here are 3 areas to focus on right away. I chose these practices because this is where I see consistent breaks in safe-attire practices and also because there's evidence you can share with your practice-breaking colleagues.

1Head coverings
Most surgeons have a strong preference for skullcaps. The skullcap, often personalized with the logos of a favorite sports team or alma mater, is symbolic of the surgical profession. It signifies "surgeon." But these caps sit above the ears, leaving lots of hair uncovered. Regardless of their popularity, we can't rely on skullcaps to contain hair above and in front of the ears or at the nape of the neck. We know for a fact that we shed skin squames and that they can contain potentially pathogenic bacteria. Studies have shown that Staphylococcus aureus and Staphylococcus epidermidis have a tendency to colonize in hair, skin and the nasopharynx (osmag.net/ybbv6t). It's why AORN recommends wearing a "clean, low-lint surgical head cover or hood that confines all hair and covers scalp skin [and is] designed to minimize microbial dispersal."

Can Skullcaps and Scrubs Cause Infections?

Could breaks in surgical attire safety put your patients at risk for infection? To find out, we polled our readers to get their take.

Improper surgical attire can harm patients.

• Strongly agree 47%
• Somewhat agree 30%
• Somewhat disagree 15%
• Strongly disagree 8%

SOURCE: Outpatient Surgery Magazine InstaPoll, March 2017, n=423

This isn't just theoretical. Several case studies demonstrate the need for proper head coverings. For example, in 2016, 10 cases of mycobacterial infection at a surgical center were traced to a single surgeon whose scalp was shedding a new species of mycobacteria during surgery (osmag.net/kqvn4m).

Surgeons might resist covering their skullcap with a bouffant. But should we sit idly by while people refuse to follow AORN recommendations based on personal preference and not on the evidence? Making surgeons happy shouldn't trump keeping patients safe. Wearing proper head coverings isn't hard or harmful. Based on everything we know, it's just common sense.

2Home laundering
Home washing machines and non-accredited laundering facilities simply can't be trusted to do an adequate job of cleaning surgical attire. There are far too many variables. Instead, all laundering of scrubs and other healthcare textiles should be done by healthcare facilities or accredited commercial laundries.

Bacteria and other pathogens can adhere to perioperative clinicians' clothing, as well as to linens. Accredited laundering facilities are subject to rigid and regular monitoring and must follow industry standards that incorporate OSHA and the Centers for Disease Control and Prevention (CDC) guidelines (for more on accreditation, see hlacnet.org).

Here again, documented cases demonstrate the danger. In one study (osmag.net/ghbs8u), 3 post-op sternal infections related to Gordonia bronchialis were traced to a CRNA's scrubs and home washing machine.

3Wearing scrubs in public
We should always keep soiled surgical attire within the healthcare setting. If soiled (including non-visible soil) surgical scrubs are worn beyond the perioperative setting, bacteria and other pathogens — which can attach to clothing and which may or may not be visible — can expose family and community members to potentially pathogenic organisms. With heightened concerns about antibiotic resistance and exposure to dangerous pathogens, why would anyone want to take the risk? Additionally, we should transport and store surgical attire in a way that keeps it contained within a clean environment. Storing clean surgical attire in a locker with personal items from outside the facility may contaminate it.

Common OR Dress Code Violations

HEAD SCRATCHER Some surgeons strongly prefer skullcaps, but should that trump patient safety?

DOUBLE HAZARD Home laundering of scrubs not only fails to get them clean, it may also expose family members to pathogenic organisms.

OFF THE JOB When you wear scrubs to and from work, are you ferrying pathogens from the OR to the home and everywhere in between?

Here are the 3 areas where I see consistent breaks in safe surgical attire practices: wearing skullcaps that leave hair uncovered, laundering scrubs at home and wearing scrubs outside of the OR area. There is evidence that these breaks could be putting patients at risk. There is still a struggle to achieve compliance with these and other recommendations, as OR members refuse to follow the recommendations based on personal preference and not on the evidence, particularly with head covering.

— Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN

Fight is intensifying
The more you let your guard down in these important areas, the more others will be inclined to do the same. We need to be professional, set an example, and not be afraid to speak up when see others violating attire policies. Maybe you're in a position to help set and enforce policy. If so, talk to people. Show them the evidence. Try to keep people on track with the overarching goal of always providing the best care for patients. That means reducing infection risks as much as possible, even if it's not always the easiest or most convenient choice. OSM