Surgical operating rooms have long been the site of many commonly accepted rituals that the staff continue to practice long after the reasons for doing them are forgotten. These "sacred cows" are an institution of many facilities' everyday practices, and yet they often provide little or no real benefit to procedure outcomes or patient satisfaction.

Here we'll examine nine practices and present the scientific and anecdotal evidence that seem to suggest that they are, in fact, sacred cows. A few are widely accepted as such, but others are still controversial. We hope that this article will help you decide what is right for your facility.

1. Wearing shoe covers in the OR
Shoe covers used to be worn to guard against contamination from staff members' feet. However, there is little evidence to prove that using shoe covers reduces the risk of infection. In 1999, the Centers for Disease Control released guidelines that recommend abolishing shoe covers, noting that they have never been shown to decrease infection risk or to lower bacterial counts on OR floors. The Occupational Safety and Health Administration and the Association of PeriOperative Registered Nurses suggest shoe covers only when gross contamination can be reasonably anticipated.

Most of the administrators with whom we spoke are heeding the new guidelines. "We have eliminated the mandatory use of shoe covers in the OR. Shoe covers are available to use as necessary," says Dale Bowman, RN, CNOR, manager of Providence Surgery Center in Mission Hills, Calif. Nancy Burden, the Surgical Services Manager at Morton Plant Mease Surgery Center, in Palm Harbor, Fla. agrees, saying, "Shoe covers are not used in our OR unless the case is expected to be messy."

If you are doing procedures where blood and bodily fluids are spilling onto the floor, your staff should take proper precautions and wear moisture-proof protective footwear, advises Dan Mayworm, an infection control expert and former publisher of Infection Control & Sterilization Technology. He recommends wearing clogs that can be wiped clean or setting aside a pair of shoes that are used solely in the OR.

2. Wearing cover gowns outside the OR
Like shoe covers, cover gowns were once worn over scrub suits when OR staff left the operating suite to prevent the spread of microbes from the OR as well as to avoid bringing microbes back into the OR. Recent studies have debunked this idea. A study published in Oncology Nursing Forum in September 1999 conducted at Georgetown University Medical Center found that even during invasive procedures such as bone marrow transplants, eliminating cover gowns did not cause a rise in infection.

AORN stopped requiring the use of cover gowns in 1994, and its 2000 recommendations state that the use of cover gowns should be determined on a case- by-case basis. Just about everyone we spoke with has done away with cover gowns.

3. Requiring patients to completely undress for minor procedures.
Traditionally, patients undress for surgery to provide easier access to the surgical site as well as to keep clothing from becoming stained. However for some procedures, notably cataract cases and some other minor plastics procedures, many facilities are safely performing procedures without requiring patients to fully undress.

At Ms. Bowman's facility, cataract patients only change from the waist up and wear pants, socks, and even shoes during the procedure. "The only reason we make patients take their tops off is to facilitate the placement of EKG leads, blood pressure cuff and stethoscope," says Ms. Bowman. Having elderly patients change for a procedure can also be time consuming. Ms. Bowman estimates that her facility's current practice saves about 15 minutes per case. But it's not just about saving time. "In our vision center, our cataract patients remain in their undergarments and pants with a gown covering," says Jim DeFontes, MD, Chief of Anesthesia for Kaiser Permanente, in Orange County, Calif. "Patients often feel more comfortable and warmer this way."

According to Melonie Marchak, BSN, deciding when to have patients undress and when not to depends mostly on the surgical site and what your surgeon and staff feel comfortable with. Patients will need to undress for cases below the neck, but for minor eye and facial procedures, it may be more convenient to let them stay partially dressed.

4. Mopping the OR after every procedure.
Mopping the floor used to be a routine chore that had to be done between each case to provide the highest standard of cleanliness. But according to Mr. Mayworm, constant cleaning actually stirs up the particles from the floor and other surfaces and into the air, and depending on room ventilation, it may take up to an hour for this debris to resettle. Consequently, many infection experts and AORN recommend cleaning on an "as needed" basis throughout the day when surfaces become contaminated with blood or body fluids.

Linda M. Reecer, RN, BS, of Clewiston, Fla.'s Hendry Regional Medical Center, says that her facility has stopped mopping the floors between cases when there is nothing visible on the floor, such as suture material or other infectious material. Ms. Bowman agrees, "Now, we only mop in between cases if there is tissue, blood or other fluid on the floor and at the end of the day." According to Ms. Bowman, skipping this step saves her facility several minutes between each case.

5. Wearing masks in the OR at all times.
Masks are worn in the OR to protect the sterility of the operative field from bacteria-laden droplets, that emit when we breathe and talk. But various studies have questioned the need to wear surgical masks all the time. One of the studies conducted at the Karolinska Institutet in Sweden and published in the May/June 1991 World Journal of Surgery found no significant difference in wound infection rates when comparing masked and unmasked general surgical procedures. And another study conducted at the Princess Royal Hospital in England, published in the July 1991 Journal of Hospital Infection found no infection risk from oral bacteria expelled by non-scrubbed personnel not in the immediate vicinity of the surgical field.

According to Mr. Mayworm, there seems to be a trend toward omitting the mask during non-invasive procedures because it reduces cost and is more comfortable for the surgeon. The CDC's recommendations have become a little more relaxed than they once were, stating that surgical masks should be worn if sterile instruments are open or if the operation is about to begin or is in progress. The AORN has released similar guidelines, stating all persons entering the suite should wear a mask when open sterile items and equipment are present.

While all of the health care professionals we talked to continue to wear masks during cases, some facilities have relaxed their policies and have seen no increase in their infection rates. "We have found the patient does well even if someone ???accidentally' comes into the room without cap and mask on," says Ms. Reecer. Ms. Bowman's facility once had a supervisor who required staff to wear masks in the operating room at all times, even when there were no open sterile supplies. Ms. Bowman has since eliminated that policy. Now her staff members are allowed to remove their masks as long as there are not open sterile supplies in the OR.

6. Over-scrubbing hands.
Scrubbing for 10 minutes prior to surgery, sometimes with stiff brushes, has been the accepted practice to ensure proper skin asepsis. But studies have shown that these practices can actually damage skin over time. This can cause a significant increase in microorganism shedding and damaged skin, which harbors more microbial flora than intact skin. In a September 2000 study published in the British Journal of Dermatology conducted at the Hopital de la Timone in France, fifty-two nurses were randomly assigned to use either an alcohol-based disinfectant or a non-antiseptic soap for an eight-day period. Both at the beginning and at the end of the test period they took bacterial skin cultures and assessed the skin tolerance. The researchers concluded that in everyday hospital practice, alcohol-based disinfectants are more effective and better tolerated than non-antiseptic soap. They found that the soap actually posed a risk of spreading contamination, and that a nurse will wash her hands more frequently and more effectively when her skin is comfortable.

Some of the nurses with whom we spoke have made the switch to alcohol rubs and no longer use brushes. Ms. Reecer's facility has reduced the amount of time they spend scrubbing from 10 minutes to about three to five minutes. But many people are looking for the CDC to give them the final okay; a final draft of their "Guidelines for Hand Hygiene in Healthcare Settings," is pending.

7. Mandating lab work for all patients
In an attempt to provide the highest standard of care, surgeons have traditionally ordered a regimen of pre-op tests on every patient prior to surgery. But today many doctors have come to believe that the majority of pre-op tests are actually irrelevant when it comes to patient outcomes. And numerous studies have reported that the patients who undergo preoperative tests fare just as well as those who do not.

One study published in the January 2000 New England Journal of Medicine assessed the value of preoperative medical testing before cataract surgery. The researchers randomly assigned 19,557 elective cataract operations in 18,189 patients at nine centers to be preceded or not preceded by a standard battery of medical tests (including electrocardiography, complete blood count, and measurement of serum levels of electrolytes, urea nitrogen, creatinine, and glucose), in addition to taking a pre-op history and performing a physical examination. They found no significant differences between the no-testing group and the testing group in the rates of intraoperative events.

Dr. DeFontes says his facilities no longer require standard lab work for all patients, such as blood work and urine analysis. A patient's pre-op lab tests are determined on a case-by-case basis. "Some facilities require EKGs for all male patients over 40 and female patients over 45 and chest x-rays for patients over 60 or 65. We look at the patients' medical conditions and their history and then make our decision based on that," Dr. Defontes says.

8. Requiring an eight-hour pre-operative fast.
Decades ago, anesthesiologists recommended that patients not eat or drink after midnight prior to surgery to reduce the chance that the patient would vomit under general anesthesia. However ,in 1999, the American Society of Anesthesiologists released updated guidelines that allow patients to take clear liquids (which include water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee) up to two hours before their procedure, and a light meal up to six hours before.

Dr. DeFontes' facilities have their patients on a clear liquid diet for two hours before the surgery and a light breakfast six hours before. Most facilities are still doing things the old way, however.. A survey published this month in The American Journal of Nursing of 155 patients found that 91 percent were still instructed to not eat after midnight. The study suggested that preoperative dehydration may actually increase postoperative discomfort and vomiting and recommended following the updated guidelines.

9. Sending scrubs out to be laundered.
Many healthcare providers believe that home-laundering scrubs increases the risk that infectious diseases may be brought into the home and contamination will be brought into the operating room. The AORN has stated that scrubs should be laundered by the health care facility. The CDC refuses to comment one way or the other, "because of the absence of well-controlled studies." And OSHA recently released guidelines that stated that employees may launder soiled scrubs at home, but the health care facility must launder contaminated attire. According to OSHA, soiling occurs from perspiration, body oils, or contact with items handled by the health care worker. Contamination involves contact with "blood or other potentially infectious materials."

Ms. Reecer's facility has laundered their scrubs for many years, as does Ms. Burden's. "Our nursing staff washes their own scrubs at home—unless there is visible contamination. Then we would treat them like our contaminated linens and send them to our laundry service," she says. "We got resistance at first. When we originally made this change, some nurses at one of the other ASC sites in the health system were so up in arms that they worked to get the surgeons to back them up against the change. When an orthopedic surgeon raised the challenge to the manager, she told him that if he trusted the nurses to keep his cases sterile in the room, why would he not trust them not to pump gas in their scrubs on the way to work? He didn't have an answer."

If you decide to allow your staff to launder their scrubs at home, OSHA guidelines recommend having scrubs available for surgeons and staff members whose scrubs may become grossly contaminated.

When determining what sacred cows to banish from your facility, it's still most important to considerwhat will work best for your staff and your patients and what feels most comfortable to you.