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Introduction

The Guideline for Surgical Attire has been approved by the AORN Guidelines Advisory Board. It was presented as a proposed guideline for comments by members and others. The guideline is effective November 15, 2014. The recommendations in the guideline are intended to be achievable and represent what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the guideline can be implemented. AORN recognizes the many diverse settings in which perioperative nurses practice; therefore, this guideline is adaptable to all areas where operative and other invasive procedures may be performed.

Purpose

This document provides guidance for surgical attire including scrub attire, shoes, jewelry, head coverings, and masks worn in the semi-restricted and restricted areas of the perioperative practice setting. This document also provides guidance for personal items such as stethoscopes, backpacks, briefcases, cell phones, and tablets.

The human body and inanimate surfaces inherent in the surgical environment are major sources of microbial contamination and transmission.1  Surgical attire and personal protective equipment (PPE) are worn to provide a high level of cleanliness and hygiene within the perioperative environment and to promote patient and worker safety. Reducing the patient’s exposure to microorganisms that are shed from the skin and hair of perioperative personnel may reduce the patient’s risk for surgical site infection (SSI). Patient safety is the primary consideration for perioperative personnel.

This document does not address patient clothing or linens used in health care facilities. A complete discussion of the use of PPE and sterile attire worn at the surgical field is outside the scope of this document. The reader should refer to the AORN Guideline for Sterile Technique,2  Guideline for Prevention of Transmissible Infections,3  and Guideline for Sharps Safety4  for additional information. The use of nail polish, artificial nails, or other nail enhancements and the recommended fingernail length for perioperative personnel is outside the scope of this document. The reader should refer to the AORN Guideline for Hand Hygiene5  for additional information. Ensuring and monitoring personnel compliance with policies and procedures for surgical attire and personal hygiene is a responsibility of the facility or health care organization administrators.

Evidence Review

On June 25 and June 27, 2013, a medical librarian conducted a systematic search of the databases MEDLINE® and CINAHL® and the Cochrane Database of Systematic Reviews for meta-analyses, systematic reviews, randomized controlled and non-randomized trials and studies, case reports, letters, reviews, and guidelines. The librarian also searched the Scopus database, although not systematically. The search was limited to literature published in English from January 2008 through June 2013.

Search terms included surgical attire, clothing, personal protective equipment, protective gloves, respiratory protective devices, masks, eye protection, goggles, scrubs, surgical gown, jumpsuit, head covering, surgical cap, hoods, coveralls, bunny suit, textiles, bedding and linens, privacy curtain, hospital laundry service, laundering, laundry, washing machine, tie, backpack, fanny pack, fleece, briefcase, purse, stethoscope, lanyard, badge, patient attire, patient clothing, colonization, fomites, tattooing, body piercing, jewelry, ring, wedding band, fingernails, eyelashes, facial hair, beard, groin, armpit, scalp, skin, squames, dandruff, epithelial cells, seborrheic dermatitis, computers, mobile communication device, mobile phone, cell phone, cellular phone, tablet computer, smartphone, iPad, iPhone, text messaging, pollen, dust, fungi, mold, equipment contamination, nosocomial, cross infection, infectious disease transmission, surgical wound infection, bacterial load, and infection control.

At the time of the search, the librarian established weekly alerts on the search topics and until March 2014, presented relevant results to the lead author.

Prior to the search, the medical librarian provided to the lead author the results of literature searches conducted for the 2010 edition of the AORN Recommended Practices for Surgical Attire. These articles had no time restriction. During the development of this edition, the authors also requested supplementary literature searches and additional literature that either did not fit the original search criteria or was discovered during the evidence-appraisal process. The time restriction was not considered in these subsequent searches. Relevant guidelines from government agencies and standards-setting bodies also were identified.

Inclusion criteria were research and non-research literature in English, complete publications, relevance to the key questions, and publication dates within the time restriction unless none were available. Excluded were non-peer-reviewed publications; literature that examined the use of sterile gowns, drapes, and masks worn for maintaining sterile technique; low-quality evidence when higher quality evidence was available; and literature outside the time restriction when literature within the time restriction was available. In total, 885 research and non-research sources of evidence were identified for possible inclusion, and of these, 123 were cited in the guidance document (Figure 1).

Figure 1.
Flow Diagram of Literature Search Results

Flow Diagram of Literature Search Results

Articles identified by the search were provided to the project team. The team consisted of the lead author, a co-author, five members of the Guidelines Advisory Board, and two evidence appraisers. The lead author and the evidence appraisers reviewed and critically appraised each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference, as applicable.

Notably, much of the evidence related to surgical attire is not recent evidence. There are no randomized controlled trials (RCTs) or systematic reviews that show a direct causal relationship between surgical attire and SSI. There are many confounding variables that affect a patient’s risk for SSI, and this makes it extraordinarily difficult to identify surgical attire as a singular source of SSIs. It is a well-accepted scientific principle that increased numbers of microorganisms in the perioperative environment will increase the patient’s risk for SSI. It is unnecessary, and it may be unethical, for researchers to perform new studies for the sole purpose of demonstrating this recognized concept.

The methodology of the research and non-research evidence used to support this document was critically evaluated by the authors for validity and generalizability to current practice. The collective evidence supporting each intervention within a specific recommendation was summarized by the authors, and the AORN Evidence Rating Model was used to rate the strength of the evidence. Factors considered in the review of the collective evidence were the quality of evidence, the quantity of similar evidence on a given topic, and the consistency of evidence supporting a recommendation. The evidence rating is noted in brackets after each intervention.

 

Note: The evidence summary table is available at http://www.aorn.org/evidencetables/.

 

Editor’s note: MEDLINE is a registered trademark of the US National Library of Medicine’s Medical Literature Analysis and Retrieval System, Bethesda, MD. CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL. Scopus is a registered trademark of Elsevier B.V., Amsterdam, The Netherlands. iPad and iPhone and registered trademarks of Apple, Inc, Cupertino, CA.

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