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The Guideline for Surgical Attire was approved by the AORN Guidelines Advisory Board and became effective as of July 1, 2019. 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 or other invasive procedures may be performed.


This document provides guidance to perioperative team members for laundering surgical attire; wearing long sleeves, cover apparel, head coverings, and shoes in semi-restricted and restricted areas; and cleaning identification badges, stethoscopes, and personal items such as backpacks, briefcases, cell phones, and electronic tablets.

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).

This document does not address patient clothing or linens used in health care facilities. The use of masks as PPE and the use of masks at the sterile field are outside the scope of this document; the reader should refer to the AORN Guideline for Sterile Technique1  and the Guideline for Transmission-Based Precautions2  for additional information. The wearing of rings, bracelets, watches, nail polish, artificial nails, or other nail enhancements is outside the scope of this document; the reader should refer to the AORN Guideline for Hand Hygiene3  for additional information.

Evidence Review

A medical librarian with a perioperative background conducted a systematic search of the databases Ovid MEDLINE®, Ovid Embase®, EBSCO CINAHL®, and the Cochrane Database of Systematic Reviews. The search was limited to literature published in English from January 2014 through February 2018. At the time of the initial search, weekly alerts were created on the topics included in that search. Results from these alerts were provided to the lead author until August 2018. The lead author requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The lead author and the medical librarian also identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies.

Search terms included armpit, axilla, backpack, bacterial load, badge, beard, bedding and linens, bouffant, briefcase, bunny suit, cell phone, cellular phone, clean room, clothing, colonization, computers, computers (handheld/hand-held/portable), computers and computerization, coveralls, cross infection, dandruff, dermatitis (exfoliative/seborrheic), desquamate, desquamation, disease transmission, disposable hats, dust, ear, environment (controlled), epithelial cells, epithelium, equipment contamination, eyelashes, facial hair, fanny pack, fleece, fomites, fungi, groin, hair, head covering, hoods, infection control, infectious disease transmission, iPad, iPhone, jewelry, jumpsuit, lanyard, laundering, laundering scrubs, laundering service (hospital), mobile communication device, mobile phone, mold, nosocomial, pollen, protective clothing, purse, scalp, scrubs, seborrhea, seborrheic dermatitis, shed, shedding, skin, skullcaps, smartphone, squames, stethoscopes, surgical attire, surgical cap, surgical wound infection, tablet computer, textiles, tie, uniforms, and washing machine.

Included were research and non-research literature in English, complete publications, and publications with dates within the time restriction when available. Excluded were non-peer-reviewed publications and older evidence within the time restriction when more recent evidence was available. Editorials, news items, and other brief items were excluded. Low-quality evidence was excluded when higher-quality evidence was available, and literature outside the time restriction was excluded when literature within the time restriction was available (Figure 1).

Articles identified in the search were provided to the project team for evaluation. The team consisted of the lead author and one evidence appraiser. The lead author and the evidence appraiser reviewed and critically appraised each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. A second appraiser was consulted if there was a disagreement between the lead author and the primary evidence appraiser. 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.

Each recommendation rating is based on a synthesis of the collective evidence, a benefit-harm assessment, and consideration of resource use. The strength of the recommendation was determined using the AORN Evidence Rating Model and the quality and consistency of the evidence supporting a recommendation. The recommendation strength rating is noted in brackets after each recommendation.

Note: The evidence summary table is available at

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

Figure 1
Flow Diagram of Literature Search Results

Flow Diagram of Literature Search Results

Adapted from: Moher D, Liberati A, Tetzlaff J, Atman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(6):e1000097.

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