Apparel in the Hospital What to Wear, Where?
By Kathy Dix
Street clothing in a hospital’s restricted areas occurs more often than might be suspected. Sterile processing department (SPD) managers complain — often to no avail — that the instruments they reprocess may be exposed to contamination by visitors or employees who reject the recommendation to wear surgical attire.
Is the solution Draconian enforcement of a sign that forbids anyone in street clothing from entering the SPD? If patient safety is your hospital’s concern, and they wish to avoid costly lawsuits from patients infected by instruments contaminated in the SPD, then yes.
Street clothing is not the only issue. Non-surgical scrubs that are laundered at home by employees are also being worn, as are warm-up jackets and other apparel inappropriate to the setting.
An AORN (Association of periOperative Registered Nurses) Journal column regularly answers questions submitted by readers; one reader queried the columnist about home laundering of scrubs and the wearing of non-scrub attire in restricted areas. Her facility had recently changed its policy and allowed visitors and other departments’ staff members to forego scrub attire or jumpsuits. Maintenance workers who may have been working on sewer lines or toilets enter the operating room (OR) with only a surgical cap to cover their hair, in the uniform exposed to innumerable pathogens; parents accompanying their children to the OR for induction wear only hair covers.
Columnist Carol Peterson, RN, MAOM, CNOR, a perioperative nursing specialist from the AORN Center for Nursing Practice, replied, “AORN does not advocate people entering the restricted or semi-restricted area in street clothes or attire that is of questionable cleanliness ... Although there is controversy about home laundering scrub attire versus facility-approved laundering, AORN recommends that all reusable surgical attire (i.e., scrubs, cloth hats, warm-up jackets) be laundered in a facility-approved and monitored laundry. Extending the concept of home-laundered surgical attire to include visitors in street clothes and personnel from other departments is a very risky proposal.”
Not only is the patient exposed, but “a person wearing street clothes into the OR also is at risk of unknowingly contaminating his or her attire with blood and body fluids and being exposed to a potentially infectious pathogen. This is not only a health risk to the visitor or repair people, but it also is a potential liability to the facility. Allowing visitors and repair people to wear street clothes into the surgical suite is a reckless and dangerous practice.” 1
Cover apparel is another issue; its use should be determined by each individual practice setting. “The value of cover apparel is unknown ... Controversy over cover apparel stems not from its effectiveness in reducing contamination, but from practical considerations of enforcement and cost,” say the AORN 2004 Standards, Recommended Practices and Guidelines. 2
“I have management responsibility for environmental services (ESD) and patient transport at two acute-care teaching hospitals in our system (Lifespan), as well as a central laundry that launders textiles for those two hospitals as well as three other hospitals,” says Jim Connors, director of environmental and textile services at Rhode Island Hospital in Providence. “We provide uniforms for ESD and transport staff at both hospitals. At Rhode Island Hospital, we have unionized staff and will launder uniforms for staff in the laundry (stipulated in the contract) but most staff prefer to take them home and launder them themselves. At Miriam Hospital, the staff are responsible for laundering their own uniforms; we don’t have an on-premise laundry there.
“At both hospitals we provide personal protective clothing for anyone who is performing a task that might put them at risk from blood or body fluid exposure or anything else, and we provide laundering services for these items if they are reusable,” Connors says. “We launder scrubs that are provided to OR personnel at both hospitals, as well as lab coats, isolation gowns and surgical cover gowns, etc. Many departments (and individuals) are now wearing scrubs as ‘uniforms’ in hospitals; these are generally not laundered by the central laundry but by the individuals.”
Connors has seen a behavior that may not meet AORN standards, however — “Daily, I see OR staff and physicians leaving the hospital in hospital scrubs. I don’t know if they change into clean scrubs before they go back into the OR or not, and no one I’ve asked has been able to answer it either.”
Children’s Memorial Hospital in Chicago has a strict policy for the use of scrubs. “We have hospital-issued misty green scrubs. It’s called our ‘misty green’ policy,” says Debbie Read-Fuimaono, RN, MBA, director of surgical services. “All of our surgical services, and anyone doing procedures in the procedure suite and cardiac cath all wear the same misty green scrubs, which are supplied by the hospital and laundered by the hospital.”
She adds, “Everyone involved with the misty green policy has to change in the hospital once they get here, and then they change prior to leaving.”
Housekeeping staff for the OR change into scrubs once the reach work, as do any other employees of the surgical services department. Housekeeping in the rest of the facility wears a uniform.
When determining what is the appropriate garb, “I think you have to go back and look at what the person is doing, and if they have the potential for coming in contact with blood and other potentially infectious material (OPIM), whether it be housekeeping or decontamination, that will guide what they have to wear,” says Jay Sommers, PhD, director of clinical and scientific documentation for Kimberly-Clark Health Care.
For example, he says, the Occupational Safety and Health Administration (OSHA) guidelines on laundering state, “’The employer shall ensure that employees who have contact with contaminated laundry wear protective gloves and other personal protective equipment,’ which is usually impervious gowns, shoe covers or boots, and gloves, face masks and eye protection.’ There have been some cases when laundry workers and housekeepers have acquired HIV, so they need to wear protective apparel to protect them against that exposure,” he says.
“If they’re going into or removing things from patient’s rooms, where there might be contaminated waste, then they need to wear that protective apparel. If they’re moving things from the chemical laboratory, which might be hazardous drugs or chemotherapy agents, then they would need to follow OSHA guidelines.”
OSHA also has guidelines for central service (CS), which require an exposure plan. “The employer’s program for protection of workers with exposure to bloodborne pathogens ... should be reviewed annually and updated for new tests or procedures. They should observe standard precautions, use engineering and work practice controls, and then the hospital has to provide the PPE to all employees at no cost,” Sommers points out.
He also references guidelines of the Association for the Advancement of Medical Instrumentation (AAMI) guidelines. AAMI ST46 refers to steam sterilization and sterility assurance in healthcare facilities. “It says that ‘The worker should wear clean facility-provided uniforms, change daily or more often as needed. Clean shoes — worn only in the hospital — should be maintained by the employee; they should have nonskid soles and should have protection against items dropping on them, so not necessarily bloodborne pathogens, but if dropping instruments, or a container, they want to have protection. ‘All head and facial hair should be covered with a surgical cap or bonnet, and employees should change into street clothes when leaving the facility or traveling between separate campuses.’”
Employees may have to travel between one medical facility and another, for example, if CS is located in a separate building from the OR. In this case, the employee might use a cover-up. “If it’s a far distance, they should change into street clothes, then change into scrubs when they get there, but if they’re going across the courtyard, they might be able to use the cover-up. They should make sure they do not do their CS work in the same clothing that they go outside in,” Sommers says.
Sommers then references a book written by Leigh Grossman, MD, Infection Control for the Healthcare Worker. “She says, ‘Never use cloth lab coats, scrub suits or street clothes as an effective barrier to blood or other fluids. Lab coats are no more effective than street clothes in preventing blood and body fluid exposure.’ She talks about wearing fluid-resistant gowns with long sleeves and tight cuffs ... the gown should have a high neck and be continuous in the front.”
Many areas of healthcare require some kind of barrier product; OSHA suggests the following groups may be at high risk: medical technologists, OR staff, phlebotomists, intravenous therapy nurses, surgeons, pathologists, oncologists, dialysis unit staff, emergency room staff, nursing personnel, staff physicians, dental professionals, laboratory and blood bank technicians and emergency medical technicians.
Sommers says that laundry should be done by the facility. “The AORN document says the facility should do it, because you never know what you’re going to come in contact with,” he observes. “If you’ve had some strike-through or microbial contamination ... some of the pathogens stayed on the front of our barrier cover gowns. You can have microbial contamination, not even in the surgical suite, but just in the patient rooms where people have MRSA or VRE, and can cause you to go home with these organisms on your scrubs.
“People are trying to take shortcuts, and that’s part of the problem. I don’t know if they think they’re saving money or they don’t have the resources, or whatever excuse you want to make, but you need to keep vigilant in carrying out these protocols.”
Home laundering has become a more contentious issue; hospitals looking to save money do sometimes encourage staff members to wash their clothing at home, but these homes can contain general household pathogens as well as those associated with children and pets — not organisms that are conducive to an infection-free environment.
“A lot of ORs are home laundering, and that’s not a recommendation by AORN,” says Rose Seavey RN, MBA, CNOR, ACSP, current president of AORN of Denver, past president of American Society for Healthcare Central Service Professionals (ASHCSP) in 2003, and director of the SPD at the Children’s Hospital in Denver.
“They say they wash them at home, and they’re hand-carrying them in, but I know that’s not always what’s reality. How do you monitor that? I can tell you what AORN recommends. The current AORN recommendation states ‘Taking soiled surgical attire into the home can result in the potential spread of contamination to the home environment. Freshly laundered surgical attire should be protected during transport to the practice setting. The difficulties in implementing a program to monitor transportation practices preclude home laundering as an acceptable method of cleaning surgical attire.’”
Seavey points out that hospitals may appreciate not having to purchase scrubs for its employees. “Laundering of surgical attire in a home laundry is not recommended, but people are doing it — I see it on listservs all the time.
“SPD should follow the same dress code as surgical services,” Seavey directs. “People tend to be more liberal in SPD, but if you are reprocessing surgical instruments and running sterilizers, then you need to wear surgical attire.”
Seavey prepared an updated dress code for sterile processing for the Children’s Hospital of Denver in April 2003. Its policies are explicit — “All personnel entering the restricted areas of sterile processing are to be attired in scrub apparel. At no time are street clothes to be worn within the restricted area ... Scrubs are not to be work outside the facility.”
All personnel entering the SPD should change cloth surgical caps and warm-up jackets daily or when visibly soiled; cloth hats should be laundered at home but flash sterilized upon leaving and reentering the hospital. And before exiting the restricted area, staff should remove and discard gloves, gowns, masks and shoe covers. 3
However, the suitability of scrubs at all is also questioned. Nathan L. Belkin, PhD, was selected by the guidelines committee of the Association for Professionals in Infection Control and Epidemiology (APIC) to author a “state-of-the-art report” (SOAR) on scrubs. A SOAR is developed to function similar to a guideline when there is little to no scientific evidence on which to base recommendations. (APIC guidelines are based on a body of scientific knowledge.) “There is no scientific evidence that the use of scrubs or other related apparel contributes to either the cause or the prevention of infections associated with healthcare facilities,” Belkin writes in his 1997 report. “However, because this type of apparel is now used so commonly as a replacement for the more traditional type of uniform, its original function as an ensemble worn by surgical personnel no longer prevails. 4
“At a time when the entire healthcare community is being pressured to contain and reduce costs, continuing a practice for which there is no identifiable benefit may not be considered cost-effective or reflect a sense of fiscal responsibility,” he adds. “Therefore, if the costs associated with the use of scrubs are significant and outweigh any identified benefit, their use may need to be reevaluated.”