The American College of Surgeons (ACS) recently released a 

 that has stimulated discussion in the perioperative nursing community. In response to numerous calls from members and nonmembers, the Association of periOperative Registered Nurses (AORN) has reviewed the ACS statement in detail to compare all available evidence to the statement and provide perioperative team members with the information necessary to achieve high quality safe patient care.

Of particular concern to AORN and its membership of 40,000 perioperative registered nurses, is the introductory statement, “The ACS guidelines for appropriate attire are based on professionalism, common sense, decorum, and the available evidence.”  Regulatory agencies, accrediting bodies, and patients expect healthcare organizations to follow guidelines that are evidence-based rather than recommendations based on professionalism, common sense, or decorum.

All current evidence for safe surgical attire is presented with recommended evidence-based practices in AORN’s Guideline for Surgical Attire. The AORN guideline development process meets the rigorous requirements of, and are accepted by, the AHRQ National Guidelines Clearinghouse.

The AORN evidence review of the ACS statement concludes:
ACS: Soiled scrubs and/or hats should be changed as soon as feasible and certainly prior to speaking with family members after a surgical procedure. 
AORN: The Occupational Safety and Health Administration (OSHA) requires attire that has been penetrated by blood, body fluids or other infectious materials be removed immediately or as soon as possible and be replaced with clean attire. 

ACS: Scrubs and hats worn during dirty or contaminated cases should be changed prior to subsequent cases even if not visibly soiled. 
AORN: Evidence shows that perioperative team members who are following standard precautions, using personal protective equipment (PPE) and conducting hand hygiene should not need to change scrubs and hats between cases. Doing so could give a false sense of security that PPE and hand hygiene are not needed. This statement may cause confusion by introducing a different standard for surgeons than for other perioperative team members. All should be following the same, evidence-based standards.

ACS: Masks should not be worn dangling at any time. 
AORN: Evidence-supported.

ACS: Operating room (OR) scrubs should not be worn in the hospital facility outside of the OR area without a clean lab coat or appropriate cover up over them. 
AORN: Evidence shows that lab coats can be contaminated with large numbers of pathogenic organisms. Evidence also shows that lab coats are not always discarded daily after use or laundered on a frequent basis and therefore, should not be recommended wear over scrubs. If one chooses to wear a lab coat it should be laundered in a healthcare accredited laundry facility after each daily use and sooner when contaminated, or should be single use.

ACS: OR scrubs should not be worn at any time outside of the hospital perimeter. 
AORN: Evidence-supported.

ACS: OR scrubs should be changed at least daily. 
AORN: Evidence-supported. 

ACS: During invasive procedures, the mouth, nose, and hair (skull and face) should be covered to avoid potential wound contamination. Large sideburns and ponytails should be covered or contained. There is no evidence that leaving ears, a limited amount of hair on the nape of the neck or a modest sideburn uncovered contributes to wound infections. 
AORN: As with most other aspects of surgical practice, there are no randomized, controlled trials demonstrating the effect of different types of surgical head covering on surgical site infection rates. 

However, there is a body of evidence that supports covering the hair and ears due to the fact that hair and skin can harbor bacteria that can be dispersed into the operating room environment. As patient safety is the primary consideration for all perioperative personnel, reducing the risk of patient exposure to microorganisms that are shed from the skin and hair to help reduce the risk for surgical site infection should be high priority for all perioperative personnel. The ACS statement says “limited amount of hair and modest sideburn can be uncovered.” Until an evidence-based definition for “limited” and “modest” can be determine, there is no way for facilities to enforce such a recommendation.

ACS: Earrings and jewelry worn on the head or neck where they might fall into or contaminate the sterile field should all be removed or appropriately covered during procedures. 
AORN: Evidence-supported. 

ACS: The ACS encourages clean appropriate professional attire (not scrubs) to be worn during all patient encounters outside of the OR. 
AORN: No opinion.

ACS: The skullcap is symbolic of the surgical profession. The skullcap can be worn when close to the totality of hair is covered by it and only a limited amount of hair on the nape of the neck or a modest sideburn remains uncovered. Like OR scrubs, cloth skull caps should be cleaned and changed daily. Paper skull caps should be disposed of daily and following every dirty or contaminated case. Religious beliefs regarding headwear should be respected without compromising patient safety. 
AORN: See the above statements regarding the enforcement confusion introduced by words such as “limited” and “modest”. Wearing a particular head covering based on its symbolism is not evidence-based, and should not be a basis for a nationwide practice recommendation. Several types of evidence exist that support recommendations that perioperative personnel cover their head and ears in the OR. This evidence includes the fact that human skin and hair is naturally colonized with many bacteria, and perioperative personnel shed microorganisms into the air around them.  We know airborne bacteria in the OR can fall into the operative field, contribute to the overall air contamination of the OR, and place patients at risk of surgical site infections. Completely covering the hair can reduce the number of bacteria introduced into OR air by perioperative personnel. 

The National Guidelines Clearinghouse requires guideline developers to examine the risk and benefit of a recommendation to patients and personnel. There is no risk to perioperative personnel to cover their skin and hair, while the benefit of doing so to patients is that it reduces the patient’s exposure to potentially pathogenic organisms and helps to protect them from harm.  Head coverings based on symbolism and a personal attachment to historical norms have no place in the patient benefits analysis expected of guidelines developers by the National Guidelines Clearinghouse.

ACS: Many different healthcare providers (surgeons, anesthesiologists, CRNAs, laboratory technicians, aids, etc.) wear scrubs in the OR setting. The ACS strongly suggests that scrubs should not be worn outside the perimeter of the hospital by any healthcare provider. To facilitate enforcement of this guideline for OR personnel, the ACS suggests the adoption of distinctive, colored scrub suits for the operating room personnel.  
AORN:  AORN supports this statement, however, nurses and scrub techs should be included in any list of healthcare providers who wear scrubs in the OR. 