Ruth LeTexier, RN, BASN, PHN
Uniforms in healthcare have changed significantly over time. One used to be able to enter the hospital and easily recognize a nurse by the starched white uniform with the mandatory cap in place. Today, one walks the halls of any healthcare setting and observes a wide range of colored cotton uniforms on nearly every worker from admissions, dietary, housekeeping, biomedical engineering, surgery, anesthesia, central processing, lab, nursery, pediatrics, intensive care, respiratory care, and in nearly all of the nursing units the staff are wearing scrubs. Discussion of the merits or literature validating home-laundered scrub attire will be exclusive of proper operating room attire which requires scrub clothing be laundered on site.
Theatre Dress: Origin of Scrub Attire
The evolution of special operating room attire as an adjunct to asepsis paralleled the development of aseptic and sterile techniques in the latter half of the nineteenth century. One of the earliest mentions of specific OR attire appeared in a nurse's training handbook that advised the nurse to bathe before a surgical procedure, to take a carbolic bath before laparotomy, and to wear long sleeves and a clean apron for the surgical procedure. The apron has given way to present scrub attire.1
The first mention of scrubs is credited to Hunter Robb, MD, as he advocated the use of "a complete change of costume rather than [to] simply don a sterilized coat and pair of trousers over the ordinary clothing" as an antiseptic method.2 The use of clothing worn only when one was "scrubbed in" or part of the sterile team was thought to minimize contamination from outside sources. Fortunato cites a 1900 photograph, in which the team was operating in short surgical gowns and rubber gloves but without caps or masks. Charles Mayo and his teams appear in another photo in 1913 operating in surgical gowns, caps, and masks. The onlookers wear white coats over street clothing. By the 1930s and 1940s, scrub dresses began to replace nursing and surgeon uniforms in the operating rooms. In the 1960s pantsuits and scrub dresses were replacing the full-skirted scrub dress to reduce the risk of the clothing contaminating the field as the healthcare worker (HCW) passed by a sterile field.
The use of scrub attire outside of the surgical suite was limited until the late 1960s. Periodically, blood and body fluid exposure would result in a contamination of a nurse's traditional white uniform and the nurse would be directed to the surgery department to change into clean scrub attire in order to continue providing care without the transmission of potentially infectious material from patient to patient. From an infection control standpoint, the practice was sound in protecting both the nursing personnel and the patients. There is no definitive timeline as to when scrubs began to be used exclusively as an alternative to the standard uniform.
Infection Control Issues
The knowledge that bacteria exist and are capable of causing disease and act as transmissible agents was acquired in the nineteenth century. The principles of asepsis as we know them today, were not developed until the mid-nineteenth century. Techniques directed at cleanliness and the elimination of all infectious agents are universally applied on a daily basis within the healthcare industry. Cleanliness of the environment, adherence to proper handwashing techniques, application of aseptic technique, clean linens, and uniforms all are important in the prevention of infection. The garment of the healthcare worker is an important part of the environment that can become contaminated by fluids or debris.
Microorganisms that cause infection are of serious concern within a hospital or healthcare setting. Staphylococci bacteria survive for long periods in the air, dust, debris, bedding, and clothing and are difficult to destroy. Pseudomonas aeruginosa bacteria thrive in a moist environment, are found in soil, water, sewage, debris and air, and are a pathogenic giant in terms of power. It has been found in intravenous fluids and soap solutions. The flesh-eating bacteria, group A streptococci, is of concern as the outbreaks occur both as nosocomial and community acquired infections. Strep A is transmitted via droplet and contamination of the environment.
Microbes Adhere to Fabric
A recent study reported that 65% of nurses who had performed patient care activities on patients with MRSA contaminated their nursing uniforms or gowns with MRSA.6 Laundering of the uniform is significant when considering the resistant bacterial infections are increasing, placing both the worker and patient at risk, if not done properly. The ability of gram-positive microorganisms to survive on common hospital surfaces is a critical aspect of bacterial transfer. A recent study conducted by the Shriners Hospital for Children and the Department of Surgery at the University of Cincinnati monitored the survival of Enterococci and Staphylococci on hospital fabrics and plastics.
One of the test fabrics was smooth, 100% cotton (clothing) and another a blend of 60% cotton and 40% polyester (scrub suits and lab coats). All Staphylococci tested survived for at least a day on both fabrics. Data in this study indicate that Staphylococci and Enterococci can survive for days to months after drying on commonly used hospital fabrics. Data from this study indicates staphylococci and Enterococci can survive for extended periods of time on materials commonly worn by patients and HCWs.7
Laundering the Scrubs
Laundering of any soiled, woven fabric which is considered contaminated, should be handled with gloved hands only. Laundry should be washed in water at 160º F or higher with 50 to 150 parts per million (ppm) of chlorine bleach. Lower temperatures may be used, if appropriate antimicrobial detergent is used.8 However, it is the use of the electric clothes dryers, not water temperature, that played the most significant role in eliminating bacteria from linen.9 From an Occupational Safety and Health Administration (OSHA) compliance perspective, the facility is required to launder items that are grossly contaminated with blood and other potentially infectious material.10
Studying Home Laundering
A pilot study was conducted at the University of Central Florida to determine if the practice of hospitals purchasing and laundering scrub clothing was based on ritual or reason. This descriptive pilot study was conducted during a four-year period in order to determine the effect on the perinatal infection rate of wearing home laundered scrub clothing in labor and delivery. Prior to the study the infection rate was 1.7%; at the study's end, it was 1.0%. The conclusions of the study support home laundering of scrubs in that home laundered scrub clothing can be worn safely in labor and delivery units, including operating rooms contained in those units. The practice was found to reduce costs without increasing surgical wound infections.11
The Association for Professionals in Infection Control (APIC) created a State of the Art Report (SOAR) designed to assist IC professionals in the development of policies and procedures related to the use of scrubs and similar apparel by HCWs outside controlled environments, such as the surgical suite. Surprisingly, there is little scientific evidence that the utilization of scrubs in the operating room setting is a means of infection control in the healthcare facility.12
Study of fabric condition, laundering practices, infection rates, and cost all must be considered as the health facility determines individual policy.
Ruth A. LeTexier, RN, BASN, PHN, is the director of surgical technology at Northwest Technical College in East Grand Forks, Minn.