By Michelle Gardner
"Scrub attire is not intended to be protective in any way; it is simply a uniform," states Dorothy Fogg, senior perioperative nurse specialist with the Association of periOperative Registered Nurses (AORN) in Denver. "It's assurance that people coming in to the operating room (OR) are wearing freshly laundered attire that has not been worn in the car where the dog sat. You put it on fresh when you get (to work)."
AORN's position is that surgical attire be laundered under controlled conditions where the laundry facility has specific formulas and they monitor the concentration of chemicals. That way, the facility knows employees are not exposing patients to anything that may have been carried in on their clothing.
Fogg identifies three areas related to the OR: restricted, semi-restricted and unrestricted. Each area and its required attire is defined by the facility. "In the unrestricted area, you can wear street clothes and it is open to anyone who needs to be there," she says. "The semi-restricted area generally includes OR corridors and support areas like sterile storage, and you need to be in surgical scrubs with your hair covered. You may or may not be required to wear shoe covers or other protective attire, but that is what is required by AORN for health and infection control concerns."
AORN does not support home laundering or facility laundering that uses home washers in the back room. If the facility is using a home washer, water temperatures may not be monitored, concentrations of bleach (if used at all) and detergents are not monitored and there may or may not be more than one rinse cycle.
"The conditions are not what we would call controlled," says Fogg. "No one can say, 'Here is our laundry formula. We do it the same every time and we know it works.' We encourage facilities to contract with a commercial laundry that knows how to do healthcare related textiles."
Fogg refers to one quality study where the infection rate was tracked before and after home laundering. The claim is that there was no difference between home laundering and facility laundering.
"I wouldn't dispute that, but it is an unresolved issue," she says. "That is what the Centers for Disease Control and Prevention (CDC) has said as well. It is not really something you can research. The number of variables to control would be astronomical and you could not foot the cost. It probably wouldn't be the best use of our healthcare dollars."
My, How Things Change
Mary Lynne Weemering, RN, MSN, CNOR, education specialist at St. Luke's Episcopal Hospital in the Texas Medical Center, Houston, remembers a time when healthcare workers didn't wear personal protective equipment (PPE).
"There were no face shields, you just wore a mask and there were no booties for your feet," she says. "Things have changed with empiric evidence and research. Practices in the operating room are based on research and we try to modify them as research sheds new light on information."
From her 40-year career, Weemering says the biggest change came around the 1980s when the industry began having bloodborne pathogen scares. "When medicine and healthcare realized blood contained transmissible pathogens, the issue of protecting yourself really came out," she recalls. "That is when the Occupational Safety and Health Administration (OSHA) became involved and said hospitals must provide equipment to protect employees from splashes and splatters that might expose them [to pathogens].
Today, the issue of surgical attire is in a state of flux. "Hospitals see scrub attire as a huge cost," says Weemering. "In order to reduce costs associated with lost and replacement scrubs, a lot of hospitals are allowing employees to purchase and launder their own. Experts in infection control will tell you there is no empiric data that shows home laundering makes patients have a higher infection rate the commercial laundering. The risk factors for surgical site infection stem from the usual risk factors like obesity, diabetes and age."
What is most important is that patients do not suffer adverse outcomes. "Hospitals need to involve the infection control department and physicians as decision makers," says Weemering. "You can't just say we are going to save money by everyone laundering their own scrubs. The infection control department must have some control over that."
A World Apart
While U.S. hospitals grapple with the cost of laundering surgical attire and providing two or three sets for each employee, Carmela Cordero, MD, senior director of technical services for EngenderHealth in New York, N.Y., sees a different side of the issue. Most of the time, medical staff working in developing countries' low-resource settings will have gowns, masks and gloves, but the gloves must go through a sterilization process because they have to be used more than once.
"Different from what happens in developed countries and the United States, the surgical caps, gowns and masks are reusable. They have to wash and sterilize them," says Cordero. "There are not enough monetary resources to provide the needed attire."
The minimum mask, gown, cap and gloves meet requirements for infection prevention, but surgeries are often canceled because of the limited resources.
"Public settings have this problem," she continues. "It is not a lack of knowledge, but a lack of resources. We take it for granted in the United States that we have all of this surgical attire. Our infection prevention course is basic because it is geared toward the people who have to reuse what they have and work with limited resources."
EngenderHealth has been working in low-resource settings for 30 years evaluating what medical personnel have to work with and improving infection prevention procedures with what they have.
"We try to make the Ministry of Health understand why this is so important," says Cordero. "Infection prevention is something you don't see; you have to do things to avoid infection. It is hard to find the resources in order to implement what we recommend. We can't take for granted that what we see in the United States will be the same in other countries."