Updated Surgical Attire Recommended Practice Takes Stronger Stance, Nixes Home Laundering

Although it has always recommended institution laundering of surgical attire, the Association of periOperative Registered Nurses (AORN) is unequivocal on this position in its newly revised Recommended Practices for Surgical Attire, due for release this month.

By Kelly M. Pyrek

Although it has always recommended institution laundering of surgical attire, the Association of periOperative Registered Nurses (AORN) is unequivocal on this position in its newly revised Recommended Practices for Surgical Attire, due for release this month. In this recommended practice (RP), AORN is underscoring the science-based rationale for quality assurance monitoring of laundering practices, as well as taking a stand on other attire-related issues that compromise patient safety.

AORN recommends that surgical attire should be laundered in a healthcare-accredited laundry facility, according to Recommendation V within the RP, and all recommendations for home laundering of surgical attire have been removed. This is the most significant change since 2005, when the Recommended Practices for Surgical Attire was first released. Like other recommendations in this updated RP, Recommendation V includes an expanded rationale section that cites literature and guidelines published since the previous version.

For more than a year, members of AORN's Recommended Practices Committee have reviewed existing evidence in the literature, and in the spring, opened the proposed RP for input from the perioperative and infection prevention communities. Ramona Conner, RN, MSN, CNOR, manager of standards and recommended practices for AORN, reports that several hundred comments were received. "This recommended practice incites a great deal of interest," Conner says. "For some people it's an emotional issue. We began working on the review of this RP in January 2009, so this has been a long process and one with which we have taken extraordinary care and invested much thought and discussion in order to reach what we feel are good, achievable recommendations, based on the best evidence we have, with as much consensus from the community as we could achieve."

Conner points to a mounting body of evidence implicating healthcare textiles in outbreaks. "The literature has demonstrated reports of outbreaks directly related to healthcare laundry, and the evidence has really been emerging in the last three or four years," Conner explains. "AORN has always recommended that surgical attire be laundered by a facility or industrial laundry. In our previous edition we had to acknowledge that the evidence was not there and not published; we felt compelled to recommend that people not home launder but our previous edition essentially said that if you are working for an employer that requires you to home launder, we will provide guidance on how to do that safely. As we conducted our literature review for this latest edition we found there is no practical way for people in their homes to be able to meet the same criteria for safe laundering as healthcare-accredited facilities do. Because the evidence has become so much stronger in the last few years we felt compelled to say that surgical attire should be laundered by an accredited laundry facility. I suspect that over the next few years we are going to see even more evidence. Much of the research we have on survival of these pathogens on fabrics comes from laboratory studies, and although we are beginning to see in vivo studies, we still need more information."

At the Fifth Decennial International Conference on Healthcare-Associated Infections held in March, an investigator from the Centers for Disease Control and Prevention (CDC) presented a paper on an outbreak of Zygomycosis, a fungal-based infection, linked to healthcare textiles. Nine cases of the infection had occurred at the hospital since 1993, but six cases occurred between August 2008 and July 2009, with five resulting in serious skin infections in patients ranging in age from newborn to 13 years. Hospital textiles were identified as the only common element among all the cases. Environmental sampling performed at the hospital on the textiles and areas in contact with textiles revealed a 40 percent presence of the pathogen, and only a 4 percent presence in items and areas not in contact with textiles. The hospital changed its laundry provider, replaced all of its linen, and disinfected its linen storage areas. Cultures taken at the hospital three weeks later were all negative. The CDC concluded that the textiles likely acted as the vector for bringing susceptible patients into contact with the pathogen, and that "hospital linens should be laundered, shipped and stored in a manner that minimizes exposure to environmental contaminants."

Accredited healthcare laundry facilities provide a monitored laundering process and must adhere to established standards established by the Healthcare Laundry Accreditation Council (HLAC), an independent accreditation organization. HLAC certifies laundry facilities based on standards such as he ANSI/AAMI ST65:2000 guidance for Processing of Reusable Surgical Textiles for Use in Health Care Facilities and regulations established by the Occupational Safety and Health Administration (OSHA). These standards mandate that healthcare institutions demonstrate regulated practices for the entire spectrum of the laundering process.

"I think laundering surgical attire is a process similar to achieving sterilization," Conner says. "It is a chain of events that must occur in order to do it properly, and if you have a break in the chain anywhere along the line of that process, you could have a failure. That is as true with laundering as it is with sterilization. For example, when the contaminated linen is handled, if the worker isn't well protected and wearing personal protective equipment (PPE), the healthcare worker can be exposed to these contaminants. Once the laundry is sorted and placed into the washers, the temperature, the dilution, the detergent, the pH level, all of those parameters need to be monitored to make certain they are all in correct proportion. Then the wet linen, although decontaminated, needs to be dried and so the temperature of the dryers and the length of the drying cycle must be monitored. The way the washers and dryers are loaded is a critical step; if they are not loaded right, are too heavy or too light, it affects the other parameters such as exposure of all surfaces to the detergent. Once the linens are dried properly, it must be protected from contaminants in the environment then transported to the point of use. Anywhere along that chain, any number of things can go wrong. What's important and why we are focused on recommending accredited laundries is that these laundries conduct stringent quality monitoring and you just can't do that home."

The prevalence of people wearing scrubs as street attire and the home-laundering of surgical attire creates exposure to infectious pathogens in the community as well as inside the healthcare institution.

"It's very important that we protect our patients, our healthcare workers and our communities from exposure to infectious microorganisms," Conner says. " I go to a grocery store and see someone standing in line wearing surgical attire and there's a significant 'ick' factor in my mind -- I wonder where they have been in those scrubs, what patients were they caring for, when was the last time that their attire was laundered, and how was it laundered. We all launder our clothes all the time and it's no big deal, but what people don't understand is that healthcare workers are exposed to some pretty nasty pathogens that are then carried on our clothing and those pathogens can survive anywhere from one to 90 days according to some reports. Healthcare workers take that attire home and include it with their family laundry, often just using a cold or lukewarm water temperature to save energy, and not necessarily using the correct amount of detergent, and perhaps not drying the attire properly. It's a concern."

In addition to the new recommendation on quality assurance monitoring of laundering processes, the updated RP on surgical attire includes:

-- New information on characteristics of safe surgical attire fabrics, including recommendations that fabrics should be tightly woven, stain resistant and durable, and that 100 percent cotton fleece should not be worn

-- Recommendations for safe footwear

-- More information on wearing of jewelry, including how, where and when jewelry can be worn

-- New information on regular and appropriate cleaning of stethoscopes and ID badges

-- A new recommendation that fanny packs, brief cases and backpacks should not be taken into semi-restricted or restricted areas

-- Updated information on disposable and reusable head coverings

Conner acknowledges that the revised RP addresses some of the most problematic and perennial issues of surgical attire. "I think the biggest challenge we have is with cloth hats," she says. "Reusable caps provide a degree of individuality and for some they certainly look better than disposable caps. Everybody wants to be attractive and have fun with their attire, but these cloth hats are not being laundered as they should be. For managers, there is a great deal of concern related to cost control. Often it is challenging to maintain a sufficient inventory so that all perioperative staff members are properly attired every day, so many institutions place that responsibility on the employees."

Conner continues, "Within the restricted area of the operating room, we encourage people not to wear jewelry, but if they have earrings, the jewelry should be confined and contained by the surgical attire. There is evidence in the literature about the contamination of watches and just how high the bacterial count can be. Rings are always an issue -- we tell healthcare workers to absolutely remove them when performing hand hygiene. We all wear ID badges but we forget to clean them. And stethoscopes are an important tool in the pre- and post-op areas, but we need to clean them. The other issue that created great debate and comment was bringing personal items such as briefcases, laptops and backpacks into semi-restricted areas of the operating room. We feel strongly that those items should not be brought into the operating room because they cannot be cleaned and we don't know what's in or on those bags and we don't know what kind of vectors we are bringing into the surgical suite. There are many people, particularly physicians, who don't like hearing that, but we feel it is the right thing to recommend."

The revisions in the surgical attire RP will necessitate change in the organizational culture, something that Conner acknowledges will require effort, communication and teamwork. "Culture change is an ongoing challenge but what we do is look at the evidence, help people understand what the best practice is, and then help them achieve it," Conner says. "Implementing any change in a healthcare facility requires a team approach. We all bring a different perspective, so if we work together and draw from each other's expertise we can often come up with some very exciting improvements. I think that infection preventionists and perioperative professionals need to work very closely, and we encourage our members to develop a relationship with their infection preventionists -- invite them into the operating room to help them examine areas that can be improved upon and practices that can be implemented to reduce the risk of contamination and infection in the surgical suite."

The AORN Recommended Practices for Surgical Attire can be ordered online at www.aorn.org or by calling AORN customer service at (800) 755-2676, ext. 1. The price is $55 for members and $95 for non-members. AORN will also host a free Webinar, "Surgical Attire: Professional Accountability," on Wednesday, Oct. 27, 2010 at 2 p.m. MDT. The speaker, Joan Blanchard, MSS, BSN, RN, CNOR, CIC, will compare surgical attire that should be worn in the semi-restricted and restricted areas of the perioperative suite; identify components of surgical attire that may introduce safety issues for patients healthcare personnel, their families and the community; and discuss the advantages of using accredited laundry facility.