To Cover or Not to Cover:
Surgical Attire in the Operating Room
By Phenelle Segal, RN, CIC, Founder, Infection Control Consulting Services
On August 4, the American College of Surgeons (ACS) released a statement on professional attire for surgeons in and out of the operating room. Titled "Statement on Operating Room Attire," ACS says the new guideline "is based on principles of professionalism, common sense, decorum, and the available evidence."
We are pleased any time an organization issues guidance that focuses on patient safety, including infection prevention, and applaud ACS for doing such with this statement. Unfortunately, aspects of the statement have created significant confusion amongst hospital and ambulatory surgery center (ASC) staff.
Background on Surgical Attire
The Medicare State Operations Manual (SOM), also known as Conditions of Participation (CoP) was revised in 2015 to include an extensive infection prevention and control worksheet for hospitals that is used by surveyors to conduct tracers and write deficiencies when hospitals are not in compliance with the elements of performance.
Under Section 4.I on surgical procedures, an element of performance addresses surgical attire, stating the following:
"4.1.3 Surgical attire (e.g. scrubs) and surgical caps/hoods covering all head and facial hair are worn by all personnel and visitors in semi-restricted and restricted areas. Note: Restricted area includes ORs, procedure rooms, and the clean core (sterile supply) area. The semi restricted area includes the peripheral support areas of the surgical suite."
The SOM for ASC participation also includes a surveyor worksheet that was updated in 2015 but does not include surgical attire. However, it is critical for ASCs to note that within the worksheet, the Centers for Medicare & Medicaid Services (CMS) includes an element of performance (#16) on the use of nationally recognized guidelines as the basis for an ASC's infection control program.
CMS notes that an ASC will be cited if, during a tracer, the surveyor observes practices not in compliance with the chosen nationally recognized guidelines. The most widely followed guidelines in the ASC industry include, but are not limited to AORN, AAMI, ANSI and CDC/HICPAC.
The ACS statement addressed several items which are in alignment with nationally recognized guidelines, but its reference to head coverings included the following potentially conflicting information:
"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.
"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."
This does not align with AORN Guidelines for Perioperative Standards, which state the following in recommendation #4 of the "surgical attire" chapter:
"All personnel should cover head and facial hair, including sideburns and the nape of the neck, when in the semirestricted and restricted areas.
"A clean, low-lint surgical head cover or hood that confines all hair and covers scalp skin should be worn. The head cover or hood should be designed to minimize microbial dispersal.
"Head coverings contain skin squames and hair shed from the scalp. It is important to prevent shed skin squames from falling onto the sterile field. Hair acts as a filter when it is uncovered and collects bacteria in proportion to its length, waviness, and oiliness. Studies have shown that Staphylococcus aureus and Staphylococcus epidermidis have a tendency to colonize hair, skin, and the nasopharynx. Head coverings designed to contain hair and scalp skin will minimize microbial dispersal. Skull caps may fail to contain the side hair above and in front of the ears and hair at the nape of the neck."
Understanding the Rules
Following several years of unresolved issues related to surgical attire, the ACS statement enters the arena after CMS and AORN have provided clarification and facilities have begun to show some compliance.
At Infection Control Consulting Services (ICCS), we believe the key to compliance with infection prevention standards is for hospitals and ASCs to recognize that the CoPs are to be followed exactly as they are spelled out (surgical attire addressed for hospitals and nationally recognized guideline compliance for ASCs) as surveyors will issue deficiencies regardless of statements written by organizations and associations.
We have seen surgical attire deficiencies as a top "write up" of hospitals during surveys for at least the past 18-24 months, and do not expect this to change. ICCS has begun to observe increasing compliance, albeit there is much room for improvement.