What's safe to wear in the OR? Surgeon, nurse groups at odds

Critics: Guidelines could 'give false sense of security'

The American College of Surgeons' (ACS) latest guidelines for clinician attire in the OR are facing criticism from the Association of periOperative Registered Nurses (AORN), which says some of the recommendations aren't evidence-based.

ASC said its guidelines for appropriate OR attire, published online earlier this month, "are based on professionalism, common sense, decorum, and the available evidence."

ACS said it "emphasizes patient quality and safety and prides itself on leading in an ever-changing and increasingly complex health care environment." The group added, "As stewards of our profession, we must retain emphasis on key principles of our culture, including proper attire, since attention to such detail will help uphold the public perception of surgeons as highly trustworthy, attentive, professional, and compassionate."

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AORN response


In response, AORN issued a statement that endorsed some of the guidelines but argued that others were not evidence-based, and critiqued ACS' overall methodology.

AORN said, "Regulatory agencies, accrediting bodies, and patients expect health care organizations to follow guidelines that are evidence based rather than conclusions based on professionalism, common sense, or decorum."

AORN said that evidence supported four of ACS' recommendations—specifically, that clinicians:

  • Not allow masks to dangle;
  • Not wear OR scrubs outside the hospital perimeter;
  • Change OR scrubs at least daily; and
  • Remove or cover jewelry on the head or neck that "might fall into or contaminate the sterile field.

AORN also said it had "no opinion" of the recommendation that professional attire should be worn during all encounters with patients outside the OR.

Disagreement over guidelines


However, AORN took issue with ACS' guideline that OR scrubs should be worn in the hospital outside of the OR area only with "a clean lab coat or appropriate cover up over them." AORN said that lab coats shouldn't be required over scrubs since evidence "shows that lab coats are not always discarded daily after use or laundered on a frequent basis."

AORN also critiqued ACS' statement that "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 said that while no randomized, controlled trials have been conducted on the subject, "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."

It added that "until an evidence-based definition for 'limited' and 'modest' can be determined, there is no way for facilities to enforce such a recommendation."

AORN took similar issue with ACS' guidance allowing the wearing of skullcaps in certain circumstances.

In response to ACS' assertion that "the skullcap is symbolic of the surgical profession," AORN said, "Wearing a particular head covering based on its symbolism is not evidence-based, and should not be a basis for a nationwide practice recommendation." Separately, Lisa Spruce, director of Evidence-Based Perioperative Practice for AORN, told HealthLeaders Media, "It's all about patient safety. It's not about our symbolism."

AORN also pushed back against ACS' recommendation that OR staff change scrubs and hats "worn during dirty or contaminated cases" before subsequent cases, even if the garments are not visibly soiled.

AORN wrote, "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."

How did Geisinger decide to change its dress code? It asked the patients.

"Doing so," as the ACS guidelines suggest, "could give a false sense of security that PPE and hand hygiene are not needed," AORN said, adding that the surgeon group's statement "may cause confusion by introducing a different standard for surgeons than for other perioperative team members" (Hospitals & Health Networks, 8/23; Wilson Pecci, HealthLeaders Media, 8/22; Frellick, Medscape, 8/12; American College of Surgeons statement, 8/4; Association of periOperative Registered Nurses statement, 8/16).

Are you leading an evidence-based organization?

Despite the shift toward broad acceptance of evidence-based practice (EBP) among medical staff, over half of physicians report not actually using guidelines day-to-day when they are available. As a result, organizations continue to see tremendous variation in clinical practice—as well as in costs and outcomes.

Our infographic outlines four principles you can use to support EBP at your organization, along with action steps to implement each one and pitfalls to avoid along the way.

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