ACORN Standard Perioperative Attire Australian College of Operating Room Nurses Copyright © 2014...

ACORN Standard Perioperative Attire

Australian College of Operating Room Nurses

Copyright © 2014 ACORN

Acknowledgements

ACORN acknowledges the

contribution of the dedicated

perioperative nurses who

contributed to the current and past

review of this standard.


Perioperative Attire

Introduction

‘Perioperative Attire’ was the

second standard to be released

in 2014 and followed on

perfectly from the first on

Infection Prevention Copyright © 2014 ACORN


Introduction

The most common question from our

first and subsequent webinars has

asked ‘how to engage medical staff,

anaesthetists/ surgeons’ in the

standards and how to aid in their

compliance Copyright © 2014 ACORN

Its all about you!


Introduction

My suggestions are;

• Provide not only the hospital policy and the

standard but also the papers that are

referenced in the attire standard and this

webinar

• Remind them ‘its all about you’

• Teach medical staff early in their careerCopyright © 2014 ACORN


Introduction

The healthcare environment is ever-

changing with new multi-drug resistant

pathogens, and viral mutations emerging

regularly (as seen in Hepatitis)

(Di Giacoma-Geffers 2014: Spruce, 2014)



Introduction

• It is important to try keep our thinking and

practice ahead of these pathogens and

their mutations

• A clean perioperative environment is of

benefit to both our patients and

perioperative team members (Spruce, 2014)



Introduction• Whilst there is no evidence actually linking non-sterile

perioperative attire to patient infections, the skin of

staff is known to be a major dispersal source of

bacteria into the air (McHugh, et al. 2014)

• We also know that mean bacterial counts on non-

sterile perioperative attire do increase significantly

during the course of the day so practices to decrease

bacteria are required (Hee et al 2014)



Background

Although there are no randomised clinical trials

that provide a direct link between surgical attire

and surgical site infections, there are other data

such as case studies and laboratory studies that

reveal the risk of infection to patients when

exposed to skin, mucous membranes and hair

from perioperative team members (Spruce, 2014)



Background

• Example: A nurse anaesthetist with forearm

dermatitis was the carrier of Gordonia

bronchialis in the sternal wounds of three

cardiac surgical patients

• Her house mate was found to be positive

• The bacteria was traced to the washing

machine in the healthcare worker’s home (Wright

2012 as cited in Spruce, 2014)



Background

• Human skin is colonised with bacteria

that are continuously shed and dispersed

into the air (Hee, 2014)

• Squames are flakes of skin (up to 80

microns in size) that are shed from the

body (Clark and De Calcina-Goff 2009)Copyright © 2014 ACORN


Background

• Dispersal of squames occurs via the natural

convection air flows occurring around the human

body because our body temperature is higher than

ambient air (Clark and De Calcina-Goff 2009)

• Airborne particles are able to contaminate the

surgical site directly by sedimentation or indirectly

by settling on surgical instruments (ACORN policy)



Background

• The scalp can be colonised & skin

shedding from the scalp can carry bacteria

• Staphylococcus aureus & staphlococcus

epidermidis adhered tightly to hair and

could not be removed by routine

shampooing (Spruce 2014) Copyright © 2014 ACORN


This presentation will:

• Discuss some new additions to the standard

• Look at the ‘Salient Information’ provided in

this standard

• Discuss some possible controversial issues

• Provide some ideas for implementation of the

‘Perioperative Attire’ standard Copyright © 2014 ACORN


New information

• There are now 11 statements compared to 9 in the

previous standard

• Expanded information on many aspects of

perioperative attire will be found in this standard

• New information concerned with:

– What constitutes perioperative attire

– Change rooms & locker space

– Tightening up of hair coveringCopyright © 2014 ACORN


New information

Perioperative attire includes;

• Head covers

• Dresses with pantyhose or trousers

• Warm up jackets

• Dedicated footwear

(no more boiler suits)


Salient Information

Statement 1

Perioperative attire is correctly donned in a

dedicated change room prior to entering a semi-

restricted or restricted area in the operating suite

• Wear clean attire daily & change when wet or soiled

• Do not re-wear attire (no hanging in change room or in

lockers)


Salient Information

Statement 1• Only wear undergarments that can be

covered

• Ensure any body hair on the back and neck

are covered

• Prevent perioperative attire coming into

contact with the floor


Salient Information

Statement 1

• Wear a fastened long sleeved, cuffed warm up

jacket in restricted areas when not scrubbed

• Refrain from tying jackets around the waist

• Wear a visible name tag (not lanyard) that is

secured to the perioperative attire (e.g.

pocket) and clean this regularly


Salient Information

Statement 1

The healthcare facility shall provide a dedicated

change room which provides enough storage to

prevent belongings having to be brought into

restricted areas;

• Briefcases

• Backpacks

• Handbags

• Laptops


Salient Information

Statement 2The scalp, sideburns, facial hair, ears and the nape of

the neck are completely covered by a surgical head

cover to minimise microbial dispersal

• Bacterial contamination of the operative field is

less with appropriate head gear (McHugh et al 2014)

• As skin squames shed in the absence of hair,

healthcare worker without scalp hair should also wear

surgical head covers


Salient Information

Statement 2

• Ensure that hairclips and pins are kept to a

minimum and secured particularly when

working in close proximity to the sterile field

• Cloth head covers must cover all hair & meet

Australian standards for textiles, labelling

and laundering (Australian Standards 2003)Copyright © 2014 ACORN

Salient Information

Statement 2

• Ensure that headwear worn for religious or

cultural reasons is cleaned daily and

completely covered by a balaclava-type

covering

• If woven fabric hats are permitted in your

hospital, please study this standard carefully

with regards to fabrics (tightly woven), sewing

& labelling Copyright © 2014 ACORN

Salient Information

Statement 3

Perioperative attire is supplied and laundered by

the healthcare facility, or its contractors

• The healthcare facility must;

– meet Australian standards in design & manufacture

– provide sufficient quantities of attire

– ensure laundering is provided in an approved facility

and transported and stored appropriately Copyright © 2014 ACORN

Salient Information

Statement 4

• As zone conformity contributes to an effective

infection prevention strategy by minimising

introduction of micro-organisms, appropriate

perioperative attire should be worn in restricted,

semi-restricted and non-restricted areas

• A full breakdown of these areas is provided in

the standard


Salient Information

Statement 5

There is expanded information on footwear under both

Australian Standards (2010) and Workplace Health and Safety

guidelines

• This includes;

– foot protection

– foot being fully enclosed

– supportive to the foot

– clean and cleanable

• Wash hands after handling footwearCopyright © 2014 ACORN

Salient Information

Statement 5

• The routine use of overshoes is not recommended

as bacterial numbers on hands are increased when

donning and removing

• A connection has been made between the bacteria

of floor origin and the rate of surgical infections

(WHO 2009)

• The function of overshoes is to protect footwear

during gross contamination Copyright © 2014 ACORN

Salient Information

Statement 6

• Disposable face masks should be worn

correctly to limit droplets arising from

oropharyngeal flora OR to protect the wearer

from blood or body splashes

• Facemasks with 95% bacterial filtration have a

wearer time of 4 hours


Salient Information

Statement 7

• Fingernails should be short, clean, and healthy and free

from artificial or acrylic nails or nail additives

• Fungal or other nail infections should be managed by a

staff health process

• No trials have investigated plain nail polish and surgical

site infections, however, accumulated evidence has

shown that artificial nails, or nails longer than 2mm may

harbour bacteria and fungi


Salient Information

Statement 8• Jewellery worn within the perioperative environment is

limited to items that can be contained within the

perioperative attire

• Only sleeper or securely fastened stud earrings should

be worn

• Rings can be caught causing avulsion of the soft tissue

• Neck chains can harbour bacteria and also be grabbed

by patients causing possible injury or breakage Copyright © 2014 ACORN

Salient Information

Statement 9

Wear personal protective attire according to the activity or

surgery being performed, including, but not limited to;

• Gloves (double gloving)

• Gowns

• Eyewear

• Masks

• Lead aprons

• Thyroid protectors

• Overshoes (if gross contamination) Copyright © 2014 ACORN

Salient Information

Statement 10• Provide initial (at orientation) and on-going

education on Perioperative Attire so all staff have an

up to date understanding of the standard

• Have competencies in wearing perioperative attire

as this provides evidence that staff have been

provided with the opportunity to understand the

purpose of the correct wearing of attire

• Assess compliance in wearing perioperative attire Copyright © 2014 ACORN

Salient Information

Statement 11

• Compliance of perioperative attire will

form part of the auditing process for the

infection prevention standard (NHMRC

2010, ACSQHC 2012)

• Quality indicators for auditing are

provided in this statement


Implications for practice

Implementation Ideas

Develop a policy regarding the use of cover gowns

outside theatre

• Whilst there is conflicting evidence regarding the

infection control advantages of cover gowns

(Hee 2014), public perception and confidence in

the ‘standard of care’ may be a benefit (Landry

2013) Copyright © 2014 ACORN


Develop a policy regarding the use personal

woven fabric hats and clothes

• The fabric must be tightly woven

• Bacteria on dispersed epithelial cells can break into

fragments of approximately 20 microns in size and would

pass through some cotton fabrics that have a pore size of

80 + 100 microns (McHugh 2014)

• The information surrounding this is complex, and needs to

be looked at carefully by the hospital and all the staffCopyright © 2014 ACORN


• Organise a system so that appropriate

personal attire owned by individual staff

members can be laundered by the facility

• With at-risk patients such as the

immunocompromised, consider having

facemasks changed after 4 hours of

surgery Copyright © 2014 ACORN


• Perform an educational audit on

perioperative attire

• Where needed include this information at

the operating suite orientation process

• Provide in-service education to existing

staff to assist in compliance


Possible controversial issues

• Lack of definite evidence linking perioperative

attire and surgical site infections

• A very recent paper published in ‘Anesthesia

2014’ looked at bacterial counts on surgical attire

worn outside the theatre without cover gowns

• They found that visits to the ward and office

respectively did not significantly increase

bacterial contamination of scrub suits (Hee 2014)Copyright © 2014 ACORN


• This research also showed that all scrub suits

(including the ones that were not soiled or those that

had not left the operating suite) had significantly

higher counts over the course of the day supporting

a possible lunchtime change for everyone (Hee 2014)

• They did not however consider the bacteria they may

have been taking out of theatre to the ward or office

areas! Copyright © 2014 ACORN



• This research is interesting however

further research is required

• This may be a great project for someone

looking for some perioperative research

• In fact, this entire topic reveals many

research gaps waiting to be filled


Strategies for implementation

• At the Monday morning meeting – clean

name tags each week

• AORN 2014 suggests some ideas to help

implementation;

– Be prepared to support the policy with evidence

(there are both nursing & medical references)Copyright © 2014 ACORN

Perioperative Attire Strategies for implementation

– Enlist support from the executive team – if

you link this policy to the infection

prevention standard with regards to

accreditation, this may be of assistance

– Emphasise to staff the importance of the

standard for patients, staff and their

families safetyCopyright © 2014 ACORN


Strategies for implementation

– invite team members to discuss and

brainstorm issues to gain ownership &

compliance

– be aware of barriers to practice change, such

as lack of awareness and education

– Send out electronic copies or letters explaining

the standard (AORN 2014) Copyright © 2014 ACORN


In conclusion (medical)

A quote from The Surgeon 2014 …

“In a general sense the donning of surgical attire

helps to demarcate the operating theatre

complex from the rest of the hospital indicating a

higher risk zone requiring extra efforts in asepsis

to prevent infection and Copyright © 2014 ACORN


In conclusion (continued)

by making theatre personnel change to specific

surgical scrubs, shoes and hats before entering

the theatre complex, this ritualistic behaviour

serves as a daily reminder of the importance of

sterility and infection prevention practices in

the operating theatre” (McHugh et al. 2014)



In conclusion (nursing)

A quote from AORN Journal 2014 ….

“ It is up to perioperative nurses to protect

patients, themselves and others from the risk of

infection”

It may be challenging to get everyone to adhere to

the attire rules, but perioperative nurses are up to

the challenge if they understand what is at stake’’ Copyright © 2014 ACORN


QUESTIONS ?


References 1. Spruce L. (2014). Back to Basics: Surgical Attire and Cleanliness.

AORN Journal, Vol. 99, No. 1. pp.138-46.

2. McHugh S, Corrigan M, Hill A, Humphreys H. (2014). Surgical attire,

practices and their perception in the prevention of surgical site

infection. The Surgeon, Vol. 12, No. 1. pp.47-52.

3. Hee H, Lee S, Chia S, Lu Q, Liew A, Ng A. (2014). Bacterial

contamination of surgical scrub suits worn outside the operating theatre:

A randomised crossover study Anaesthesia, Vol. 69, No. 8. pp.816-25.

4. Di Giacomo-Geffers E. (2014). Reviewing requirements for surgical

attire. Briefings on the Joint Commission, Vol. 25, No. 2. pp.7-9.

5. Landry K, Dornelles A, Hayek G, Deichmann R. (2013). Patient

Preferences for doctor attire: The white coat place in the medical

profession. The Ochsner Journal Vol. 13, No. 3. pp.334-42.

References

6. Australian Commission on Safety and Quality in Health Care,

(2012) National Safety and Quality Health Service Standards,

Canberra: Commonwealth Government 2012.

7. World Health Organization, (2009) Guidelines for Safe Surgery.

Department of Human Service, 2009.

8. Clark R, De-Calcina-Goff M. (2009). Some aspects of the

airborne transmission of infection. Journal of the Royal Society of

Interface, Vol. 6, No. Suppl. 6. pp.S767-S82.

9. National Health and Medical Research Council. (2010)

Australian Guidelines for the Prevention and Control if

Infection in Healthcare. Commonwealth of Australia; 2010

ACORN Standard Perioperative Attire Australian College of Operating Room Nurses Copyright © 2014...

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