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Statement on Surgical Attire

Developed By: Committee on Occupational Health
Last Amended: October 26, 2022 (Original Approval: October 23, 2019)

Introductory Remarks

The American Society of Anesthesiologists (ASA) Committee on Occupational Health (COOH) is charged with periodically reviewing current scientific evidence and expert opinion on matters related to infectious outcomes associated with anesthesia care. Anesthesiologists serving on the COOH developed the following expert consensus statement pertaining to surgical attire. The objective of these surgical attire recommendations is to limit infectious spread in surgical and procedural settings. In addition to these recommendations, the ASA Committee on Quality Management & Departmental Administration includes important guidance for establishing and implementing local policies regarding surgical attire.

Recommendations

  1. In restricted or semi-restricted procedural areas, wear clean scrub attire that fits well.
  2. When choosing scrub material, consider both containment of shed skin particles and comfort.
  3. Establish and implement a process for laundering scrubs regularly and whenever they become visibly soiled. Change out of visibly soiled scrub attire as soon as possible without delaying exigent patient care.
  4. When in a restricted or semi-restricted procedural area, cover the hair and scalp with head gear made of a disposable or launderable re-useable material.
  5. When choosing head gear material, consider containment of shed particles, comfort and fit.
  6. Establish and implement a process for laundering reusable head coverings regularly and whenever they become visibly soiled.
  7. During a procedure that exposes (or enters by means of a needle or cannula) tissue planes or mucous membranes that are normally sterile, wear a surgical mask that fully covers the mouth and nose. Wear the mask when sterile instruments intended for the procedure are exposed. This does not apply to the insertion of cannulas into superficial peripheral veins for short-term intravenous access.
  8. When in a restricted or semi-restricted procedural area, cover facial hair not contained within a mask, especially when working over or near the surgical field.
  9. When choosing a facial hair covering material, consider containment of shed particles, comfort and fit.

Process Recommendations

  1. Local surgical attire policy should be developed with the consideration of all available information. Evidence should be evaluated for its validity, reliability, relevance, and potential for bias. Deference should be given to peer-reviewed articles.  
  2. The goals of local surgical attire policy should be: a) to ensure optimal infectious outcomes for patients and health care workers in the perioperative setting; b) to comply with applicable state and federal regulations; c) to promote professionalism and a positive patient experience. 
  3. Groups entrusted with developing local surgical and procedural attire policies should include physician anesthesiologists, other anesthesia care team members, surgeons, other procedurally based physicians, nursing staff, surgical technicians and other healthcare professionals involved in perioperative patient care area. Other clinicians with infectious disease expertise in the perioperative setting and facility administrators may also serve as consultants.
  4. Local surgical attire policies should be developed with the objectives of reducing the risk of patient harm balanced against pragmatic considerations such as the strength of evidence, feasibility of implementation, and environmental and economic burden.  Individual care facilities and health systems may benefit from a thorough review of existing statements to guide the development of local policies.

Regulations Governing Infection Control and Prevention Policies

The Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (under Federal regulation §482.42)1 requires that facility level programs for prevention, control, and investigation of infections and communicable diseases be conducted in accordance with nationally recognized infection control practices or guidelines, as well as applicable regulations of other federal and state agencies. 

Local policy should consider: 1) applicable state and federal regulatory and accrediting organization statutory requirements; 2) the care environments of individual facilities and health systems; and 3) requirements of other healthcare organizations.

Once a policy is established and agreed to by relevant stakeholders, all perioperative and procedure team members should comply with the attire policies in facilities where they practice. Auditing and compliance with infection control and surgical attire policies should be handled in accordance with other nationally established best practices.

Discussion

The most common pathogen source for surgical site infection is the patient’s endogenous microbial flora, particularly that which colonizes the skin, mucous membranes, or hollow viscera.2,3

Pathogens causing surgical site infection may also originate from an airborne exogenous source (i.e., outside of the patient).  Shed skin cells and hair from individuals other than the patient have long been recognized as potential reservoirs for airborne infectious particles in the operating room setting.4-10 These particles may settle directly into the surgical wound or contact the wound indirectly by settling onto gloves, sterile sponges, and instruments. 

Airborne infectious particles play a greater role as a source for surgical infections for procedures classified as “clean,” especially those during which implants are placed (e.g., total joint replacement, vascular graft insertion, cardiac valve replacement, and spine surgery with instrumentation).6-9 Surgical procedures involving implants are most vulnerable to infection from intraoperative settling of bacteria-laden airborne particles because a smaller inoculum is required to cause infectious complications. In the operating room environment, the potential pathogen most frequently cultured from air samples is coagulase-negative Staphylococcal spp. (e.g., Staph. epidermidis).4

All humans shed dead skin cells and hair. About ten percent of shed skin cells carry bacteria.4 During low level activity such as walking, each person sheds about 10,000 enucleated keratinocytes per minute (600,000 per hour) from the outermost layer of the epidermis. Humans also shed between 50-100 hairs per day.

Healthy human skin and hair is colonized by bacteria which are generally not harmful and may be beneficial to the host. In healthy adults, skin microbiology is stable over time, despite a changing environment. Bacteria are firmly attached and generally are not eliminated by routine bathing or shampooing.11

Shed skin particles that measure approximately 10 to 25 microns in the greatest diameter have the greatest potential to carry bacteria as compared to smaller particles.5 For particles larger than 10 micrometers, factors such as turbulence and particle velocity have far less affect upon settling as compared to gravitational factors; therefore, settling occurs at distances closer to the source. Therefore, measures to prevent dispersion of shed squames are of greatest importance to individuals who are over or near the surgical field.

The recommendation to wear scrub attire made from “fabrics … that are tightly woven and low linting”12 stems from a theoretical concept that material impermeable to shed skin scales would prevent their dispersion by “containing” or “holding them in.” 

Some investigations found that ambient airborne infectious particles in the operating room were reduced when occlusive or semi-occlusive scrubs and/or surgical gowns were worn as compared to conventional weave cotton attire.13,14 However, the results of these studies were often conflicting, and the investigations were conducted in settings with varying air flow and filtration systems (e.g., conventional turbulent air flow, laminar air flow, ultrafiltration).

Total body exhaust gowns are currently used during high-risk orthopedic procedures; they represent the most extreme barrier precaution to reduce surgical site infections. Not all studies demonstrate their superiority over other forms of surgical garb. Polyester gowns were found to contain infectious particles at least as well as total body exhaust gowns.15

Wearing head gear during surgical procedures is also recommended to prevent dispersion of infectious particles shed from the scalp and hair. Hair may entrap and sequester shed skin particles, and these may be released into the ambient air, especially when contacted by hands or inanimate objects. 

Ritter et al.16 studied the airborne infectious particles sampled during the use of various head covers. These investigators found no significant difference during the use of a cloth cap, a cloth hood tucked into gown, and no head cover. However, the use of hair spray diminished bacterial counts with or without a head cover. 
 
In contrast, Friberg et al.17 found that the omission of mask and skull cap head covering resulted in 3- to 5-fold increase in bacterial air counts and an almost 60-fold increase in bacterial sedimentation rate. This study took place in a laminar flow operating room environment. Sterile helmet respirators provided no benefit beyond wearing head coverings and masks. 
 
If containment of shed infectious particles is the goal, then, in theory, impermeable coverings that completely cover the hair would most effectively prevent dispersion. However, no studies have demonstrated an association between the material from which scrubs, head gear, and beard covers are constructed and surgical infectious outcomes (e.g., the incidence of surgical site infection). Similarly, no studies show that the extent to which these articles cover the hair or scalp affects infectious outcomes in surgical patients.

Markel et al.18 compared disposable bouffant-style caps and skull caps to home-laundered cloth caps to determine permeability, particle transmission, and pore size. All three types of caps were evaluated twice at two different institutions for a total of four one-hour long mock surgeries for each. In addition, all cap types underwent permeability and porosity testing. The researchers found that the material of the disposable bouffant cap was more permeable as compared to the material of the disposable skull cap and the cloth cap. By using settle plates, the investigators observed greater bacterial shed when bouffant caps were worn than when cloth skull caps were worn. 
 
Kothari et al.19 conducted a retrospective study to compare SSI rates following procedures performed when the surgeon wore a bouffant cap versus a skullcap. A total of 1,543 patients were included in the trial. Factors pre-disposing to infection (e.g., smoking, diabetes mellitus) were similar between groups. When adjusting for the type of surgery (e.g., clean, contaminated, clean-contaminated), SSI rates were not significantly different for procedures performed wearing skullcaps compared to those performed wearing bouffant caps. Three additional retrospective studies20-22 found that strict implementation of a policy to substitute bouffant caps or surgical hoods in place of skull caps had no effect on the incidence of postoperative surgical infections.

Facial hair coverings are also recommended to contain infectious particles shed by health care workers during surgical procedures. Wakeam et al.23 compared facial bacterial colonization among 408 male health care workers with and without facial hair. Male hospital workers with facial hair did not harbor more potentially concerning bacteria than clean shaven workers. Clean shaven workers were significantly more likely to be colonized with Staph. aureus including MRSA. Both groups shed bacteria at high rates. 
 
Parry et al.24 studied the infectious particles shed by bearded and clean-shaven men during standardized facial motions. The researchers concluded that, while wearing surgical masks, bearded surgeons and non-bearded surgeons had similar rates of bacterial shedding. The addition of surgical hoods did not decrease the amount of shedding in either group. 

In contrast to these results, McLure et al.25 found that bearded men had significantly more bacterial shedding than women or clean-shaven men, even when wearing a mask. Workers with facial hair were more likely to shed bacteria after rubbing their faces; however, both men (whether bearded or clean shaven) and women shed bacteria at high rates with facial manipulation. The investigators concluded that facial manipulation leads to bacterial shedding in both male and female HCWs, and that facial hair can increase bacterial shedding in male HCWs even when they wear surgical masks.

Clothing itself may increase skin scale shedding by friction. Researchers have demonstrated that naked men shed approximately a third to a half as many bacteria as the same men wearing street clothes or scrub suits.26 Others demonstrated that women wearing stockings shed more bacteria than women with bare legs.27

Surgical attire that is too tight promotes friction. Prolonged friction may cause chafing. In addition, less porous fabrics promote sweating, and hyperhydrated skin from sweating promotes bacterial colonization. Moisture promotes skin maceration, which causes further skin damage.

Prolonged chaffing and moisture can lead to skin damage. Damaged skin often harbors more pathogens than normal skin. Washing damaged skin is less effective at reducing the number of bacteria, and the number of organisms shed from damaged skin are often higher than from healthy skin.28 When inflammatory and/or desquamating skin conditions such as eczema and atopic dermatitis are present, the skin affected by these conditions is more likely than normal skin to be colonized by pathogenic bacteria (e.g., Staph. aureus and gram negatives).28 Moreover, skin affected by these conditions sheds more squames than normal skin and the shed squames are more likely to contain pathogenic bacteria.28 Because of the effects of friction and the potential for less “breathable” materials to evoke skin damage and inflammatory skin conditions, comfort and fit are important considerations for surgical attire beyond the containment of shed skin particles.

There are case reports describing infectious outbreaks associated with airborne particles shed by a health care worker. One published case report describes an outbreak of surgical infections associated with an individual who carried Staph. aureus in his hair.29 Even though he wore a head covering and a mask during procedures, eleven infections were linked to this carrier. After abatement measures were taken, the infections ceased temporarily. However, the carrier again became colonized and he was subsequently linked to five more infections. After the carrier left the facility, no further outbreaks were observed.

Another case report described a series of surgical wound infections linked to a skin carrier of Group A beta-hemolytic Streptococcus.30 Settle plates were used to detect airborne infectious particles shed by this carrier. The carrier was identified as a woman with a history of psoriasis and seborrhea, and multiple skin and hair sites were found to be colonized with the specific Streptococcal strain. Interestingly, the carrier consistently wore paper head gear when in the operating room.

Ultraclean air filtration and laminar air flow have each been shown to significantly impact microbiologic air quality. However, improved air quality with these systems has not translated into reductions in surgical site infections following joint implantation procedures.31 Importantly, several studies indicate that operating room air quality is affected by the number of people in the operating room and their behavior (e.g., activity level and traffic in and out of doorways). Published data about the impact of operating-room behaviors on the risk of infection are limited and heterogeneous; some have indicated that the “studies exhibit major methodological flaws.”32

The 2017 CDC recommendations for prevention of Surgical Site Infections (SSI),33 based upon information available through April 2014, did not address surgical attire. The supplemental material (eAppendix 1) states “that many of the 1999 strong recommendations should be re-emphasized as accepted practice for preventing surgical site infections.”

The 1999 CDC Guideline for the Prevention of Surgical Site Infection33 reads as follows:

  1. Wear a surgical mask that fully covers the mouth and nose when entering the operating room if an operation is about to begin or already under way, or if sterile instruments are exposed. Wear the mask throughout the operation. Category IB*
  2. Wear a cap or hood to fully cover hair on the head and face when entering the operating room. Category IB*
  3. Do not wear shoe covers for the prevention of SSI. Category IB*
  4. Wear sterile gloves if a scrubbed surgical team member. Put on gloves after donning a sterile gown. Category IB*
  5. Use surgical gowns and drapes that are effective barriers when wet (i.e., materials that resist liquid penetration). Category IB
  6. Change scrub suits that are visibly soiled, contaminated, and/or penetrated by blood or other potentially infectious materials. Category IB*
  7. No recommendations on how or where to launder scrub suits, on restricting use of scrub suits to the operating suite, or for covering scrub suits when out of the operating suite. Unresolved issue
     
*Federal regulation: OSHA

References

  1. State Operations Manual Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals §482.42 Condition of Participation: Infection Control.
  2. Owens CD, Stoessel K. Surgical site infections: epidemiology, microbiology and prevention. J Hosp Infect. 2008 Nov;70 Suppl 2:3-10. doi: 10.1016/S0195-6701(08)60017-1.
  3. Reichman DE, Greenberg JA. Reducing surgical site infections: a review. Rev Obstet Gynecol. 2009;2(4):212-221.
  4. Hambraeus A. Aerobiology in the operating room—a review. J Hosp Infect 1988; 11:68-76. 
  5. Clark RP. Skin scales among airborne particles. J Hyg (Lond). 1974; 72:47.
  6. Eickhoff TC. Airborne nosocomial infection: a contemporary perspective. Infect Control Hosp Epidemiol 1994; 15:663-72.
  7. Chauveaux D. Preventing surgical-site infections: Measures other than antibiotics. Orthopaedics & Traumatology: Surgery & Research 2015; 101:S77-83. https://doi.org/10.1016/j.otsr.2014.07.028
  8. Lidwell OM, Lowbury EJ, Whyte W, et al. Airborne contamination of wounds in joint replacement operations: the relationship to sepsis rates. J Hosp Infect 1983; 4:111-131. 
  9. Darouiche RO, Green DM, Harrington MA, et al. Association of Airborne Microorganisms in the Operating Room with Implant Infections: A Randomized Controlled Trial. Infect Control Hosp Epidemiol 2017; 38: 3-10.
  10. Preventing Surgical Site Infections. In: Association for Professionals in Infection Control and Epidemiology: APIC Implementation Guides: Infection Preventionist’s Guide to the OR:19-29. APIC website. Available at: https://www.APIC.org. Accessed May 23, 2022.
  11. Mase K, Hasegawa T, Horii T, et al. Firm adherence of Staphylococcus aureus and Staphylococcus epidermidis to human hair and effect of detergent treatment. Microbiol. Immunol. 2000; 44(8):653-6.
  12. Link T. Guidelines in Practice: Surgical Attire. AORN Journal 2020; 111:25-39.
  13. Tammelin A, Hambraeus A, Stahle E. Source and route of methicillin-resistant Staphylococcus epidermidis transmitted to the surgical wound during cardio-thoracic surgery. Possibility of preventing wound contamination by use of special scrub suits. J Hosp Infect 2001; 47:266– 276. 
  14. Whyte W, Hamblen DL, Kelly IG, Hambraeus A, et al. An investigation of occlusive polyester surgical clothing. J Hosp Infect 1990; 15:363-74.
  15. Sanzen L, Carlsson AS, Walder M. Air contamination during total hip arthroplasty in an ultraclean air enclosure using different types of staff clothing. J Arthroplasty 1990; 5:127-30. 
  16. Ritter MA, Eitzen HE, Hart JB, French ML. The surgeon’s garb. Clin Orthop Relat Res 1980; 153:204-9. 
  17. Friberg B, Friberg S, Ostensson R, Burman LG. Surgical area contamination comparable bacterial counts using disposable head and mask and helmet aspirator system, but dramatic increase upon omission of head gear: Experimental study in horizontal laminar airflow. J Hosp Infect 2001; 47:110-5. 
  18. Markel TA, Gormley T, Greeley D, et al. Hats off: A study of different operating room headgear assessed by environmental quality indicators. J Am Coll Surg. 2017; 225:573-81. 
  19. Kothari SN, Anderson MJ, Borgert AJ, et al. Bouffant vs skull cap and impact on surgical site infection: Does operating room headwear really matter? J Am Coll Surg 2018; 227(2):198-202. 
  20. Farach SM, Kelly KN, Farkas RL, et al. Have Recent Modifications of Operating Room Attire Policies Decreased Surgical Site Infections? An American College of Surgeons NSQIP Review of 6,517 Patients. J Am Coll Surg 2018; 226:804-13. 
  21. Shallwani H, Shakir HJ, Aldridge AM, et al. Mandatory Change from Surgical Skull Caps to Bouffant Caps Among Operating Room Personnel Does Not Reduce Surgical Site Infections in Class I Surgical Cases: A Single-Center Experience With More Than 15,000 Patients. Neurosurgery 2018; 82:548–54. 
  22. Rios-Diaz AJ, Chevrollier G, Witmer H, et al. The art and science of surgery: Do the data support the banning of surgical skull caps? Surgery 2018; 164:921–5. 
  23. Wakeam E, Hernandez RA, Rivera-Morales D, et al. Bacterial ecology of hospital workers’ facial hair: a cross-sectional study. J Hosp Infect 2014; 87:63-7. 
  24. Parry JA, Karau MJ, Aho JM, et al. To Beard or Not to Beard? Bacterial Shedding Among Surgeons. Orthopedics 2016; 39: e290-4. 
  25. McLure HA, Mannam M, Talboys CA et al. The effect of facial hair and sex on the dispersal of bacteria below a masked subject. Anaesthesia 2000; 55:173-6. 
  26. Hill J, Howell A, Blowers R. Effect of clothing on dispersal of Staphylococcus aureus by males and females. Lancet 1974; 2:1131–3. 
  27. Mitchell NJ, Gamble DR. Clothing design for operating room personnel. Lancet 1974; 2:1133-36. 
  28. Larson EL, Norton Hughes CA, Pyrek JD, et al. Changes in bacterial flora associated with skin damage on hands of health care personnel. Am J Infect Control 1998; 26:513-21. 
  29. Dineen P, Drusin L. Epidemics of postoperative wound infections associated with carriers. Lancet 1973; 2:1157-9. 
  30. Mastro TD, Farley TA, Elliott JA, et al. An outbreak of surgical-wound infections due to group A Streptococcus carried on the scalp. N Engl J Med 1990; 323:968–72. 
  31. Eisen DB. Surgeon’s garb and infection control: What’s the evidence? J Am Acad Dermatol 2011; 64:960. 
  32. Birgand G, Saliou P, Lucet J-C. Influence of staff behavior on infectious risk in operating rooms: what is the evidence? Infect Control Hosp Epidemiol 2015; 36:93-106. 
  33. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. 2017; 152(8):784-91. eAppendix 1. Background, Methods and Evidence Summaries. https://doi.org/10.1001/jamasurg.2017.0904
  34. Mangram A, Horan T, Pearson M, Silver L, et al. Guideline for Prevention of Surgical Site Infection, 1999. Infection Control & Hospital Epidemiology 1999; 20(4):247-80. https://doi.org/10.1086/501620

Curated by: Governance

Last updated by: Governance

Date of last update: October 26, 2022