6 Surgical Attire Best Practices for Ambulatory Surgery Centers

The following article is written by Kathleen Bernicky, RN, BSN, director of clinical operations for Regent Surgical Health. The article discusses best practices for wearing and laundering surgical attire.

Proper surgical attire is intended to protect both the patients and the perioperative staff.

AORN and APIC recommendations and guidelines have been published for years and are very clear. However, implementing and enforcing compliance of the recommended standards can be quit challenging.

AORN has published "Perioperative Standards and Guidelines." This document provides guidelines for surgical attire and addresses clothing, head covers, masks, shoes and jewelry.

1. Don't launder at home. Home laundering of surgical attire is not recommended. I have seen a significant decrease in home laundering practice over the years. Most ASCs have mandated staff wear only scrubs that have been laundered through the facility's contracted laundry service. Research has shown that home laundering does not meet the measures needed to reduce the levels of microbes.

When choosing a laundry service, choose one that is a healthcare-accredited company. These accredited companies use OSHA and CDC guidelines for laundering and perform quality control monitoring. It's a good idea to visit your contracted service facility annually and do your own on site audit looking at the cleanliness of the facility, the type of orientation and education the staff there receives, and the quality monitoring that is being done. Most laundry services have an alternative process for cleaning scrubs for staff with sensitivities. This is important because some staff are sensitive to the cleaning solutions being used, making it difficult to wear the scrubs.

2. Keep scrubs inside the facility. Perioperative staff and physicians know they should change their scrubs before leaving the facility. Sometimes they need to be reminded of this. The same surgical scrubs should never be worn from one facility to another. There may be times when the administrator or the medical director will need to speak to a physician on the side and reinforce the facility’s policy and the expectations of the center.

3. Keep arms and hair covered. One of the newest AORN recommendations is that all non-scrubbed staff in the perioperative area should be wearing a long-sleeved warm up jacket that is completely snapped. This prevents skin and hair shed from the arms. When prepping a patient, the staff can tuck the jacket in, but should be reminded not to push the sleeves up. Some scrub companies offer long-sleeved scrub tops.

It's usually chilly in the ORs, and personal clothing, such as a tee shirt under scrubs, is acceptable if it does not extend above the neckline or below the sleeves.

4. Use appropriate footwear. Proper footwear will decrease the risk of injury from dropped scalpels, needles, instruments or equipment and minimizes the risk of exposure from blood and body fluids. OSHA standard 1910.132 and 1910.136 outlines compliance guidelines for proper shoes in perioperative settings. Shoes should be clean and without holes, such as those found in Crocs. Proper shoes have closed toes and backs and are not made of fabric or cloth.

It's important to review your facility's policy with staff and explain the reason behind the guidelines. An occasional audit can be done for compliance and continued education as needed.

5. Require proper head covers and masks. One of the most difficult recommendations to enforce that I am seeing is proper head covers. All head and facial hair should be covered in the semi-restricted and restricted areas. This includes sideburns, hair on the back of the head and nap of the neck. Covering these areas prevents skin and hair shedding from the scalp from falling into the sterile field.

Skull caps are not recommended because they do not completely cover the hair. In some cases, the only way to enforce compliance is to completely remove skull caps from the facility and providing the bouffant caps for all that enter into the perioperative area. Another option is to allow the skull caps if they are covered with a bouffant cap when in the restricted and unrestricted areas. Personal re-usable head coverings are acceptable if they are laundered each day by the facility's laundry service or if they are covered by a disposable bouffant head cap.

Masks should be worn by all those entering a restricted area where sterile supplies and equipment are open. The mask should cover the mouth and the nose at all times. When leaving the restricted area, the staff member should remove the mask and discard it in the trash, followed by hand sanitizing. In many facilities, the surgical mask is left hanging around the neck. This is an infection control issue. The staff can assist each other with compliance by reminding each other to remove any mask forgotten around a neck. This is a practice that goes way back and old habits are hard to break.

6. Keep unnecessary items out of restricted areas. Backpacks, brief cases and fanny packs made of porous material harbor bacteria and microbes. These should not be brought into an OR. If fanny packs and medication boxes are used by anesthesia they should be made of a non-porous material and should be thoroughly wiped down and disinfected before entering each case. Fanny packs are not recommended because they are difficult to wipe down and they come in contact with so many different surfaces.

It is recommended that minimal jewelry be worn by perioperative staff. AORN states that jewelry can be worn if it is contained in the surgical attire. It's important for OR staff to realize that bacteria found under rings is nine times greater than other areas and may become colonized.


As you work towards best practice by updating policy and procedure and implementing changes at your center, you have and most likely will continue to encounter resistance. Being prepared to show practice recommendations from expert sources such as AORN, APIC, CDC and ASCA may be helpful. Keep in mind that you have the ability to mandate proper attire be worn by all facility staff. The administrator, medical director and the board of managers can also assist with encouraging and enforcing physician participation. Change is always difficult but we are obligated to be patient advocates and to always do what is right according to the evidence that’s available to us.

Please feel free to contact me (kbernicky@regentsurgicalhealth.com) if you have any questions or would like a copy of an audit tool you can use for monitoring compliance.

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