Over the course of the last year, many Fellows, Associate Fellows, and Resident Members of the American College of Surgeons (ACS) have taken to the ACS Communities to voice concern that the hospitals where they practice have imposed restrictive guidelines regarding proper attire in and out of the operating room (OR). As an organization that is dedicated both to serving the professional interests of our members as well as to safeguarding the well-being of the surgical patient, the ACS sought to determine whether the restrictions at these institutions were reasonable and appropriate.
This issue of the Bulletin includes an article on the efforts of the Young Fellows Association of the ACS to gauge young surgeons’ reaction to the protocols and to study the scientific evidence supporting or refuting the need for these restrictions. Also in this issue is the College’s “Statement on operating room attire.” A task force led by ACS Regent L. Scott Levin, MD, FACS, and comprising members of the ACS Committee on Perioperative Care and the Council on Surgical and Perioperative Safety developed the statement, which is based on the principles of professionalism, common sense, decorum, and the available evidence. The Board of Regents approved the guidelines in July.
Turning the “green tide”
One of the behaviors that led members of the patient safety community to develop OR attire restrictions is the rising “green tide” of hospital personnel who arrive at and leave their work area and institutions at the start or the end of their shifts or breaks in their OR scrubs. It has become commonplace in cities such as New York, NY, and Chicago, IL, to see droves of hospital personnel emerging from medical center campuses and entering restaurants, stores, and subway stations while still in their green scrubs. When patients and their families see health care professionals wearing greens in environments that are anything but sterile, it raises red flags about patient safety and welfare.
To address this problem, the College’s statement recommends that OR scrubs be worn outside of the hospital’s OR area only when worn under a clean lab coat or other appropriate cover up and even then should only be worn only within the hospital perimeter. Furthermore, the ACS encourages surgeons to wear clean professional attire (not scrubs) during all patient encounters outside of the OR. To facilitate enforcement of the guideline on wearing scrubs only within the perimeter of the hospital, the ACS also suggests the adoption of distinctively colored scrub suits for OR personnel.
Another concern that led to the development of OR attire guidelines is the debate over proper covering of the head. The College maintains that during invasive procedures, the mouth, nose, and hair on the skull and face should be covered to avoid potential wound contamination, and that the surgical mask should never be allowed to dangle from the face during an operation.
Large sideburns and ponytails should be covered or contained; however, we found no evidence to suggest that leaving ears, a limited amount of hair at the nape of the neck, or modest sideburns uncovered contributes to wound infections. In fact, covering the ears may be detrimental to patient care by making communication more difficult. Therefore, contrary to the guidelines set forth at some institutions, the College maintains that the surgical skullcap provides sufficient coverage of the head when worn with a mask and proper eyewear and in accordance with other patient safety protections. We have found no evidence to suggest that the bouffant head covers mandated under some guidelines provide more effective coverage. Indeed, as the photo below shows, hair is as likely to creep out of bouffant hats as any other head covering.
Keep it clean
Further debate has centered on how frequently scrubs need to be changed, especially since they are often worn under impermeable OR gowns. The ACS maintains that scrubs and hats worn during dirty or contaminated cases should be changed as soon as feasible and certainly before speaking with family members after an operation. Furthermore, scrubs and caps worn during dirty or contaminated cases should be changed prior to subsequent cases even if not visibly soiled. All cloth caps should be cleaned and sanitized daily, and paper caps should be disposed of daily.
The professional attire guidelines implemented at some institutions are based largely on protocols that other organizations have developed recently. Now that the College has produced this statement, we look forward to being a constructive contributor to this conversation.
To ensure the widespread implementation of our recommendations, the College also is collaborating with the Centers for Medicare & Medicaid Services and The Joint Commission to ensure that their policies and regulatory oversight activities are aligned with the ACS recommendations. Mark R. Chassin, MD, MPP, MPH, FACP, president and chief executive officer of The Joint Commission, has indicated that he is sympathetic to the College’s perspective and is willing to work with verification programs to adopt policies that are based on the available evidence and common sense. We will be reaching out to other groups to achieve consensus.
The ACS “Statement on operating room attire” reflects our strong commitment to patient safety and to providing an optimal surgical care environment for our patients. These recommendations for a comprehensive dress policy for surgeons will help us to achieve that goal.