Comfort and Convenience, Processes: Optimisation and Solutions

Surgical scrubs: Choosing the right clothing improves patients’ safety

Surgical scrubs can aid in containing the spread of microorganisms found on the skin and on clothing worn outside the surgical area, and lower the incidence of surgical site infections. Choosing the right clothing for the personnel transfer area and establishing guidelines are important steps in limiting microbial spread and promoting patient safety.

Until the middle of the nineteenth century most patients undergoing surgery would not survive the procedure. Death rates of nearly 80% were usual in hospitals in London.1 Surgeons operated with bare hands, using non-sterile instruments, wearing dark, unwashed frock coats. Dried blood stains were regarded as a sign of experience. Nobody knew at that time that bacteria and other microorganisms were the main cause for the high mortality. Reports commonly stated that “operation was successful, but the patient died”. This changed in the following decades as the relationships between microorganisms and infections became clearer and surgeons started cleaning their hands, sterilising their instruments, and wearing gowns over their street clothes.

Today, very detailed hygiene guidelines regulate clothing in the OR and in the restricted surgery area. Clean surgical scrubs, sterile surgical gowns and headgear are worn to protect the perioperative personnel as well as to decrease microbial contamination of surgical wounds. Nevertheless, surgical site infections (SSI) are still among the most common healthcare-associated infections (HAIs) and are linked with a high financial burden.2

SSI occur after surgery mostly in the operated body part and can be either superficial or involve organs, tissues or implants, often causing longer post-operative hospital stays, additional surgical procedures, treatment in intensive care units and higher mortality.3 They can originate from the OR staff or from the operating room environment. Reports from the European Centre for Disease Prevention and Control (ECDC) estimate that every year half a million patients suffer SSI4, which could be avoided by enhancing infection control and monitoring hygiene measures. As the skin of OR personnel harbours microorganisms that represent a potential source of cross-contamination, surgical scrubs play a key role in keeping patients free from infections and lowering SSI rates. In Europe, surgical scrubs are worn in the surgical area by many healthcare providers such as surgeons, anaesthesiologists, nurses, and laboratory technicians. Sterile gowns are then worn over the surgical scrubs to ensure sterile conditions when performing surgery.

Escherichia coli

The missing link between surgical scrubs and SSI

Determining the contamination of surgical scrubs is essential information for designing infection control guidelines for the personnel transfer area. A study by Hee HI et al., 20145 observed a significant increase over time in bacterial burden on scrubs worn by medical professionals.

Other studies also reported similar findings, underlining the importance of regularly changing scrubs during the day, for example after toilet visits, after surgeries with visible soiling of the surgical scrubs or after leaving the surgical department to prevent the transfer of microbes to the patients.6 The most common bacteria found on worn scrubs were coagulase-negative Staphylococci, Staphylococcus aureus, coliform bacteria (E. coli) and gram-positive rods. 7

Based on this data, it is difficult to establish a direct relationship between contaminated scrubs and SSI incidence. Many risk factors such as number and type of microbes, or the patients’ immune defences, can favour the incidence of SSI. Yet, the continuous shedding of skin-harboured microorganisms throughout the day leads to an increase in scrubs colonisation and could enhance the contamination risk in the OR environment. This is why changing scrubs and gowns before each surgical procedure is crucial, not only when performing procedures with high infection risk, such as heart or implant surgery.

As an alternative to reusable scrubs, that need to be washed frequently to remove contamination, disposable scrubs provide numerous advantages. Freshly unpacked, the risk of contamination by clothing particles is significantly lower, it provides an effective barrier against germs and thus reduces the frequency of SSI. With conventional reusable surgical scrubs, the user cannot be sure that all contaminants have been removed after washing. After all, the performance of the material is influenced by the quality and number of washes. Although the use of disposable materials can raise environmental concerns and can be associated with a lack of comfort, the possible reduction of infection rates and costs associated with SSI are surely key factors that need to be considered before choosing surgical clothing.8

Establishing a medical dress code

The medical community is taking an increased interest in professional medical dress codes. Many local or national associations as the National Institute for Health and Care Excellence 9 in the UK or the Working Group “Hospital and Practice Hygiene” of the AWMF (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften) in Germany have released guidelines for personnel entering areas of the operating department10. They recommend wearing specific colour-coded, non-sterile surgical scrubs in all areas where operations are undertaken. Moreover, they recommend not wearing surgical scrubs in the hospital outside of the OR area without an appropriate cover over them. They also underline the importance of a daily change of scrubs.

OR clothing should have some key features: Scrubs should provide an effective barrier for pathogens, reduce the risk of infection, be lint-free, and comfortable* to wear. A multi-centre study conducted by Loison G et al. 11 in France assessed compliance of OR staff with clothing regulations during a large number of procedures. Just 56% of the examined surgical attire showed full compliance with the guidelines, suggesting that there is still room for improvement.

The development and implementation of guidelines and standardised procedures for surgical scrubs in the perioperative setting is crucial for increasing staff compliance and for promoting patients’ safety. Reducing the number of resident microorganisms on surgical scrubs to a minimum and preventing the transfer of microorganisms from personnel to the patients would result in a lower incidence of SSI and ultimately save lives.

FURTHER INFORMATION

  1. Frock coats to scrubs: a story of surgical attire, Susan Isaac, Royal College of Surgeons

  2. Impact of surgical site infection on healthcare costs and patient outcomes: a systematic review in six European countries, J.M. Badia, Journal of Hospital Infection

  3. Surgical Site Infection: Prevention and Treatment of Surgical Site Infection., National Collaborating Centre for Women’s and Children’s Health, Surgical Site Infection: Prevention and Treatment of Surgical Site Infection.

  4. Facts about surgical site infections, European Centre for Disease Prevention and Control

  5. Bacterial contamination of surgical scrub suits worn outside the operating theatre: a randomised crossover study, H. Hi, Anaesthesia

  6. Reducing the risk of surgical site infection: a case controlled study of contamination of theatre clothing, I. Sivanandan, Journal of Perioperative Practice.

  7. Comparison of bacteria on new, disposable, laundered, and unlaundered hospital scrubs, J.M. Nordstrom, American Journal of Infection Control

  8. Comparison of three distinct clean air suits to decrease the bacterial load in the operating room: an observational study, P. Kasina, Patient Safety in Surgery

  9. Surgical site infection, National Institute for Health and Care Excellence

  10. OP-Kleidung und Patientenabdeckung, HygMed

  11. Compliance with clothing regulations and traffic flow in the operating room: a multi-centre study of staff discipline during surgical procedures, G. Loison, Journal of Hospital Infection

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