New guidelines around clinicians’ clothing aim to maximize infection prevention

Cheryl Herbert, MSN, RN, CIC

In the 1990s, Cheryl Herbert, MSN, RN, CIC, Service Line Director for Medical, Skin and Wound Care at CHRISTUS Health, banned long and artificial fingernails for her patient-care staff. The nurses and nail technicians in her town pushed back—hard. But Herbert knew it was a necessary step to help prevent the spread of infection in the hospital.

“There is some evidence that the more unencumbered you are—no rings, no watches—the better your hand hygiene will be,” says Herbert, who works in supply chain now, but has over 40 years of experience in infection prevention. “And anything but your natural fingernail that is a reasonable length can cause problems.”

Research has shown chipped or old nail polish, as well as gel and acrylic nails, can lead to trapped bacteria and fungus that hand-washing doesn’t remove. Research has also shown rings to pose a problem, as they not only increase the chances of a glove tear, but the skin under the rings can trap bacteria.

Updated surgical attire standards
Antibiotic-resistant bacteria can be transmitted on clothing. In July 2019, the Association of periOperative Registered Nurses (AORN) updated its guidelines for infection prevention related to surgical attire.

Key takeaways:

  • Surgical attire should be laundered by the hospital (or an accredited facility) and not at home.
  • Scrubs should be removed before leaving the hospital.
  • Scalp and hair should be covered (as well as beards in certain instances), with head covers being removed either due to contamination or when a shift ends.
  • Employee ID badges must be properly cleaned if they come into contact with blood, bodily fluids or pathogens.
  • Facilities should create standards for personal clothing worn under scrubs, taking a look at things like the fabric and fit, such as sleeve length and turtlenecks.
  • A space should be designated for outside items, like backpacks, to prevent contamination of the central service/sterile processing (CS/SP) area.

“Anything that could obstruct you from doing excellent hand hygiene is an issue,” Herbert says. “When I ran infection prevention in hospitals, I would always say, ‘Why do you want to wear that large ring that will trap bacteria, and possibly get damaged?’ From the tips of your fingers up, you need to establish policies and procedures for infection prevention.”

And it doesn’t stop at your hands. Healthcare facilities across the country, like CHRISTUS Health, which is headquartered in Irving, Texas, are continually adapting their policies to ensure their infection prevention plan is up-to-date with the most current standards for clothing and other attire, from head to toe. Official recommendations surrounding infection prevention in hospital attire change often, meaning facilities must continually adapt as new standards are released.

“Working with HealthTrust in the role of a clinical advisor in supply chain, we use our expertise to keep abreast of evidence-based best practices, so we can support our facilities and ensure they have everything they need to meet changing standards,” Herbert says.

Keeping up with industry standards

Best practices for infection prevention in attire are typically centered on the following areas:

  • Bare below the elbows (BBE). Many facilities have a BBE policy, which prohibits watches, jewelry, ties and long- sleeved shirts.
  • Laundering attire. Most facilities launder surgical attire and hospital-issued scrubs on site. All nonsurgical healthcare professionals are typically advised to launder their scrubs daily.
  • White coats. Employees who interact with patients should have at least two white coats. White coats are typically recommended to be cleaned once per week if the physician is involved in patient care.
  • Ties. The science isn’t definitive in this area, so facilities typically have their own policies for neckties. Some, for example, will recommend that neckties be secured during patient interactions.
  • Shoes. Herbert says there is no evidence that shoes pose an infection risk to patients. Most policies involve shoes being professional and clean, with no open toes in clinical areas. In addition, some perioperative areas still dedicate shoes to the operating room, and some employees choose to have separate clinical shoes.
Tara Coleman, MBA, BSN, RN

HealthTrust regularly consults official infection prevention recommendations to ensure member facilities have what they need on contract, says Tara Coleman, MBA, BSN, RN, Director of Nursing Services, Clinical Operations at HealthTrust.

Coleman says they keep track of new recommendations that are released from organizations like The Joint Commission, the Food and Drug Administration (FDA), the Association for the Advancement of Medical Instrumentation (AAMI), the Association for Professionals in Infection Control and Epidemiology (APIC), the USP 800 and the Occupational Health and Safety Administration (OSHA).

“Standards drive compliance within facilities, which directly impacts our membership and what we have on contract,” Coleman says. “If we don’t have the right products or supplies on contract to meet those standards, it’s difficult to support our members.”

Good practice, good business

In addition to having the right products and services, an official infection prevention program is a vital component of keeping people safe—both inside and outside a hospital’s walls. Not only are healthcare workers protecting themselves, but also their patients and their families at home.

Infection prevention is also a priority for healthcare facilities, because infection rates are often how patients assess a hospital’s quality of care. Many infection rates are publicly reported, Coleman says.

“Just like we shop for the best deal or search for the five-star rating, people look at the same thing in healthcare because they want the best care,” Coleman says. “They want the surgeon who has the lowest infection rates, and they want to know that when they go into a facility, they’re not at risk for coming out with an infection.”

Cautiously professional

When Herbert first began working as a nurse four decades ago, she says professionalism mattered more than infection control. Back then, blood and bodily fluids were the primary concerns. Attire standards have since shifted slowly toward infection prevention (e.g., scrubs) due to the rise of antibiotic-resistant bacteria, which can be transmitted on clothing. During this transition, however, healthcare workers adopted an appearance many believed was too casual.

Now, Herbert says, most standards include a balance in which both professionalism and infection prevention are taken into account.

“I think there’s a happy medium between having a professional appearance so a patient can identify you, and following the evidence- based best practices that have come out about cross-contamination and infection prevention based on what you’re wearing,” Herbert says.

At the end of the day, Herbert says common sense is still superior when it comes to balancing professionalism with infection prevention in hospital attire. “Rather than prescribing to the nth degree—which never works—you need a commonsense approach to preventing infection that goes across the whole continuum of care,” she adds.

Hand-held hazard
In the world of infection prevention, the risk posed by infections spread by cellphones and other hand-held devices is continually being researched and discussed. Although the science is not yet definitive in this area, some studies suggest small hand-held devices, like tablets and cellphones, can become contaminated with pathogens.

There are no official standards or recommendations in place for decontaminating devices, meaning healthcare facilities must take precautions as they see fit. Coleman says this is a particularly popular topic in healthcare right now, with many hospitals interested in infection rates related to the use of small electronics.

“Some of our members have expressed interest in what is out there to clean these devices, such as the use of ultraviolet rays,” Coleman says, adding that HealthTrust’s Nursing and Surgical Advisory Boards are reviewing various options for the proper cleaning of small electronics.

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