Games of the Clothes-Minded

The Association of Operating Room Nurses (AORN) recently published updated recommendations for operating room (OR) attire,1 causing managers to promulgate new rules, nurses to complain, doctors to rebel and everyone to play a new round of the clothing games. Because rules for attire are based on expert beliefs, not scientific studies, anyone who wears scrubs can declare their expertise and play in order to demonstrate their sartorial savvy, supervisor scorn or suck-up subservience.

One current battle involves disposable bouffant hats, a favorite of rule makers. A puffed-out bouffant worn over the ears covers hair better than a paper surgical cap tied behind the head, but does it make any difference in patient outcomes or worker safety? W ho knows? There are no good studies. Rule makers claim the need to prevent infections empowers them to try different things and make everyone in the OR look like identical dweebs. Many anesthesiologists like the tighter fit and feel of surgical caps and feel awkward in the puffy pate pullovers, so they rebel, actively or passively, and play the clothes game.

Some anesthesiologists like to wear surgical caps made from cloth with college, sports or military logos on them, personal statements of their past affiliations or present interests, building camaraderie among OR teams. Rule pooh-bahs disdain such individual behavior, and demand daily disposal or washing of these hats. Then, in a deft Catch-22 move, they ruled out home laundering, citing the new AORN recommendations.
In a recent online comment and response on cloth surgical caps, one nurse complained, “AORN can supply NO evidence-based research/studies that prove wearing home-laundered scrubs increases the incidence of surgical site infections.” An administrator responded, “(You are) falling into the trap of evidence-based practice. Because evidence-based practice does not exist on a behavior is not justification to engage in the practice.”2 I translate this as “wear it because I said so.” Players might note that the evidence that does exist generally shows no difference in microbial populations among facility-laundered, third-party–laundered or single-use scrubs.3

So why are there no OR clothing outcome studies? Actually there are a few, but they generally show no improvements with surgical outfits, not even facemasks. Tunevall, in a study of 3,088 patients undergoing general surgery, found a reduced rate of wound infections when surgeons operated without masks.4 In a recent “Expert Guidance,” the Society for Healthcare Epidemiology of America stated, “Healthcare personnel attire is an aspect of the medical profession steeped in culture and tradition. The role of attire in cross-transmission remains poorly established, and until more definitive information exists priority should be placed on evidence-based measures to prevent healthcare-associated infections.”

Good luck with citing evidence to clothes-minded OR managers. Many sit in suite offices hoping for quarterly performance and expense reports that qualify them for bonuses. Issuing clothing rules proves they are managing. Buying patient gowns without arm snaps or scrub shirts without pockets can save five cents apiece, enough in aggregate to fund bonuses. If doctors and nurses do not like OR manager rules, at least the scrub-mask-and-bootie salespeople do. Stamping out personal styles, comfort and fun among workers and patients is just collateral damage.

OR clothing games started decades ago. When institutions developed surgical suites in the 1950s and 1960s, managers asked everyone to wear institutional scrub clothes. Surgeons then demanded their own lounges and lockers to change into these scrubs. Tit-for-tat demands continued until someone warned that static electricity in the OR could ignite flammable anesthetics and he would have to inspect nurses for silk underwear, a known cause of sparks. This tit-for-tat response caused managers to ban all flammable agents, and end that round of clothing games.

Eventually, the public associated scrub clothes with surgeons and anesthesiologists, so young men started wearing scrubs outside hospitals, around campuses, to parties, hoping to attract young women. “I am wearing scrub clothes because I am studying brain surgery—would you like to have a drink with me?” became a successful pick-up line. The enormous loss of scrub clothes from hospital inventories led administrators to lock them up, dispense them like narcotics, color them ugly or ban their wear outside the OR. The commanding general at one U.S. Army hospital who saw his expenses for scrubs approach that for pills, ordered the military police to arrest anyone wearing scrubs outside the hospital, one of the few clothing rules that has worked.

Another current clothing battle pits the thin-blooded who wear surgical jackets in cold ORs against the bare-arms people who think jacket sleeves transport germs to patients. Each justifies his or her preference on preventing infections, without any real data. Similarly, the need to wear hospital name badges pits retractable-cord zealots against lanyard devotees. Cord people claim lanyards are unsafe because they can hang into a wound. One lanyard player inspected the retractable cord of an adversary and let it snap back into the face of the wearer, demonstrating its unsafeness, playing that game to a draw.

Footwear is another favorite area for rules. Some suites mandate shoe covers, whereas others don’t stock them, expecting everyone to provide suitable OR shoes. And the rules about which shoes are suitable are lengthy and diverse. Anesthesiologists who work in multiple institutions often observe different rules, without apparent differences in infection rates, personal safety or any other outcome.

So workers rebel and mock whimsical rule makers. Some wear one of each style hat on their heads, some find individuality with rigid compliance. After one rule maker harangued and annoyed staff to minimize waste and save money, signs appeared in the surgical lounge to conserve toilet paper by using both sides.

Players should understand the why’s and who’s of clothing rules and makers, and understand everything is ultimately about teams delivering good patient care. A pain doctor recently lost his medical license for not wearing a facemask when performing an epidural injection. He had to get a court order to overturn the suspension.

The Centers for Disease Control and Prevention estimated there are 157,500 surgical site infections per year in the United States, a huge burden for patients and health care costs. Perhaps anything that could reduce these infections is worth trying. But most infections relate to preexisting patient conditions, such as peripheral vascular disease and diabetes, or missed evidence-based medical practices, such as chlorhexidine skin preps and timely antibiotic prophylaxis, not to the color, texture or style of surgical attire. Managers trying to remove comfort and individuality from OR attire without supporting evidence are likely to find themselves the subject of gamesmanship. Maybe as an alternative, we could all demand well-done clothing studies?

References
1. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN; 2014.

2. www.outpatientsurgery.net/discussions/85/Cloth-surgical-caps. Accessed September 3, 2014.

3. Twomey CL, Beitz H, Johnson HB. Bacterial contamination of surgical scrubs and laundering mechanisms: Infection control implications. Infection Control Today, October 19, 2009.  www.infectioncontroltoday.com. Accessed September 3, 2014.

4. Tunevall TG. Postoperative wound infections and surgical face masks: a controlled study. World J Surg.1991;15:383-387.