I have worked in quite a few hospitals. Some things were very similar. One had to wear a cap and mask, wash hands for a specified period, don a sterilized full body suit and wear sterile gloves before doing any procedure.
This is good. A time-tested practice. From the time of the unfortunately prescient Simmelweiss and later, the towering Lister, the practice do seem to have solid evidence base. Pasteur and Koch- I am not forgetting them.
Surgical site infections are the eternal enemy of the surgeon. Massively subdued, it is by no means dead. Whenever our vigilance falters, it rears its ugly head, festooned with dirty bacteria.
But I have noticed that, certain questions remain vague.
- What should people who are not operating, wear?
- Do caps and masks help?
One thing is clear. We are not looking at sterilized clothes or bacteria free bodies and breath. We cannot do that. ‘Clean’ is the operative word here.
Most hospitals insist on half-sleeved scrubs that are washed in-house, and forbids their use outside the theatre. I remember changing umpteen number of times during my residency to scuttle between the operation room, emergency, wards, and the blood bank. What a horrible bother. But many places I worked in after my early years are relaxed in this regard. Surgeons and proceduralists happily roam the hospital in their scrubs.
It is interesting that many government places that insist on scrubs-in-theatre-alone mandates the junior staff and students to bring their own scrub dresses. What the heck!
I attempted to review the evidence. I was surprised and I understood.
I understood why the attire issue was vague. While washing, hand hygiene and sterility when one is operating rested on solid evidence, the rationale to use special attire inside is shaky. It can only be seen as a tradition. That is all.
The Association of Operating room Nurses (AORN) came out in 2015 with a set of guidelines. Hair and ears had to be covered completely. A mere skull cap is not enough. Scrubs should be full sleeved (yes!), and rolled back during washing up and patient contact.
But they rolled it right back ( I mean, the recommendations) in 2019 when it became clear that the evidence base was next to nothing.
The NHS came with the “Bare Below the Elbow” policy in 2007. Short sleeves or rolled up ones- always and for everyone. The regal full sleeved white coat had to go!
It appears that there were many attempts to see whether the “BBE” policy decreased surgical infections. They did not!
The next argument was that if you were bare below the elbow, washing up was easy, and had better adherence. This premise was investigated and found to be false. People could just roll up their sleeves and wash. And they did. No problem there.
In the ‘Bare Below Elbow” policy, wedding rings were allowed! Would the bacteria, being binary fissionists and chronic bachelors, avoid the rings as a matter of principle? Seems unlikely. Some say that the entire thing was an attack by envious managers to curtail the power of the white-coated-doctor. And I half believe that narrative.
Caps may prevent some bacteria from shedding. Clean clothes from home and scrubs were equal even in this regard. And shedding is not a good metric.
For example, Men shed twice the number of bacteria as women! No wonder Women are wary of them. Shedding seems to be due to rubbing of clothes on skin. Naked people shed considerably less than clothed ones.
Then, not only do we need to allow only women inside the theatre, but make sure they are naked as well! Please! Let us be more practical.
In short, there is no need to be dogmatic as far as this is concerned. Let us follow the tradition loosely. Make sure everything is clean. Scrubs are good, but more specifications are not required.
Hand washing, and sterile practices while operating must be meticulous. (Jimmy Mathew)
- Bartek M, Verdial F, Dellinger EP. Naked surgeons? The debate about what to wear in the operating room. Clinical Infectious Diseases. 2017 Oct 16;65(9):1589-92.
- Salassa TE, Swiontkowski MF. Surgical attire and the operating room: role in infection prevention. JBJS. 2014 Sep 3;96(17):1485-92.
- ACS A, ASA A, AST T. A statement from the meeting of ACS. AORN, ASA, APIC, AST, and TJC concerning recommendations for Q12 operating room attire. 2018.
- Farach SM, Kelly KN, Farkas RL, Ruan DT, Matroniano A, Linehan DC, Moalem J. Have recent modifications of operating room attire policies decreased surgical site infections? An American College of Surgeons NSQIP review of 6,517 patients. Journal of the American College of Surgeons. 2018 May 1;226(5):804-13.
- Tse G, Withey S, Yeo JM, Chang C, Burd A. Bare below the elbows: was the target the white coat?. Journal of Hospital Infection. 2015 Dec 1;91(4):299-301.
