Orthopedics

Guest Editorial 

Scrub Suits: Revisited

James J. Hamilton, MD

Abstract

Dr Hamilton is from the Department of Orthopedics, Truman Medical Center, Kansas City, Missouri.

Dr Hamilton has no relevant financial relationships to disclose.

Correspondence should be addressed to: James J. Hamilton, MD, Department of Orthopedics, Truman Medical Center, 2301 Holmes St, Kansas City, MO 64108 (james.hamilton@tmcmed.org).

Scrub suits have long been identified as the ubiquitous clothing of surgeons. It is time to look at how we are currently using (and misusing) this staple of the medical profession.

With the advent of surgical antisepsis came the concept that surgeons’ attire could be responsible for the spread of pathogens and the infection of operative cases. Procedures were instituted that required surgeons to change out of clothing worn outside the hospital and into special scrub suits to prevent the dissemination of community- and hospital-acquired contaminants into the sterile operative field. Personnel in operating rooms were required to shed their outside clothing and don newly cleansed clothing.1 When the personnel left the operating room, they were to change back into their own clothing to depart the hospital.

In modern times, government regulators have incorporated that concept into hospital requirements. Scrub suits and other devices designed to isolate infections from cross-contamination with other patients are considered personal protective equipment (PPE). Personal protective equipment, including everything from latex gloves and masks to isolation gowns and scrub suits, is issued by an employer to an employee to prevent them from being exposed to patient germs, and also to protect patients and personnel from contamination. It is not meant for use away from the hospital. The provision of and rules for the use of PPE are now incorporated into Occupational Safety & Health Administration regulations, which clearly state that PPE must be discarded (changed) prior to leaving the hospital, or a severe fine applies to the hospital.2

Regardless of rules and regulations, scrub suits are comfortable—like working in your pajamas. It is also cost-effective for the personal budget if street clothes do not have to be worn to work.

However, scrub suits are being worn in and out of the hospital. Where have you seen hospital-issued scrubs? In my town, I have seen them in restaurants, grocery stores, athletic clubs, libraries, and shopping centers, to name a few. I would hypothesize that now, instead of protecting our patients from community pathogens, we are actively exporting much more dangerous hospital pathogens into the community. On multiple occasions, I have stopped outside surgeons from entering my hospital’s operating room wearing another institution’s scrub suit, thus cross-contaminating operating rooms with pathogens. The Association of periOperative Registered Nurses (AORN) standards for surgical attire specifically state that everyone should change into freshly laundered attire before entering the operating room.3

Have you observed an orthopedic supply representative going from 1 hospital operating room to another wearing his company’s scrub suit uniform? When I stopped such a representative recently, he was indignant, stating that he was wearing scrubs. He failed to recognize that his scrub suit was transporting potential pathogens among hospitals.

I recently stopped some young physicians leaving the hospital in hospital-issued scrubs. I asked them why they were taking the hospital infections home to their families. They stated that they washed the scrubs at home in their washing machines, to which I asked, “How are you decontaminating your washing machines afterward?” They were utterly amazed, having never considered it in that light. Both AORN and Association of Surgical Technologists regulations specifically recommend that hospital scrub suits not be laundered at home.3,4

I would hate to have to admit that perhaps the rapid increase of community-acquired methicillin-resistant Staphylococcus aureus could be linked to the…

Dr Hamilton is from the Department of Orthopedics, Truman Medical Center, Kansas City, Missouri.

Dr Hamilton has no relevant financial relationships to disclose.

Correspondence should be addressed to: James J. Hamilton, MD, Department of Orthopedics, Truman Medical Center, 2301 Holmes St, Kansas City, MO 64108 (james.hamilton@tmcmed.org).

Scrub suits have long been identified as the ubiquitous clothing of surgeons. It is time to look at how we are currently using (and misusing) this staple of the medical profession.

With the advent of surgical antisepsis came the concept that surgeons’ attire could be responsible for the spread of pathogens and the infection of operative cases. Procedures were instituted that required surgeons to change out of clothing worn outside the hospital and into special scrub suits to prevent the dissemination of community- and hospital-acquired contaminants into the sterile operative field. Personnel in operating rooms were required to shed their outside clothing and don newly cleansed clothing.1 When the personnel left the operating room, they were to change back into their own clothing to depart the hospital.

In modern times, government regulators have incorporated that concept into hospital requirements. Scrub suits and other devices designed to isolate infections from cross-contamination with other patients are considered personal protective equipment (PPE). Personal protective equipment, including everything from latex gloves and masks to isolation gowns and scrub suits, is issued by an employer to an employee to prevent them from being exposed to patient germs, and also to protect patients and personnel from contamination. It is not meant for use away from the hospital. The provision of and rules for the use of PPE are now incorporated into Occupational Safety & Health Administration regulations, which clearly state that PPE must be discarded (changed) prior to leaving the hospital, or a severe fine applies to the hospital.2

Regardless of rules and regulations, scrub suits are comfortable—like working in your pajamas. It is also cost-effective for the personal budget if street clothes do not have to be worn to work.

However, scrub suits are being worn in and out of the hospital. Where have you seen hospital-issued scrubs? In my town, I have seen them in restaurants, grocery stores, athletic clubs, libraries, and shopping centers, to name a few. I would hypothesize that now, instead of protecting our patients from community pathogens, we are actively exporting much more dangerous hospital pathogens into the community. On multiple occasions, I have stopped outside surgeons from entering my hospital’s operating room wearing another institution’s scrub suit, thus cross-contaminating operating rooms with pathogens. The Association of periOperative Registered Nurses (AORN) standards for surgical attire specifically state that everyone should change into freshly laundered attire before entering the operating room.3

Have you observed an orthopedic supply representative going from 1 hospital operating room to another wearing his company’s scrub suit uniform? When I stopped such a representative recently, he was indignant, stating that he was wearing scrubs. He failed to recognize that his scrub suit was transporting potential pathogens among hospitals.

I recently stopped some young physicians leaving the hospital in hospital-issued scrubs. I asked them why they were taking the hospital infections home to their families. They stated that they washed the scrubs at home in their washing machines, to which I asked, “How are you decontaminating your washing machines afterward?” They were utterly amazed, having never considered it in that light. Both AORN and Association of Surgical Technologists regulations specifically recommend that hospital scrub suits not be laundered at home.3,4

I would hate to have to admit that perhaps the rapid increase of community-acquired methicillin-resistant Staphylococcus aureus could be linked to the careless observation by physicians of simple procedures on the use of scrub suits. With the recent advent of vancomycin-resistant pathogens and decreasing advances in new antibiotics, are we risking having these organisms also become community based by our lax enforcement of time-tested procedures?

It is time to go back to the basics and reinstitute the original rules regarding hospital provided scrub suits, specifically:

  1. All personnel entering the operating suite must change into freshly laundered, hospital-provided scrub suits.

  2. All personnel must wear their own clothing into and out of the hospital.

  3. Scrub suits must be changed between contaminated cases.

Hospital personnel in various departments have adopted distinctive scrub suits as a departmental uniform. Occupational Safety & Health Administration regulations apply only to hospital-provided scrubs. However, some young physicians feel that having “St Elsewhere Medical Center” stamped across their backside is an announcement that they are “real doctors.” Perhaps it is time to change the stamp to read “This scrub suit has been stolen from St Elsewhere Medical Center. Please call 555–1212 if you see it outside of our hospital.”

References

  1. Siegel JD, Rhinehart E, Jackson M, Chiarello Lthe Healthcare Infection Control Practices Advisory Committee. 2007Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf. Updated September 29, 2010. Accessed March 26, 2011.
  2. Occupational Safety & Health Administration. Personal Protective Equipment (PPE). Occupational Safety & Health Administration Web site. http://www.osha.gov/SLTC/personalprotectiveequipment/. Accessed March 26, 2011.
  3. Association of periOperative Registered Nurses. Perioperative Standards and Recommended Practices. Denver, CO: Association of periOperative Registered Nurses; 2009.
  4. Association of Surgical Technologists. AST Recommended Standards of Practice for Laundering of Scrub Attire. Association of Surgical Technologists Web site. http://www.ast.org/pdf/Standards_of_Practice/RSOP_Laundering_Scrub_Attire.pdf. Published April 13, 2008. Accessed March 26, 2011.
Authors

Dr Hamilton is from the Department of Orthopedics, Truman Medical Center, Kansas City, Missouri.

Dr Hamilton has no relevant financial relationships to disclose.

Correspondence should be addressed to: James J. Hamilton, MD, Department of Orthopedics, Truman Medical Center, 2301 Holmes St, Kansas City, MO 64108 (james.hamilton@tmcmed.org).

10.3928/01477447-20110317-01

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