User experience of wearing comfort of reusable versus disposable surgical gowns and environmental perspectives: A cross-sectional survey

OBJECTIVE

To determine the user experience of wearing comfort of reusable sterile surgical gowns and compare these gowns with conventional disposable surgical gowns.

DESIGN

Cross-sectional survey.

SETTING

An academic hospital in the Netherlands.

POPULATION

Gynaecologists, surgeons, residents and operating room assistants (n=80).

METHODS

Quantitative and qualitative data were obtained via a written questionnaire. Participants provided subjective comments and scored the reusable gown on each individual topic with a score from 1 to 5 (1 = unsatisfactory, 2 = moderate, 3 = good, 4 = very good, 5 = excellent) and compared the reusable gown with the conventional disposable alternative (better, equal or worse).

MAIN OUTCOME MEASURES

Wearing comfort: ventilation and temperature regulation, fit and length, functionality, barrier function and ease of use.

RESULTS

The results of the overall scores of the reusable gown are scored as 'very good' (mean 4.3, SD ± 0.5) by its users. Regarding comparison of the gowns, more than 79% (lowest score 79%, highest score 95%) of the participants scored the reusable gown equal or higher on six of seven topics. The topic 'ease of use' was scored equal or higher by 59% of the participants. Subjective comments provided information on possible improvements.

CONCLUSIONS

The findings of this study demonstrate that there is professional acceptance regarding the utilisation of reusable surgical gowns. To facilitate broader adoption, it is imperative to foster collaboration among suppliers and healthcare institutions. The reusable surgical gown is an environmentally sustainable, safe and comfortable alternative in the operating room.

Surgical gowns as a safety barrier under non-standard environmental conditions

In this prospective study, we aimed to investigate whether surgical gowns become contaminated during surgery. Samples from the gowns of five surgeons during 19 surgeries were collected using sterile swabs in circular standard delimited areas on both wrists and the mid-chest at three time-points: immediately before surgical incision (t=0), 30 min (t=30), and 60 min (t=60) later. Additionally, at t=0 and t=60, three settle plates of plate count agar were positioned at 1.5 m from the ground and remained open for 20 min. The operating room temperature and relative humidity were monitored. The swabs were cultivated and incubated, and colony-forming units per gram (CFU/g) counts were measured. The CFU/g counts for bacteria or fungi did not differ among the three sampling sites. The surgeons' lateral dominance in manual dexterity did not influence the gowns' contamination. There were significant variations in the temperature and relative humidity over time, but not in the CFU/g counts. In conclusion, during the first hour of surgery, surgical gowns did not become a source of contamination and are an effective barrier against bacterial and fungal contamination even under non-standard surgical environmental conditions.

Does the Type of Surgical Headwear Worn in the OR Matter? A Review of Evidence and Opinions

Proper surgical attire is essential in decreasing surgical site infections; however, the effectiveness of the different types of headwear is a controversial topic. We conducted a narrative review based on studies identified through a focused literature search to summarize and critically assess evidence and opinions on the most appropriate type of headwear for OR personnel. We included 48 articles: 17 original research studies and 31 non-peer-reviewed articles of various types. Research published before 2014 mostly supports the complete coverage of all hair, which aligns with the 2015 AORN guidelines. However, more recent literature rebuts these guidelines and emphasizes the importance of clean headwear. Although earlier studies (published before 2017) lacked scientific rigor, later studies (published after 2017) have other various limitations, including missing data on compliance, surgery-related techniques, and surgical attire other than headwear. The findings from this review highlight the importance of solid evidence-based guidelines and expert collaboration.

Iatrogenic Contamination With a Surgical Helmet System in Orthopedic Surgery

Surgical helmet systems (SHSs) have been used to decrease iatrogenic contamination to prevent periprosthetic joint infections. However, the use of SHSs has been controversial. Therefore, the purpose of this study was to investigate iatrogenic contamination of traditional surgical attire (TSA), SHSs, and SHSs with delayed ventilation (SHS-DV) (helmet fan not turned on until surgeon gowned and gloved). A total of 180 orthopedic surgical procedures were prospectively enrolled and randomized into one of three cohorts. The TSA cohort included any orthopedic procedures, while the SHS and SHS-DV cohorts included arthroplasty procedures. Cultures were obtained from bilateral forearms, axillae, the sternum, and face shields for SHS groups. There were 60 surgeries in each group. The rate of positive cultures was calculated for each cohort and stratified by location and type of microorganism. The positive culture rates were 15% in the TSA, 25% in the SHS, 18% in the SHS-DV cohorts. The positive swab culture rates were 6% in the TSA, 7% in the SHS, and 4% in the SHS-DV cohorts. The positive culture rate was highest from the forearms in the TSA cohort (10%), the face shield in the SHS cohort (20%), and the chest in the SHS-DV cohort (7%). Coagulase-negative Staphylococcus was the most common bacteria cultured. The overall bacterial contamination rates were similar between the TSA and the SHS cohorts, with a lower rate in the SHS-DV cohort. Waiting to initiate airflow in SHSs and treating the shields as contaminated may reduce iatrogenic contamination. [Orthopedics. 2021;44(6):e753-e756.].

Children's and parents' perceptions concerning surgical attire: a systematic review

OBJECTIVE

To review the literature about children's and parent's perceptions on surgical attire.

DATA SOURCE

A systematic search was conducted in the databases EMBASE, Latin American and Caribbean Health Sciences (LILACS), PubMed, PsycINFO, Scopus and Web of Science. Grey literature was searched on Google Scholar, Open Grey and ProQuest Dissertations, and Theses Database.

DATA SYNTHESIS

A total of 2,567 papers were identified. After a two-phase selection, 15 studies were included in narrative synthesis. Children favored wearing white coats in five of the nine included studies (55.5% [95%CI 48.3-62.7]; p=1.00). With respect to parents' preferences, results of vote counting showed that in 11 of 15 included studies, they favored physicians wearing white coats (73.3% [95%CI 67.9-78.6]; p=0.11).

CONCLUSIONS

Children and parents have preferred physicians to wear a white coat with a very low certainty of evidence.

A Grounded Theory of Intraoperative Team Members' Decision Making Regarding Surgical Attire Guideline Adherence

Surgical attire guidelines (SAGs) assist perioperative nurses with minimizing the risk of patients developing surgical site infections. However, some intraoperative team members fail to fully adhere to SAGs, which may put patients at risk. Because there is a lack of published literature on the reasons for intraoperative team members' SAG nonadherence, I undertook a grounded theory study to explore the decision making of intraoperative team members related to the AORN SAG. The resulting model identifies the factors that affect decision making regarding SAG adherence, including personal identity needs, adherence anchoring activities, SAG awareness, direction from authority figures and organizations, guideline evidence strength, and resource availability. After weighing the influence of each factor, team members decide to what extent they will adhere to the SAG. The theory also provides guidance for enhancing adherence decisions.

The Effect of an Orthopedic Hand Surgeon's Attire on Patient Confidence and Trust

Background: Multiple studies have concluded that patients are more likely to understand and trust physicians who dress in more formal attire (shirt and tie) as opposed to casual attire (t-shirts and jeans). The white coat has repeatedly been reported as a major source of trust and confidence in a patient's eyes. Methods: This study explores the effect an orthopedic hand surgeon's attire has on a patient's perception of their surgeon's clinical values. All patients 18 years of age and older who visited our orthopedic hand surgeon's suburban outpatient practice were asked to participate in our survey-based study. Results: Ninety-seven surveys were completed and included. A majority of our responders are female (n = 59, 60.8%), Caucasian (n = 83, 85.6%) between the ages of 55 and 74 years (n = 40, 41.2%), currently employed (n = 59, 60.8%) with private health insurance (n = 69, 71.1%), and married (n = 64, 66.0%). Patients rated male and female hand surgeons wearing a white coat highest using the Likert scale and when asked about their perceived clinical qualities. Patients consistently poorly rated their surgeons wearing casual attire. Patients did note that the white coat, or any specific attire, was not necessary during the initial encounter to build a strong patient-surgeon relationship. Finally, goatees and beards do not positively or negatively impact a surgeon's patient-constructed image. Conclusions: Combining strong clinical skills with appropriate clinical attire highlighted by the physician wearing a white coat appears to be an effective way to enhance patient satisfaction while ultimately gaining the trust and respect needed to properly care for patients.

THE CHANGING FACE OF NURSING UNIFORMS

Nursing uniforms have transformed dramatically over the past century on the back of emerging trends, demand for practicality and comfort, and strict workplace policy.

To Beard or Not to Beard? Bacterial Shedding Among Surgeons

Beards in the operating room are controversial because of their potential to retain and transmit pathogenic organisms. Many bearded orthopedic surgeons choose to wear nonsterile hoods in addition to surgical masks to decrease contamination of the operative field. The goal of this study was to determine whether nonsterile surgical hoods reduce the risk of bacterial shedding posed by beards. Bearded (n=10) and clean-shaven (n=10) subjects completed 3 sets of standardized facial motions, each lasting 90 seconds and performed over blood agar plates, while unmasked, masked, and masked and hooded. The plates were cultured for 48 hours under aerobic and anaerobic conditions. Colony-forming units (CFUs) were quantified, expanded, and identified. Overall, the addition of surgical hoods did not decrease the total number of anaerobic and aerobic CFUs isolated per subject, with a mean of 1.1 CFUs while hooded compared with 1.4 CFUs with the mask alone (P=.5). Unmasked subjects shed a mean of 6.5 CFUs, which was significantly higher than the number of CFUs shed while masked (P=.02) or hooded (P=.01). The bearded group did not shed more than the clean-shaven group while unmasked (9.5 vs 3.3 CFUs, P=.1), masked (1.6 vs 1.2 CFUs, P=.9), or hooded (0.9 vs 1.3 CFUs, P=.6). Bearded surgeons did not appear to have an increased likelihood of bacterial shedding compared with their nonbearded counter parts while wearing surgical masks, and the addition of nonsterile surgical hoods did not decrease the amount of bacterial shedding observed.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

BACKGROUND

In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or SARS, healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Contact precautions by means of personal protective equipment (PPE) can reduce the risk. It is unclear which type of PPE protects best, what is the best way to remove PPE, and how to make sure HCWs use PPE as instructed.

OBJECTIVES

To evaluate which type or component of full-body PPE and which method of donning or removing (doffing) PPE have the least risk of self-contamination or infection for HCWs, and which training methods most increase compliance with PPE protocols.

SEARCH METHODS

We searched MEDLINE (PubMed up to 8 January 2016), Cochrane Central Register of Trials (CENTRAL up to 20 January 2016), EMBASE (embase.com up to 8 January 2016), CINAHL (EBSCOhost up to 20 January 2016), and OSH-Update up to 8 January 2016. We also screened reference lists of included trials and relevant reviews, and contacted NGOs and manufacturers of PPE.

SELECTION CRITERIA

We included all eligible controlled studies that compared the effect of types or components of PPE in HCWs exposed to highly infectious diseases with serious consequences, such as EVD and SARS, on the risk of infection, contamination, or noncompliance with protocols. This included studies that simulated contamination with fluorescent markers or a non-pathogenic virus.We also included studies that compared the effect of various ways of donning or removing PPE, and the effects of various types of training in PPE use on the same outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data and assessed risk of bias in included trials. We intended to perform meta-analyses but we did not find sufficiently similar studies to combine their results.

MAIN RESULTS

We included nine studies with 1200 participants evaluating ten interventions. Of these, eight trials simulated the exposure with a fluorescent marker or virus or bacteria containing fluids. Five studies evaluated different types of PPE against each other but two did not report sufficient data. Another two studies compared different types of donning and doffing and three studies evaluated the effect of different types of training.None of the included studies reported a standardised classification of the protective properties against viral penetration of the PPE, and only one reported the brand of PPE used. None of the studies were conducted with HCWs exposed to EVD but in one study participants were exposed to SARS. Different types of PPE versus each otherIn simulation studies, contamination rates varied from 25% to 100% of participants for all types of PPE. In one study, PPE made of more breathable material did not lead to a statistically significantly different number of spots with contamination but did have greater user satisfaction (Mean Difference (MD) -0.46 (95% Confidence Interval (CI) -0.84 to -0.08, range 1 to 5, very low quality evidence). In another study, gowns protected better than aprons. In yet another study, the use of a powered air-purifying respirator protected better than a now outdated form of PPE. There were no studies on goggles versus face shields, on long- versus short-sleeved gloves, or on the use of taping PPE parts together. Different methods of donning and doffing procedures versus each otherTwo cross-over simulation studies (one RCT, one CCT) compared different methods for donning and doffing against each other. Double gloving led to less contamination compared to single gloving (Relative Risk (RR) 0.36; 95% CI 0.16 to 0.78, very low quality evidence) in one simulation study, but not to more noncompliance with guidance (RR 1.08; 95% CI 0.70 to 1.67, very low quality evidence). Following CDC recommendations for doffing led to less contamination in another study (very low quality evidence). There were no studies on the use of disinfectants while doffing. Different types of training versus each otherIn one study, the use of additional computer simulation led to less errors in doffing (MD -1.2, 95% CI -1.6 to -0.7) and in another study additional spoken instruction led to less errors (MD -0.9, 95% CI -1.4 to -0.4). One retrospective cohort study assessed the effect of active training - defined as face-to-face instruction - versus passive training - defined as folders or videos - on noncompliance with PPE use and on noncompliance with doffing guidance. Active training did not considerably reduce noncompliance in PPE use (Odds Ratio (OR) 0.63; 95% CI 0.31 to 1.30) but reduced noncompliance with doffing procedures (OR 0.45; 95% CI 0.21 to 0.98, very low quality evidence). There were no studies on how to retain the results of training in the long term or on resource use.The quality of the evidence was very low for all comparisons because of high risk of bias in studies, indirectness of evidence, and small numbers of participants. This means that it is likely that the true effect can be substantially different from the one reported here.

AUTHORS' CONCLUSIONS

We found very low quality evidence that more breathable types of PPE may not lead to more contamination, but may have greater user satisfaction. We also found very low quality evidence that double gloving and CDC doffing guidance appear to decrease the risk of contamination and that more active training in PPE use may reduce PPE and doffing errors more than passive training. However, the data all come from single studies with high risk of bias and we are uncertain about the estimates of effects.We need simulation studies conducted with several dozens of participants, preferably using a non-pathogenic virus, to find out which type and combination of PPE protects best, and what is the best way to remove PPE. We also need randomised controlled studies of the effects of one type of training versus another to find out which training works best in the long term. HCWs exposed to highly infectious diseases should have their use of PPE registered and should be prospectively followed for their risk of infection.

SURGICAL ATTIRE--MATTER OF PREFERENCE OR EVIDENCE?

Surgical attire can be an emotional and controversial topic among health care providers. The reality, however, is that exposing perioperative patients to the skin and hair of the perioperative team members may be putting patients at risk for a surgical site infection.

Surgical attire, practices and their perception in the prevention of surgical site infection

INTRODUCTION

Clean surgical scrubs, surgical gowns and headgear are worn by operative teams to decrease bacterial contamination and lower surgical site infection (SSI) rates.

METHODS

A detailed review was undertaken of peer-reviewed publications and other sources of material in the English language over the last 50 years included.

RESULTS

Surgical scrubs should be clean and made of tightly woven material. Studies investigating single-use gowns and drapes versus reusable gowns report conflicting evidence. Double gloving may reduce SSI rates in procedures where no antibiotic prophylaxis was administered. Bacterial contamination of the operative field has been shown to be decreased by the wearing of surgical headgear by the operating team.

CONCLUSIONS

Further consideration and better trials are required to determine the impact of different theatre clothing on SSI rates.

Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial

IMPORTANCE

Antibiotic-resistant bacteria are associated with increased patient morbidity and mortality. It is unknown whether wearing gloves and gowns for all patient contact in the intensive care unit (ICU) decreases acquisition of antibiotic-resistant bacteria.

OBJECTIVE

To assess whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS

Cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from January 4, 2012, to October 4, 2012.

INTERVENTIONS

In the intervention ICUs, all health care workers were required to wear gloves and gowns for all patient contact and when entering any patient room.

MAIN OUTCOMES AND MEASURES

The primary outcome was acquisition of MRSA or VRE based on surveillance cultures collected on admission and discharge from the ICU. Secondary outcomes included individual VRE acquisition, MRSA acquisition, frequency of health care worker visits, hand hygiene compliance, health care–associated infections, and adverse events.

RESULTS

From the 26,180 patients included, 92,241 swabs were collected for the primary outcome. Intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95% CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95% CI, 14.09 to 20.28) in the study period, whereas control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95% CI, 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95% CI, 13.48 to 19.68) in the study period, a difference in changes that was not statistically significant (difference, −1.71 acquisitions per 1000 person-days, 95% CI, −6.15 to 2.73; P = .57). For key secondary outcomes, there was no difference in VRE acquisition with the intervention (difference,  0.89 acquisitions per 1000 person-days; 95% CI, −4.27 to 6.04, P = .70), whereas for MRSA, there were fewer acquisitions with the intervention (difference, −2.98 acquisitions per 1000 person-days; 95% CI, −5.58 to −0.38; P = .046). Universal glove and gown use also decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference, −0.96; 95% CI, −1.71 to −0.21, P = .02), increased room-exit hand hygiene compliance (78.3% vs 62.9%, difference, 15.4%; 95% CI, 8.99% to 21.8%; P = .02) and had no statistically significant effect on rates of adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference, −15.7; 95% CI, −40.7 to 9.2, P = .24).

CONCLUSIONS AND RELEVANCE

The use of gloves and gowns for all patient contact compared with usual care among patients in medical and surgical ICUs did not result in a difference in the primary outcome of acquisition of MRSA or VRE. Although there was a lower risk of MRSA acquisition alone and no difference in adverse events, these secondary outcomes require replication before reaching definitive conclusions.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT0131821.