THE METROHEALTH SYSTEM POLICIES. POLICY No: II -71(p) Surgical Attire for Operating Rooms and Procedural Areas Originated By: Perioperative Services

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1 Surgical Attire for Operating Rooms and Procedural Areas Originated By: Perioperative Services Converted from Perioperative Service and name changed from Attire for Operating Room Personnel Policy *12/2013 Last Review Date: Last Revised Date: POLICY No: II -71(p) Original Date: 3/2014 Policy Owner(s): Perioperative Services Approval: President and Chief Executive Officer or Designee Policy Committee (Signatures on file) I. POLICY: The MetroHealth System (MHS) promotes adherence by all members of the workforce to industry standards for Surgical Attire within Restricted and Semi- Restricted Areas of all surgical and invasive procedural settings. This includes: Attire worn within Restricted and Semi-Restricted Areas of all surgical and invasive procedural settings Attire worn prior to or after daily duty within Restricted and Semi- Restricted Areas of all surgical and invasive procedural settings Attire worn when leaving those designated areas but remaining within the organization Appropriate personal protective equipment (PPE) to be used within the Restricted and Semi-Restricted Areas of all surgical and invasive procedural settings, are to dress in a manner that reflects our commitment to providing professional service and high quality patient care. Surgical Attire are worn to promote worker safety and a high level of cleanliness II. PURPOSE: To provide guidelines for Surgical Attire including jewelry, clothing, shoes, head coverings, masks, jackets, other accessories, and PPE worn in the Semi- Restricted, Restricted and Non-Restricted Areas within surgical and invasive procedure areas as well as appropriate attire while outside all of these areas. III. IV. SCOPE: The MetroHealth System (MHS) DEFINITIONS: Restricted Area: Includes the Operating Rooms, Ambulatory Surgery Center Operating Rooms, Labor & Delivery Operating Rooms, and Procedure rooms in 1

2 Interventional Radiology, Interventional Cardiology, and Endoscopy; clean core and scrub sink areas. Semi-Restricted Area: Includes the areas immediately outside of the surgical suite, including storage areas for sterile and clean supplies, work areas for storage and processing instruments and corridors leading to the Restricted Areas of the surgical suites. 2 Non-Restricted Area: Includes Holding Areas, Recovery Rooms, and Unit desks, and Nursing Stations Surgical Attire: Includes Hospital laundered scrubs (two-piece pantsuits), cover jackets and other PPE (head coverings, shoes, masks, protective eyewear) V. PROCEDURE: A. Identification: MHS identification badge, with the employees photograph and appropriate title, will be worn by each employee while on hospital premises, displayed in clear sight above the waist with name, title, and picture clearly visible. ID badge should in no way interfere with patient care nor jeopardize aseptic technique. B. Hygiene: 1. Good personal hygiene shall be observed. The body shall be clean/free of body odor and/or strong fragrances. 2. Hand washing or hospital approved waterless hand sanitizer is required between patients or when gloves are removed; hand washing is required when visibly soiled. 3. Fingernails are kept clean, well-cared for, and no longer than ¼ inch from fingertip in length. Artificial and long natural fingernails are not permitted for those providing direct patient care. The definition of artificial fingernails includes, but is not limited to, acrylic nails, all overlays, tips, bondings, extensions, tapes, inlays, and wraps. Nail jewelry is not permitted. Nail polish, if worn, is well maintained. Chipped nail polish is prohibited. C. Personal Protection Equipment (PPE): 1. Hats/head covers: Must be worn in Restricted and Semi-Restricted Areas; may be worn in the Non-Restricted Areas as defined above. Only disposable are permitted; Cloth Hats are prohibited. Must be removed when going to other areas within the hospital outside of the Restricted/Semi-Restricted Areas (e.g. offices, cafeteria, classrooms/conference rooms such as Scott Auditorium, Rammelkamp rooms, etc.)

3 All head and facial hair must be completely covered in Restricted and Semi-Restricted Areas 2. Masks: Must be worn in Restricted Areas and applied to prevent "venting". The mouth and nose should be completely covered at all times. Remove and discard when leaving the Restricted Area (between cases) and when they become moist or soiled. Mask must be changed between cases. 3. Shoe Covers, disposable fluid resistant: Must be worn in Restricted Areas Remove and discard when torn, wet, or soiled; and when leaving the Semi-Restricted Area. 4. Eyewear or face shields: Must be worn in Restricted Areas by all personnel when performing duties that require direct patient contact or contact with contaminated items. Remove and discard when leaving the Restricted Area (between cases) and when they become soiled. Eyewear or face shields must be changed between cases. 5. Gloves: Sterile gloves must be worn when performing sterile procedures. Non-sterile gloves must be worn for non-sterile patient contact. Change gloves between patients or after contact with contaminated items. Appropriate hand hygiene is to be performed before and after donning gloves. D. Clothing and Personal Articles: 1. Personal clothing: Personnel clothing worn to and from work should be clean and in good repair prior to changing into hospital laundered scrubs Hospital laundered scrubs may not be worn to and from the hospital grounds. 2. Jewelry: All scrub personnel entering the Semi-Restricted and Restricted Areas of the surgical suite are required to remove all jewelry below the elbows and confine other types, including dangle earrings or large beaded/dangle necklaces. 3. Cloth Hats are prohibited 4. Scrubs: Home laundering of MHS issued scrub attire is prohibited. All scrubs worn in the Restricted and Semi-Restricted Areas must be the property of MHS and be hospital laundered. Attire from institutions other than MHS is prohibited. 3

4 Scrub clothes must be clean at all times and should be changed when soiled by blood, body fluids, food or following documented isolation cases. 5. Additional tops: A white or black short sleeve t-shirt may be worn by any personnel under scrub tops. Long sleeve tops may not be worn when scrubbed or in areas with newly born infants; but may be worn by non-scrubbed personnel if covered by a clean scrub jacket. 6. Jackets: Only hospital laundered warm up jackets are allowed in the Restricted and Semi-Restricted Areas. A clean white lab coat or personal warm-up jacket other than the one worn in the Restricted and Semi-Restricted Area is required to be worn when leaving the Restricted and Semi- Restricted Areas to protect the scrub clothes from becoming soiled. The cover garment must be removed before reentering a Restricted and Semi-Restricted Area. Fleece apparel is NOT permitted in the Restricted and Semi Restricted Area. 7. Shoes: Shoes worn within the surgical environment should be clean with no visible soiling and should provide protection. Shoes must have closed toes and backs, low heels, no skid soles, no holes or perforations. 8. Fanny packs, backpacks, brief cases, or other personnel belongings: The above is discouraged in Restricted or Semi-Restricted Areas If brought into the Restricted or Semi-Restricted Areas must be placed in a plastic bag. E. Life Banc Personnel /Vendors/Visitors Any non-employees must change into hospital laundered scrubs or disposable jump suits before entering into the Semi-Restricted and/or Restricted Areas of The MetroHealth System. Scrubs are to be removed and returned to laundry hamper before leaving the area within MHS. VI. Reference The Association of Operating Room Nurses (2013). AORN Standards and Recommended Practices for Perioperative Nursing. Denver: AORN, Inc. VI. Cross References MHS Personal Appearance Policy II-10 4

5 MHS Casual Dress Policy II-44 5