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Tuesday, January 10, 2006

The following recommended practices were developed by the AORN Recommended Practices Committee and have been approved by the AORN Board of Directors. They were presented as proposed recommended practices for comments by members and others. They are effective January 1, 2005.

These recommended practices are intended as achievable recommendations representing what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings or clinical situations, which will determine the degree to which the recommended practices can be implemented.

AORN recognizes the numerous types of settings in which perioperative nurses practice. These recommended practices are intended as guidelines adaptable to various practice settings. These practice settings include traditional ORs, ambulatory surgery units, physicians' offices, cardiac catheterization suites, endoscopy suites, radiology departments, and all other areas where operative and other invasive procedures may be performed.

Purpose: These recommended practices provide guidelines for attire worn within the semirestricted and restricted areas of the surgical environment. The human body is a major source of microbial contamination in this environment; therefore, scrub clothing is worn to promote a high-level of cleanliness and hygiene within the surgical environment. These recommended practices are not intended to address sterile attire worn at the surgical field.

RECOMMENDED PRACTICE I

All individuals who enter the semirestricted and restricted areas of the surgical suite should wear freshly laundered surgical attire intended for use only within the surgical suite.

1. Facility approved, clean, and freshly laundered surgical attire should be donned in a designated dressing area of the facility upon entry or re-entry to the facility. (1-3) If scrubs are worn into the institution from outside, they should be changed before entering semirestricted or restricted areas to minimize the potential for contamination (eg, animal hair, cross contamination from other uncontrolled environments). (4)

2. Surgical attire helps contain bacterial shedding and promotes environmental control. (1,5) Surgical attire made of reusable woven fabric or single-use, nonwoven fabric that is low-linting should be worn. Low-linting surgical attire that minimizes bacterial shedding and provides comfort, safety, and a professional appearance should be selected. As personnel move, friction between their bodies and clothing frees bacteria. Research indicates that chafing increases dispersal of body scurf into the environmental. (5) If a two-piece pantsuit is worn, the top of the scrub suit should be secured at the waist, tucked into the pants, or fit close to the body. There is little evidence to support a preference for scrub pants over scrub dresses.

3. Surgical attire should be changed daily or whenever it becomes visibly soiled, contaminated, or wet. (2,4,6) Worn surgical attire should be placed in an appropriately designated container for washing or disposal and should not be hung or placed in a locker for wearing at another time. This promotes high-level cleanliness and hygiene within the practice setting. It has been reported that bacterial colony counts are higher when scrub clothing is removed, stored in a locker, and used again. (7-9)

4. Reusable woven or single-use, nonwoven attire should be appropriately placed in designated containers after use. (1,4,5)

5. Visibly soiled, contaminated, or wet surgical attire should be removed as soon as possible and replaced with fresh, clean surgical attire. Changing contaminated, soiled, or wet attire reduces the potential for cross-infection and protects personnel from prolonged exposure to potentially harmful bacteria. (4,5)

6. Surgical attire contaminated with visible blood or body fluids must remain at the facility and be laundered by the hospital or a hospital-contracted commercial laundry. (4,5,6,10) Controlled laundering of attire contaminated by blood or body fluids reduces the risk of transferring pathogenic microorganisms from the facility to the home or the general public.

7. Home laundering of surgical attire is not recommended. (4,6,10-15) Without clear evidence about the safety for patients, health care workers, and their family members, AORN does not support the practice of home laundering of surgical attire. Reusable surgical attire, including cover jackets and cloth hats, should be laundered by a designated facility-approved and monitored commercial laundry after daily use.

Commercial laundries are required to follow strict guidelines (4,8,16-19) that incorporate

* proper and controlled water temperatures;

* use of detergents;

* use of oxidizing agents (eg, chlorine bleach) in specified and monitored concentrations;

* repeated changes of water; and

* dryer or iron and press drying temperatures that typically are not found in home laundry equipment.

Home laundering of surgical attire that is not visibly soiled is controversial, and there is no concrete evidence to either support or refute the practice. Surgical attire becomes soiled or contaminated with microorganisms during wear. Taking worn, soiled, or contaminated surgical attire into the home can result in the spread of contamination to the home environment.

AORN is aware that some provider facilities require personnel to launder scrub attire at home. Although AORN does not support this practice, steps should be taken to minimize contaminants to the home environment; therefore, laundering practices similar to regulations and professional standards for commercial laundries are recommended. When a facility requires home laundering of surgical attire, minimum criteria should be met. (4,8,16-18)

Suggested criteria for home laundering soiled surgical attire should include

* using an automatic washer and hot air dryer;

* using water temperature of 110[degrees]F to 125[degrees] F (43.33[degrees]C to 51.67[degrees]C) to facilitate microbial kill;

* using chlorine bleach (ie, sodium hypochlorite);

* using detergent according to manufacturer's instructions;

* laundering surgical attire in a separate load with no other items;

* laundering surgical attire as the last load after all other items have been laundered;

* washing hands immediately after placing laundry in the washing machine;

* keeping laundry items completely submerged during the entire wash and rinse cycle to facilitate removal of soil and microorganisms;

* avoiding placing hands or arms in the laundry or rinse water to keep items submerged;

* thoroughly cleaning the door and lid of the washing machine before removing the laundered attire to prevent reintroduction of contaminants on clean attire when removing it from the washing machine and before placing it in the dryer;

* using the highest drying setting possible that is safe for the material of attire construction; and

* promptly removing attire when dry to avoid desiccation of materials.

8. Laundered surgical attire should be protected from contamination during transfer and storage. (1,20) Freshly laundered surgical attire should be protected during transport to the practice setting.

9. The use of cover apparel should be determined by the individual practice setting. The value of cover apparel within the institution is unsubstantiated. (1,21-23) The use of cover apparel has been found to have little or no effect on reducing contamination, but it is used for practical enforcement and cost considerations. Donning fresh scrubs after each trip to other areas increases costs and is time-consuming. Laboratory coats or the use of cover gowns may provide a professional appearance, but they should be removed before entering a semirestricted or restricted area because they can be a source of contamination. (24) The decision on cover gowns depends on individual state regulatory rulings, the culture in each perioperative suite, and the manager's assessment of priorities.

(10.) Nonscrubbed personnel should wear long-sleeved jackets that are buttoned or snapped closed during use. Complete closure of the jacket avoids accidental contamination of the sterile field. Long-sleeved attire is advocated to prevent bacterial shedding from bare arms and is included in the Occupational Safety and Health Administration (OSHA) regulation for the use of personal protective equipment (PPE). (1,2)

(11.) Other garments should be contained completely within or covered by the surgical attire. Clothing that cannot be covered by the surgical attire should not be worn.

RECOMMENDED PRACTICE II

Personnel should cover head and facial hair, including sideburns and necklines, when in the semirestricted and restricted areas of the surgical suite.

1. A clean, low-lint surgical head cover or hood that confines all hair should be worn. Hair covers eliminate the possibility of hair or dandruff being shed onto surgical attire. (1,2,4,25) A bald or shaved head is covered to prevent shedding of squamous cells (ie, scurf).

2. The head cover or hood should be designed to minimize microbial dispersal. Hair acts as a filter when left uncovered and collects bacteria in proportion to its length, curliness, and oiliness. (1,25) Shedding from hair has been shown to affect surgical wound infection; therefore, complete coverage is necessary. Disposable bouffant and hood-style covers are preferred. (4) Skullcaps that fail to cover the side hair above the ears and hair at the nape of the neck should not be worn in the surgical suite. Net caps should not be used because they do not provide a barrier to dandruff and hair fallout.

3. Single-use headgear should be removed and discarded in a designated receptacle as soon as possible after daily use. Reusable hats or hoods should be laundered in a commercial laundry after each use. (2,4,16)

4. Contaminated headgear must be removed and laundered by the facility. (10)

RECOMMENDED PRACTICE III

All individuals entering restricted areas of the OR suite should wear a mask when open sterile items and equipment are present.

1. A single surgical mask should be worn in surgical environments where open sterile supplies or scrubbed persons are located. A mask should fully cover both mouth and nose and be secured in a manner that prevents venting. (1,2,26) Masks are intended to contain and filter droplets of microorganisms expelled from the mouth and nasopharynx during talking, sneezing, and coughing. (27,28) Use of a double mask creates an impediment to breathing and does not increase filtration; therefore, this is unacceptable. (25,26) Differences of opinion about whether masks should be worn exist in the literature. AORN recommends further research to determine changes in current practice. (29-31) In addition to possible surgical site contamination, blood exposure occurring on the face and neck of OR personnel is not uncommon; therefore, individual practice settings should develop policies based on OSHA and state-mandated recommendations for wearing masks. (32)

2. Masks should be removed carefully by handling only the ties, and they should be discarded immediately. Masks should not be saved by hanging them around the neck or tucking them into a pocket for future use. The filter portion of a surgical mask harbors bacteria collected from the nasopharyngeal airway. Handling this portion of the mask after use can transfer bacteria to the hands and initiate potential cross contamination. (1,2,33)

RECOMMENDED PRACTICE IV

All personnel entering the semirestricted and restricted areas of the surgical suite should confine or remove all jewelry and watches.(2,34-37)

1. Rings should be removed from hands. These items may harbor organisms that cannot be removed during hand washing. Higher bacterial counts have been noted when jewelry is worn.

2. Other jewelry (eg, watches, earrings, bracelets, necklaces, piercings) should be removed or totally confined within the scrub attire. Although there is no evidence to demonstrate that other jewelry increases bacterial shedding, there is concern that jewelry could fall onto the sterile field or into the wound if not contained. Necklaces could contaminate the front of the sterile gown if not confined. (1)

RECOMMENDED PRACTICE V

Fingernails should be kept short, clean, natural, and healthy. (2,35,38)

1. The subungual region harbors the majority of microorganisms found on the hand. Removing debris from fingernails requires the use of a nail cleaner under running water; additional effort is necessary for longer nails. The risk of tearing gloves increases if fingernails extend past the fingertips. Long fingernails may cause injury when moving or positioning patients. (38)

Recent studies found no increase in microbial growth related to wearing freshly applied nail polish; (35,37) however, nail polish that is obviously chipped or worn longer than four days is associated with the presence of greater numbers of bacteria and has been associated with infections. Surgical conscience, therefore, must be a foremost behavior in individuals who choose to wear nail polish in the surgical setting.

2. Artificial nails should not be worn. (2,32,38-51) Studies show that artificial (eg, acrylic) nails on healthy hands increase the risk of surgical site infection. Artificial nails harbor organisms and prevent effective hand antisepsis. Higher counts of gram-negative microorganisms have been cultured from the fingertips of personnel wearing artificial nails than from personnel with natural nails, both before and after hand washing. Fungal growth occurs frequently under artificial nails as a result of moisture becoming trapped between the natural and artificial nail. (47-49)

RECOMMENDED PRACTICE VI

Protective barriers must be made available to reduce the risk of exposure to potentially infectious materials. (34,52,53)

1. Gloves should be selected and worn as follows according to the task to be performed. (1)

* Sterile gloves must be worn when performing sterile procedures.

* Medical, nonsterile gloves are recommended for nonsterile activities.

2. Gloves should be changed between patient contacts or after contact with contaminated items when a task is complete. Surgical or examination gloves should be changed-not washed--between patient contacts. Hand hygiene should be performed after gloves are removed. (52-54) Gloves are worn to reduce gross contamination of the hands. Changing gloves between patient contacts and after completing a task reduces the risk of microorganism transmission. Disinfecting agents may cause glove deterioration. Research indicates that microorganisms are not always removed from gloves despite friction, use of cleansing agents, and drying. In addition, washing the glove may decrease the integrity of the glove. (50)

3. Protective eyewear, masks, or face shields must be worn when splashing or spraying is likely). (1,2,4,6,53,54) Masks should be worn, along with protective eyewear (eg, goggles, glasses with solid side shields, chin-length face shields) whenever eye, nose, or mouth contamination reasonably can be anticipated as a result of splashes, spray, or splatter of blood droplets or other potentially infectious materials. (53,54) Personal protective equipment is considered appropriate only if it prevents blood or other potentially infectious materials from contaminating an employee's work clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time for which the protective equipment will be used. (52)

4. Protective eyewear or face shields that become contaminated should be discarded or decontaminated promptly according to manufacturers' written instructions. (1,4,6,53) Failure to decontaminate or dispose of these items could result in contamination to the wearer.

5. Additional protective attire (eg, liquid-resistant aprons, gowns, shoe covers) should be worn when exposure to blood or potentially infectious materials is anticipated. (6) Protective barriers are worn to reduce the risk of exposure to blood, body fluids, or other liquids that may contain potentially infectious agents. There is evidence that supports the need for circulating personnel to wear PPE appropriate to the task being performed. (53,55,56)

6. Fluid-resistant shoe covers are considered part of PPE and must be worn when it can be reasonably anticipated that splashes or spills may occur. Foot attire has no proven significance in reducing the incidence of surgical site wound infections; the primary reason for its use is to facilitate sanitation. (1,57) If shoe covers are worn, they should be changed whenever they become torn, wet, or soiled, and they should be removed and discarded in a designated container before leaving the surgical area. (1,4)

7. Shoes worn within the surgical environment should be clean with no visible soiling and should provide protection. (1) Cloth or open-toe shoes do not offer protection against spilled liquids or sharp items that may be dropped or kicked. Shoes should have closed toes and low heels to minimize the risk of injury. (57,58)

RECOMMENDED PRACTICE VII

Policies and procedures for surgical attire should be developed, reviewed periodically, and readily available in the practice setting. These policies and procedures should include, but not be limited to, definition of areas where surgical attire must be worn, appropriate attire within those defined areas, and the choice for the use of cover apparel outside the surgical suite.

1. These recommended practices should be used as guidelines for the development of policies and procedures within the practice setting. Policies and procedures establish authority, responsibility, and accountability and serve as operational guidelines. AORN's "Recommended practices for traffic patterns in the perioperative practice setting" (59) and "Recommended practices for surgical hand antisepsis and hygiene" (54) also should be consulted when developing policies and procedures. An introduction and review of policies and procedures should be included in the orientation and ongoing education of personnel to assist in the development of knowledge, skills, and attitudes that affect patient outcomes. Policies and procedures also assist in the development of quality assessment and improvement activities.

GLOSSARY

ARTIFICIAL NAILS: Substances or devices applied or added to the natural nails to augment or enhance the wearer's own nails. They include, but are not limited to, bonding, tips, wrappings, and tapes.

CLEANING: The physical removal of soil or organic material using water or mechanical action with or without detergent; cleaning removes rather than kills microorganisms.

CONTAMINATED: The presence of pathogenic organisms (eg, blood, other potentially infectious material) on or in the material.

COVER GOWN: A garment, such as a laboratory coat, gown, or jacket, worn over surgical attire to prevent contamination.

PERSONAL PROTECTIVE EQUIPMENT: Personal protective equipment for standard precautions includes intact gloves, gowns, masks, and eye protection (eg, face shields, goggles, glasses with side shields).

SCRUB ATTIRE: Additional sterile clothing worn to cover the surgical attire to present sterile boundaries during a sterile invasive procedure.

SCURF: A branlike desquamation of the epidermis.

SURGICAL ATTIRE: Nonsterile apparel designated for the OR practice setting that includes two-piece pantsuits, cover jackets, head coverings, shoes, masks, protective eyewear, and other protective barriers.

SOILED: Worn or dirty, especially on the surface. Smirched or stained by body perspiration, body oils, or other substances.

RESTRICTED AREA: Includes the OR and procedure room, the clean core, and scrub sink areas. People in this area are required to wear full surgical attire and cover all head and facial hair, including sideburns, beards, and necklines.

SEMIRESTRICTED AREA: Includes the peripheral support areas of the surgical suite and has storage areas for sterile and clean supplies, work areas for storage and processing of instruments, and corridors leading to the restricted areas of the surgical suite.

UNRESTRICTED AREA: Includes a central point that is established to monitor the entrance of patients, personnel, and materials. Street clothes are permitted in this area, and traffic is not limited.

NOTES

(1.) D Fogg, "Infection prevention and control" in Alexander's Care of the Patient in Surgery, 12th ed, J C Rothrock, ed (St Louis: Mosby, 2003) 134-147.

(2.) Centers for Disease Control and Prevention, "Guideline for Prevention of Surgical Site Infection, 1999," Infection Control and Hospital Epidemiology 20 (April 1999) 250-278.

(3.) N L Belkin, "Use of scrubs and related apparel in health care facilities," American Journal of Infection Control 25 (October 1997) 401-404.

(4.) "Safe handling and biological decontamination of reusable medical devices in health care facilities and in nonclinical settings," ANSI/AAMI ST35:2003 (Arlington, Va: Association for the Advancement of Medical Instrumentation, 2003) 11-12; 51-57.

(5.) B M Anderson, N Solheim, "Occlusive scrub suits in operating theaters during cataract surgery: Effect on airborne contamination," Infection Control Hospital Epidemiology 23 (April 2002) 218-220.

(6.) "Regulations (Standards 29 CFR) Bloodborne pathogens--1910-1030," US Department of Labor, Occupational Safety and Health Administration, http://www.osha-slc.gov/pls/oshaweb/owadisp.show_document? p_table=STANDARDS&p_id=10051 (accessed 22 May 2004) 15-16.

(7.) "Report to Congress on workers' home contamination study conducted under the Workers' Family Protection Act (29 USC 671A)" Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, http://www.cdc.gov/niosh/contamin.html (accessed 8 April 2002) 6.

(8.) A N Neely, M P Maley, "Survival of enterococci and staphylococci on hospital fabrics and plastic," Journal of Clinical Microbiology 38 (February 2002) 724-726.

(9.) I Callaghan, "Bacterial contamination of nurse's uniforms: A study," Nursing Standard 13 (Sept 23-29, 1998) 37-42.

(10.) Centers for Disease Control and Prevention, "Guidelines for environmental infection control in health-care facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)," Morbidity and Mortality Weekly Report 52 (June 6, 2003) 27-28.

(11.) N Hawkes, "Infection Fear Over Nurses Who Wash Uniforms at Home," The Times, 30 June 2003, sec 2W.

(12.) Market and Opinion Research International, "Nurses' uniforms survey for JLA" (June 2003) 1-7.

(13.) N L Belkin, "Home laundering of soiled surgical scrubs: Surgical site infections and the home environment," American Journal of Infection Control 29 (February 2001) 58-64.

(14.) P Jurkovich, "Home versus hospital-laundered scrubs," The American Journal of Maternal/Child Nursing 29 (March/April 2004) 106-110.

(15.) L Spannraft, "Laundering scrubs at home," (Readers' Responses) The American Journal of Maternal/Child Nursing 23 (January/February 1998) 53.

(16.) D Barrie, "How hospital linen and laundry services are provided," Journal of Hospital Infection 27 (March 1994) 219-235.

(17.) D Fogg, "Body piercings in the OR; tabletop sterilizers; Joint Commission initiative; West Nile virus; home laundering" (Clinical Issues) AORN Journal 77 (February, 2003) 428-433.

(18.) J M Jaska, D L Fredell, "Impact of detergent systems on bacterial survival on laundered fabrics," Applied and Environmental Microbiology 39 (April, 1980) 743-748.

(19.) N L Belkin, "Surgical scrubs--Where we were, where we are going," Today's Surgical Nurse 20 (March/April 1998) 28-34.

(20.) L L McDonald, "Linen services," in APIC Text of Infection Control and Epidemiology (Washington, DC: Association for Professionals in Infection Control and Epidemiology, Inc, 2002) 75(1)-75(4).

(21.) H Kenny, E Lawson "The efficacy of cotton cover gowns in reducing infection in neutropenic patients: An evidence-based study," International Journal of Nursing Practice 6 (June 2000) 135-139.

(22.) J L Thigpen, "Responding to research: Realistic use of scrub clothes and cover gowns," Neonatal Network 9 (February 1991) 41-44.

(23.) Mailhot et al, "Cover gowns: Researching their effectiveness," AORN Journal 46 (September 1987) 482-490.

(24.) W Loh, VV Ng, J Holton, "Bacterial flora on the white coats of medical students," Journal of Hospital Infection 45 (January 2000) 65-68.

(25.) B Friberg et al, "Surgical area contamination-Comparable bacterial counts using disposable head and mask and helmet aspirator system, but dramatic increase upon omission of head-gear: An experimental study in horizontal laminar air-flow," Journal of Hospital Infection 47 (February 2001) 110-115.

(26.) N J Mitchell, S Hunt, "Surgical face masks in modern operating rooms--A costly and unnecessary ritual?" Journal of Hospital Infection 18 (July 1991) 239-242.

(27.) M G Romney, "Surgical face masks in the operating theatre: Re-examining the evidence," Journal of Hospital Infection 47 (April 2001) 251-256.

(28.) F McCluskey, "Does wearing a face mask reduce bacterial wound infection? A literature review," British Journal of Theatre Nursing 6 (August, 1996) 18-29.

(29.) N L Belkin "Surgical face masks in the operating theatre: Are they still necessary?" (Letters to the Editor) Journal of Hospital Infection 50 (March 2002) 233-235.

(30.) T G Tunevall, "Postoperative wound infections and surgical face masks: A controlled study," World Journal of Surgery 15 (May/June 1991) 383-387.

(31.) G A J Ayliffe, "Masks in surgery?" (Editorial) The Journal of Hospital Infection 18 (July 1991) 165-166.

(32.) Y Uehara et al, "Bacterial interference among nasal inhabitants: Eradication of Staphylococcus aureus from nasal cavities by artificial implantation of Corynebacterium sp." Journal of Hospital Infection 44 (February 2000) 127-133.

(33.) L Emsley, "Why wear surgical face masks?" Nursing Times 96 (July 2000) 38-39.

(34.) Centers for Disease Control and Prevention, "Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force," Morbidity and Mortality Weekly Report 51, RR-16 (Oct 25, 2002) 29-33.

(35.) V A Arrowsmith et al, "Removal of nail polish and finger rings to prevent surgical infection," The Cochrane Database of Systematic Reviews 2 (2004) 1-16.

(36.) W E Trick et al, "Impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital," Clinical Infectious Disease 36 (June 2003) 1383-1390.

(37.) E Edel et al, "Impact of a 5-minute scrub on the microbial flora found on artificial, polished, or natural fingernails of operating room personnel," Nursing Research 47 (January/February 1998) 54-59.

(38.) R L Moolenaar et al, "A prolonged outbreak of Pseudomonas Aeruginosa in a neonatal intensive care unit: Did staff fingernails play a role in disease transmission?" Infection Control and Hospital Epidemiolosngy 21 (February 2000) 80-85.

(39.) C A Wynd, D E Samstag, A M Lapp, "Bacterial carriage on the fingernails of OR nurses," AORN Journal 60 (November 1994) 796-805.

(40.) R Baran, "Pathogen carriage in health care workers wearing nail cosmetics," Dermatology Online Journal 9, no 1 (2003) 17D.

(41.) C A Baumgardner et al, "Effects of nail polish on microbial growth of fingernails: Dispelling sacred cows," AORN Journal 58 (July 1993) 84-88.

(42.) A Jeanes, J Green, "Nail art: A review of current infection control issues," Journal of Hospital Infection 49 (October 2001) 139-142.

(43.) J Porteous, "Artificial nails: Very real risks," Canadian Operating Room Nursing Journal 20 (September 2002) 16-21.

(44.) L Saiman et al, "Banning artificial nails from health care settings," American Journal of Infection Control 30 (June 2002) 252-254.

(45.) M F Parry et al, "Candida osteomylitis and diskitis after spinal surgery: An outbreak that implicates artificial nail use," Clinical Infectious Diseases 32 (February 2001) 352-356.

(46.) S A Hedderwick et al, "Pathogenic organisms associated with artificial fingernails worn by healthcare workers," Infection Control and Hospital Epidemiology 21 (August 2000) 505-509.

(47.) D J Passaro et al, "Postoperative Serratia marcescens wound infections traced to an out-of-hospital source," Journal of Infectious Diseases 174 (April 1997) 992-995.

(48.) E H Winslow, A F Jacobson, "Can a fashion statement harm the patient?" American Journal of Nursing 100 (September 2000) 63-65.

(49.) J Pottinger, S Burns, C Manske, "Bacterial carriage by artificial versus natural nails," American Journal of Infection Control 17 (December 1989) 340-344.

(50.) "Make a 'revolutionary' change in hand hygiene," Hospital Employee Health 21 (February 2002) 13-24.

(51.) "CDC draft guidelines say no artificial nails," Same-Day Surgery 25 (August, 2001) 91.

(52.) B N Doebbeling et al, "Removal of nosocomial pathogens from the contaminated glove," Annals of Internal Medicine 109 (September 1988) 394-398.

(53.) B Goodner, The OSHA Handbook: Interpretive Guidelines for the Bloodborne Pathogen Standard (El Paso, Tex: Skidmore-Roth Publishing, Inc, 1993) 61-62.

(54.) "Recommended practices for surgical hand antisepsis/hand scrubs, "Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2004) 291-299.

(55.) "Occupational exposure to bloodborne pathogens; Final rule," Federal Register 56 (Dec 6, 1991) 64177.

(56.) S Hubbard et al, "Reducing blood contamination and injury in the OR: A study of the effectiveness of protective garments and OR procedures," AORN Journal 55 (January 1992) 194-201.

(57.) M O'Neale, "Used sponge exposure; processing peel packages; flash sterilization; protective arm attire; beverages in the OR" (Clinical Issues) AORN Journal 59 (February 1994) 504-506.

(58.) G Copp et al, "Footwear practices and operating room contamination," Nursing Research 36 (November/December 1987) 366-369

(59.) "Recommended practices for traffic patterns in the perioperative practice setting," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2004) 397-399.

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