Jaime Ortiz, MD


Jaime Ortiz, MD

Associate Professor of Anesthesiology
Deputy Chief of Anesthesiology
Director of Regional Anesthesia
Co-Director Acute Pain Management Service
Ben Taub General Hospital
Baylor College of Medicine
Houston, TX

Can I wear that?:
Guidelines for Surgical Attire in the Operating Room


In 2014, the Association of periOperative Registered Nurses (AORN) published its "Guidelines for Surgical Attire" which recommended the use of bouffant hats instead of skull caps, mandated covering of arms, and prohibited the use of personal clothing underneath scrubs1. Regulatory agencies use these guidelines during their audits of facilities in the United States, causing significant controversy in our operating rooms. A recent study performed at a facility using these guidelines showed that implementation increased healthcare costs and did not decrease the incidence of surgical site infections (SSIs)2. There is no question that, although it is important to look for ways to help decrease hospital-acquired infections throughout our healthcare system, any changes to current practice should be evidence-based and not just based on the opinions of one organization.

Since these guidelines were published, continued efforts by the American Society of Anesthesiologists (ASA), the American College of Surgeons, and others has led to a recent update of the guidelines3. The new guidelines now state that "no recommendation can be made for the type of head covers worn in the semi-restricted and restricted areas"3. This states that either bouffant or skull caps may be worn, as there is no evidence to show any difference in the incidence of SSIs. It is, however, still recommended to cover the scalp, hair, and beards in these restricted areas.

The previous mandate to cover arms has been modified to state that "no recommendation can be made for wearing long sleeves in the semi-restricted and restricted areas other than during performance of preoperative patient skin antisepsis"3. Therefore, only providers involved in prepping patients are required this additional protection layer. One final major change deals with the previous prohibition of personal clothing underneath scrubs. The guidelines now state that "no recommendation can be made regarding personal clothing worn under scrub attire"3.

One important note from these guidelines is that they defer to individual facilities to create their own surgical attire guidelines, especially when no recommendations are given by the AORN. Regulatory agencies may give their own recommendations to individual facilities. In preparation for a recent Centers for Medicare and Medicaid Services regulatory visit, consultants recommended that our hospital update our surgical attire guidelines. Due to this change in guidelines, we can no longer wear operating room jackets unless they are the disposable type. In addition, although cloth and personal head covers may be worn, they are to be covered with disposable covers to avoid soiling of these personal items. Another specific request regarding personal clothing worn under scrubs is that it "not interfere with surgical scrub boundary of 2 inches above the elbow". If you have not recently read the surgical attire guidelines at your facility, I recommend you review them now before an outside agency makes recommendations which will be difficult to change going forward.

The ASA's Committee on Occupational Health passed their "Guidelines for Surgical Attire" as a consensus statement representing our specialty this past August4. It highly recommends the development of local policy based upon scientific evidence led by all healthcare professionals who care for patients in the operating room4. It reiterates the general recommendations for the use of clean scrub attire, head covers, and covering of facial hair, but does not specify which materials to use. This allows for local policy to address specific needs4. The statement also recommends clear processes to be developed for the cleaning of any reusable attire4.

It is important for our specialty to be actively involved in research going forward that will assist hospital and professional organizations in the development of guidelines which affect our daily practice. Many of these policies and guidelines pertaining to the operating room have been historically driven by the AORN, so it is important for physician anesthesiologists to be active participants in this and other regulatory matters going forward. As the saying goes, "if you do not have a seat at the table, you are probably on the menu."



  1. Chi, JS. New Surgical Attire Guidelines Published: Restrictions on head covers, sleeves and clothing relaxed. Anesthesiology News 2019 Sept. Retrieved from https://anesthesiologynews.com/Clinical-Anesthesiology/Article/09-19/New-Surgical-Attire-Guidelines-Published-Restrictions-on-head-covers-sleeves-and-clothing-relaxed/55785

  2. Elmously A, Gray KD, Michelassi F, Afaneh C, Kluger MD, Salemi A, Watkins AC, Pomp A. Operating Room Attire Policy and Healthcare Cost: Favoring Evidence over Action for Prevention of Surgical Site Infections. J Am Coll Surg 2019; 228(1): 98-106.

  3. Association of perioperative Registered Nurses (AORN). Guidelines for perioperative practice: surgical attire. AORN Facility Reference Center. 2019. Retrieved from https://aornguidelines.org/guidelines/content?sectionid=173717946&view=book#221232892

  4. American Society of Anesthesiologists' Committee on Occupational Health. Guidelines for Surgical Attire. August 18, 2019.

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