Work attire and Personal Protective Equipment

Personal protection besides surgical gloves and gowns

What protection options are recommended

"Personal protective equipment (PPE) refers to protective clothing, helmets, gloves, face shields, goggles, face masks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness...

...When used properly, PPE acts as a barrier between infectious materials such as viral and bacterial contaminants and your skin, mouth, nose, or eyes (mucous membranes).”1

Here, the focus will be on area clothing, caps, masks, shoes, etc., with a particular focus on PPE.

Guidelines

Guidelines
GuidelinesRecommendationCategory (if mentioned)
CDC2“Wear a surgical mask that fully covers the mouth and nose when entering the operating room if an operation is about to begin or already under way, or if sterile instruments are exposed. Wear the mask throughout the operation.”

Category IB*

“Wear a cap or hood to fully cover hair on the head and face when entering the operating room.”Category IB*

Do not wear shoe covers for the prevention of SSI.

Category IB*

“Change scrub suits that are visibly soiled, contaminated, and/or penetrated by blood or other potentially infectious materials.”

Category IB*

WHO3“Appropriate personal protective equipment must be provided at each entry point into the sterile services department.”3No explicit recommendation
“A discard bucket for used personal protective equipment must be provided at the exit point, preferably near the wash hand basin.”No explicit recommendation
NICE4“All staff should wear specific non-sterile theatre wear in all areas where operations are undertaken.”-
KRINKO5The Commission recommends that all persons who wish to enter the operating department remove all their outer clothing, including shoes, in the staff changing room and put on low-germ area clothing (e.g. trousers, shirt/gown, surgical shoes) in the clean area after hygienic hand disinfection.Category II
If moisture penetration is to be expected, liquid-tight shoes must be used (under the aspect of personnel protection).Category IV

Before entering the operating room, a mouth-nose mask and hair protection must be worn.

Category IB

Hair protection and mouth-nose mask must completely cover all beard and head hair as well as the mouth and nose, as well as any additional headgear worn for personal reasons.

Category II
The mouth-nose mask must be replaced before every operation and if it is visibly soiled or soaked.

Category II

If the mouth-nose mask has been removed, it must be replaced with a new mouth-nose mask. Hygienic hand disinfection is then carried out.

Category IB

If there is a risk of splashing body or rinsing fluids, it is advisable to wear safety goggles or a face shield to protect personnel and prevent contact with potentially infectious body fluids.

-

Staff should leave the operating department through the staff changing room and remove all their departmental clothing there.

-

HARTMANN:

Denise Leistenschneider, Senior Clinical Consultant
“Self-protection should be at least as important in the operating theatre as the protection of others.”

Remark

However, it is important to understand that in Europe, formal or different legal requirements for hospital hygiene and occupational health and safety are defined in parallel and independently of each other (different perspectives). Here, the individual, prescribed risk assessment by the employer in a dynamic and situational sense plays a special role in occupational health and safety, so that customer needs for additional requirements or certifications may arise, even if there are no general mandatory requirements for certain certifications. Sometimes "quasi" general requirements can also arise regionally from general administrative action in the sense of a "chain reaction".

Recommended instructions

  • All persons who want to enter the operating room should remove their outer clothes and put on low-germ theatre wear.5

  • Before entering the operating room put on a mouse-nose mask that completely covers mouth and nose2,5 and wear it throughout the operation.2

Brief digression on different masks

  • Before entering the operating room put on a cap or hood that completely covers head and face hair.2,5

  • Do not wear shoe covers but if moisture penetration is to be expected, liquid-tight shoes must be used5.


  • If there is a risk of splashing body or rinsing fluids, wear safety goggles or a face shield to prevent contact with potentially infectious body fluids5.

  • Appropriate PPE should be provided at the entrance to the operating room and there should be a discard bucket for used PPE at the exits.3

A further important aspect achieving best surgical outcomes

In addition to the protective function - be it from the perspective of patient or employee protection - the correct wearing, donning and discarding as well as comfort and, in this context, breathability play a decisive role in addition to overall good wearing properties. This is not only crucial for the general wellbeing of the surgeon, particularly during long, strenuous and sweaty procedures, but can also improve the outcome of the operation and actively reduce the risk of infection for patients and staff through improved wellbeing and better concentration.

Risk factors for contamination3

The risk of transferring microorganisms from instruments and equipment is dependent on the following factors:

  • the presence of microorganisms, their number, and their virulence;
  • the type of procedure that is going to be performed (invasive or non-invasive);
  • the body site where the instrument or equipment will be used.

Consideration of PPE

There are 2 basic principles for occupational safety:

  • Risk assessment

  • Definition of protective measures to minimize the risks

As PPE is considered to be the least safe measure, an attempt should always be made beforehand to reduce the risk with other measures so that PPE is not necessary in the first place.

Studies carried out that protective practices are influenced by:6

  • a clear understanding of guidelines

  • support received from managers and supervisors

  • communication about guidelines

  • sufficient resources

  • the perceived value of following guidance

  • the comfort of personal protective equipment

  • availability of resources

For effective protection in clinical areas HCWs need adequate PPE knowledge and skills including:6

  • appropriate selection

  • donning

  • removal

  • decontamination

  • disposal

All content and recommendations listed are to be regarded as extracts from the original literature and do not claim to be exhaustive.
Click to see full list References
  1. U.S. Food & Drug Administration (2020) Personal Protective Equipment for Infection Control. Retrieved from https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/personal-protective-equipment-infection-control.
  2. CDC (1999) Guideline for Prevention of Surgical Site Infection. Infect Control Hosp Epidemiol. 20(4): 247–278.
  3. WHO (2018) Global guidelines for the prevention of surgical site infection. World Health Organization 2018.
  4. NICE (2020) Surgical site infections: prevention and treatment. NICE guidelines. Published: 11 April 2019. Last updated:19 August 2020. www.nice.org.uk/guidance/ng125.
  5. KRINKO (2018) Prävention postoperativer Wundinfektionen. Empfehlungen der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut. Bundesgesundheitsbl 61: 448–473.
  6. George J, et al. (2023) Factors Influencing Compliance With Personal Protective Equipment (PPE) Use Among Healthcare Workers. Cureus 15(2): e35269.

In focus

Skin care

Consistent skin antisepsis of OR Team significantly reduces the risk of infection and is essential during invasive procedures.

Find out more about this aspect of infection prevention…

Double gloving

Is there evidence to formulate a clear recommendation for double gloving?

Answers to this and other questions you can find here…

Hand disinfection or gloves?

What are the standard proceduresfor the two measures and in whichsituations can they contribute toinfection prevention together?

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How we keep Healthcare Professionals safe with PPE

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