Policies,Clinical,UWHC Clinical,Department Specific,Surgical Services,Administrative

Dress Code in the Department of Surgical Services (1.06)

Dress Code in the Department of Surgical Services (1.06) - Policies, Clinical, UWHC Clinical, Department Specific, Surgical Services, Administrative





JUNE 2017
OF 4

 OTHER: Surgical Services


A. To create a safe environment.
B. To protect workers, their families, and the community from exposure to bloodborne and other
C. To promote professionalism within the surgical suite.
D. This policy specifically applies to attire worn in the Operating Room (O.R.) suites and is not
intended to apply to persons working in other areas within UW Health.


A. A surgical suite is divided into three designated areas that are defined by the physical activities
performed in the area.
1. Restricted: Personnel in this area are required to wear full surgical attire with the hair
covered. Masks are required where open sterile supplies or scrubbed personnel are located.
This includes the O.R. suites.
2. Semi-Restricted: Personnel are required to wear surgical attire with the hair covered. This
area includes peripheral support areas of the surgical suite such as the sterile supply core,
O.R. corridors, supply rooms, etc.
3. Unrestricted: Street clothes are permitted in this area. These areas include PACUs,
Preoperative and Postoperative areas, O.R. front desks and the hallways outside them,
locker rooms, and staff offices.
4. Surgical Attire: includes hospital supplied scrub clothing (cloth or disposable), shoes and
hair coverings, masks, protective eyewear, and other hospital issued protective garments
(e.g., surgical gowns) that help provide a barrier to contamination that may pass from
personnel to patient as well as from patient to personnel. This does not include non-hospital
issued warm up jackets.

A. In addition to requirements outlined in Policy 9.16 - "UW Health Dress Code and Appearance
Policy", the following requirements apply to all Surgical Services employees of UW Health.
B. Scrub attire:
1. All persons entering semi-restricted and restricted areas must be dressed in clean UW Health
issued surgical attire. Cloth or disposable surgical attire may be worn. Attire from any
source other than UW Health is prohibited. Scrubs should be close-fitting and scrub tops and
tie strings should be tucked into scrub pants. A short sleeve t-shirt that does not extend
beyond the sleeves of the scrub top may be worn by personnel under scrub tops. Long sleeve
tops may not be worn.
2. Hospital supplied scrub attire worn by individuals who meet the criteria of UW Health Policy
2.3.12 “Scrub Attire” must be clean at all times. Scrub attire is to be changed at least daily or
when soiled by blood, body fluids, excessive prep solution, or food. Home laundering of


scrub attire is not allowed. All scrubs worn in the OR must be laundered by the hospital
contracted laundry.
3. Hospital supplied scrub attire will be dispensed by the hospital and returned prior to
leaving the hospital per UW Health Policy 2.3.12 “Scrub Attire”.
4. In the semi-restricted and restricted areas only hospital supplied scrub attire may be worn.
5. Scrub attire should not be worn arriving or departing from the hospital buildings.
C. Parents/significant others accompanying children into the O.R. will don a hat and a gown to
cover their street clothes (refer to Policy 1.15 - "Parents/Support Person Present with Child at
Induction of Anesthesia").
D. Security officers or guards accompanying prisoners to the O.R. will wear disposable scrub
attire, cover jacket to cover existing clothing, hat and mask. This preparation should be done
before the O.R. nurse comes to get the patient for surgery (refer to policies 1.36 - "Prisoners,
Care of in the Outpatient Surgery Center" and 1.40 - "Prisoners, Care of in the Inpatient
E. Masks will be worn at all times in the O.R. when open sterile supplies are present and/or the
sterile fields are established. For TB masks information refer to the UW Health Respiratory
Protection for Health Care Workers and Patients.
1. Masks must be applied to prevent "venting". The mouth and nose should be completely
2. Masks are changed between cases and when conditions indicate (e.g. soiled or moist).
3. Masks are to be either off or on; they are not to be left dangling around the neck or saved for
future wear.
4. Remove masks upon leaving the O.R., avoiding contact with the filter area, handling the ties
and discard immediately. When staff move directly from one O.R. room or procedure suite
to another within the O.R. suite a mask may be kept on, but must be left in place.
5. Masks are not required in the supply core, but are recommended when in close proximity to
scrubbed persons who are in the core during x-rays.
6. Procedures deemed clean (non-sterile procedures) by the surgeon do not require a mask to
be worn.
7. Masks and eye protection should be worn to prevent mucous membrane contamination on
non-sterile procedures (i.e. dental procedures).
8. Masks will be worn by the Block Team during regional catheter placement.
F. Hats: Surgical hats will be worn in all restricted and semi-restricted areas of the O.R. suite at all
times. All head and facial hair must be completely covered, but small amounts of hair at the
eyebrows, sideburns, and nape of the neck may be exposed. Cloth hats must be laundered after
each day’s use in the hospital laundry system or disposable head covers will be worn.


G. Protective eyewear will be worn in the O.R. by all O.R. staff involved in direct patient care
when a reasonable risk of eye splash exists (refer to the UW Health Bloodborne Pathogens
Exposure Control Plan).
H. Gloves will be worn for touching blood and body fluids, mucous membranes, or non-intact
skin of all patients, for handling items or surfaces soiled with blood or body fluids, and for
performing venipuncture and other vascular access procedures (refer to the UW Health
Bloodborne Pathogens Exposure Control Plan).
I. Shoes and Shoe Covers: Shoes worn within the surgical environment should be clean with no
visible soiling and should provide protection. Open-toe shoes are not allowed. Shoes worn in
the O.R. should be kept for that purpose and not worn outside of the hospital buildings. If street
shoes must be worn in the O.R. they must be covered by fresh shoe covers. Vented shoes should
be covered by fluid-resistant shoe covers when it is anticipated that splashes or spills may occur.
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.
J. Name badges will be worn by all O.R. team members (refer to Policy 9.16 - "UW Health
Dress Code and Appearance Policy"). Tapes, stickers, pins are not allowed on badges as is
anything that would impact the ability to interact with the card reader.
K. Briefcases and backpacks are not permitted in restricted and semi-restricted areas. Any items
needed for patient care such as cameras or computers or stethoscopes should be removed from
the bag prior to the procedure and cleaned appropriately considering the manufacturer’s
recommendations and guidelines, if pertinent.
L. Jewelry: All jewelry should be kept to a minimum. Jewelry must be removed or confined,
including earrings and necklaces. Watches and simple rings may be worn in the O.R., except
when scrubbing.
M. Sterile gowns and gloves, which are worn during a case, will not be worn outside the O.R.
except in the case of intraop-radiologic exams, and must be discarded in the trash or linen
N. Nails: Refer to UWHC Administrative Policy 13.08 Hand Hygiene.


A. American College of Surgeons Statement on Operating Room Attire August 4, 2016:
B. AORN Guideline for Clinical, 2017 Edition
C. Surgical Services Policy 1.15 Parents/Support Person Present with Child at Induction of
Anesthesia: https://uconnect.wisc.edu/policies/clinical/uwhc-clinical/department-
D. UW Health Policy 1.36 Prisoners, Care of in the Outpatient Surgery Center:
E. UW Health Policy 1.40 Prisoners, Care of in the Inpatient OR:
F. UW Health Policy 9.16 - "UW Health Dress Code and Appearance Policy":
G. Scrub Attire - Policy Number: 2.3.12 - Previous Policy Number: 9.29
H. UW Health Policy Hand Hygiene - Policy Number: 13.08
I. Haskins IN, Prabhu AS, Krpata DM, Perez AJ, Tastaldi L, Tu C, Rosenblatt S, Poulose BK,


Rosen MJ, Is there an association between surgeon hat type and 30-day wound events following
ventral hernia repair?, Hernia. 2017 Jun 19.
J. Hussain, S., Shakir, H., Aldridge, A., Donovan, M., Levy, E., Gibbons, K., Mandatory Change
From Skull Caps to Bouffant Caps Among Operating Room Personnel Does Not Reduce
Surgical Site Infections in Class I Surgical Cases: A Single-Center Experience With More Than
15,000 Patients. Neurosurgery, 2017 May.


A. UW Health Respiratory Protection for Health Care Workers and Patients
B. UW Health Bloodborne Pathogens Exposure Control Plan

Surgical Services Policy and Procedure Committee
Inpatient OR RN Council
Inpatient OR ST Council

Christopher R. Turner, MD PhD, MBA, Director of Perioperative Services
Anne Mork, MHCDS, MS, RN, Director of Surgical Services University Hospital
Charles Heise, MD FACS, FASCRS, Director of Surgical Operations
Catherine Madsen, MSN, RN, CNOR, RNFA Director of Surgical Services – American Family
Children’s Hospital
Petros V. Anagnostopoulos, MD, MBA, Surgeon in Chief – American Family Children’s Hospital
Deborah Rusy, MD, MBA, Director of Perioperative Services – American Family Children’s Hospital
Michael Ford, MD, Chief of Anesthesiology - The American Center
Michael Garren, MD FACS, Clinical Director – The American Center
Bridget Shaffer, MBA, MSHA, BSN, RN, CNOR, Director of Surgical Services – The American