CONTINUING EDUCATION
Clinical Issues 1.7
SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA(E), CPSN-R, PLNC;
SCOTT A. BRUBAKER, CTBS
Continuing Education Contact Hours
indicates that continuing education (CE) contact hours are
available for this activity. Earn the CE contact hours by
reading this article, reviewing the purpose/goal and objectives,
and completing the online Learner Evaluation at http://
www.aorn.org/CE. Each applicant who successfully completes
this program can immediately print a certificate of completion.
Event: #15532
Session: #0001
Fee: Members $13.60, Nonmembers $27.20
The contact hours for this article expire September 30, 2018.
Pricing is subject to change.
Purpose/Goal
To provide the learner with knowledge of AORN’s guidelines
related to surgical wound classification; storing and using
small, prefilled containers of formalin in the OR; latex-free
environments for tissue recovery and organ procurement
procedures; covering facial hair in semirestricted and restricted
areas; and covering ears in semirestricted and restricted areas.
Objectives
1. Discuss practices that could jeopardize safety in the peri-
operative area.
2. Discuss common areas of concern that relate to perioper-
ative best practices.
3. Describe implementation of evidence-based practice in
relation to perioperative nursing care.
Accreditation
AORN is accredited as a provider of continuing nursing ed-
ucation by the American Nurses Credentialing Center’s
Commission on Accreditation.
http://dx.doi.org/10.1016/j.aorn.2015.06.002
ª AORN, Inc, 2015
www.aornjournal.org
www.aorn.org/CE
Approvals
This program meets criteria for CNOR and CRNFA recerti-
fication, as well as other CE requirements.
AORN is provider-approved by the California Board of
Registered Nursing, Provider Number CEP 13019. Check
with your state board of nursing for acceptance of this activity
for relicensure.
Conflict-of-Interest Disclosures
Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA(E),
CPSN-R, PLNC, and Scott A. Brubaker, CTBS, have no
declared affiliations that could be perceived as posing a po-
tential conflict of interest in the publication of this article.
The behavioral objectives for this program were created by
Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor,
with consultation from Susan Bakewell, MS, RN-BC, direc-
tor, Perioperative Education. Ms Starbuck Pashley and Ms
Bakewell have no declared affiliations that could be perceived
as posing potential conflicts of interest in the publication of
this article.
Sponsorship or Commercial Support
No sponsorship or commercial support was received for this
article.
Disclaimer
AORN recognizes these activities as CE for RNs. This
recognition does not imply that AORN or the American
Nurses Credentialing Center approves or endorses products
mentioned in the activity.
AORN Journal j 299
 CLINICAL
ISSUES

1.7 www.aorn.org/CE

THIS MONTH
Surgical wound classification
Key words: wound classification, documentation, surgical site infection.
Storing and using small, prefilled containers of formalin in the OR
Key words: formalin, formaldehyde, eyewash stations, Occupational Safety and Health Administration.
Latex-free environments for tissue recovery and organ procurement procedures
Key words: allografts, organ donation, tissue recovery, latex sensitivity, latex-free environment.
Covering facial hair in semirestricted and restricted areas
Key words: facial hair, beards, surgical masks.
Covering ears in semirestricted and restricted areas
Key words: ears, pierced earrings, surgical head coverings.

Surgical wound classification

QUESTION:
We are having disagreements at our facility about how
certain procedures should be classified when using the
Centers for Disease Control and Prevention (CDC) sur-
gical wound classification system. Can you discuss the
wound classifications that should be assigned to some
common procedures?
ANSWER:
Perioperative RNs should assign surgical wound classifica-
tion collaboratively with the surgeon after a careful assess-
ment of the specific factors associated with each surgical
procedure. According to the CDC, surgical wounds should
be classified based on the likelihood and degree of wound
contamination at the time of surgery.1 The following are

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 September 2015, Vol. 102, No. 3
print & web 4C=FPO
Figure 1. Surgical Wound Classification Decision Tree.
the CDC’s definitions of the four surgical wound
classifications:
[Class I] Clean wounds: These are uninfected operative
wounds in which no inflammation is encountered and the
respiratory, alimentary, genital, or uninfected urinary tracts
are not entered. In addition, clean wounds are primarily
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Clinical Issues
closed, and if necessary, drained with closed drainage [eg, bulb
drain]. Operative incisional wounds that follow non-
penetrating (blunt) trauma should be included in this category
if they meet the criteria.
[Class II] Clean-contaminated wounds: These are operative
wounds in which the respiratory, alimentary, genital, or
AORN Journal j 301
Van WicklindBrubaker September 2015, Vol. 102, No. 3

Table 1. Wound Classifications for Specific Procedures

Cesarean section with long labor or ruptured membranes
A cesarean section should be classified as Class II (clean-contaminated) because the uterus is entered to deliver the child.
Cesarean deliveries with or without ruptured membranes or long labors are Class II procedures unless there is a specific reason
(eg, presence of meconium representing spillage from the fetal gastrointestinal [GI] tract) to assign a Class III (contaminated)
rating. Class IV (dirty or infected) would be assigned if an existing clinical infection were present, evidenced by the presence of
purulence.

Circumcision
A circumcision does not enter the genitourinary (GU) tract; therefore, the wound classification should be Class I (clean).

Coronary artery bypass grafting
Coronary artery bypass grafting does not enter the respiratory tract and should be classified as Class I (clean).

Hepatectomy
Within the liver is a network of fine tubular channels known as bile capillaries that collect and carry bile. These capillaries merge
to form the bile ducts and eventually become the hepatic duct; therefore, a procedure where the liver is completely or partially
removed transects the biliary tract, which is a part of the GI tract, and should be classified as Class II (clean-contaminated).

Laparoscopic Nissen fundoplication with esophagogastroduodenoscopy
In a laparoscopic Nissen fundoplication, the upper curvature of the stomach is wrapped around the esophagus and sutured into
place. If the patient has a hiatal hernia, this is also repaired. The GI tract is not entered. For this reason, a laparoscopic Nissen
fundoplication is a Class I (clean) procedure. There is no classification for the esophagogastroduodenoscopy because there is no
surgical wound.

Orchiectomy
An orchiectomy procedure should be classified as Class II (clean-contaminated) because the spermatic cord is severed.

Orchiopexy
An orchiopexy procedure enters the inguinal canal but not the GU tract. It should be classified as Class I (clean).

Pancreatectomy
The pancreas is part of the GI tract; therefore, a procedure in which the pancreas is completely or partially removed should be
classified as Class II (clean-contaminated).

Parotidectomy
The salivary glands (parotid, submandibular, sublingual) produce saliva and are part of the GI tract. For this reason, surgical
procedures involving the salivary glands should be classified as Class II (clean-contaminated).

Penile prosthesis
A procedure in which a penile prosthesis is inserted enters the erection chambers but not the GU tract. For this reason, it should
be classified as Class I (clean).

Penrose drain
A surgical wound that is closed with a Penrose drain should be classified as Class III (contaminated). According to the CDC,
“clean wounds are primarily closed, and if necessary, drained with closed drainage.”1(p109) A Penrose drain is a form of open
drainage; therefore, a procedure in which a Penrose drain is placed cannot be classified as Class I. Class II (clean-contaminated)
procedures are those where the respiratory, GI, or GU tracts are entered; unless these tracts are entered, the procedure cannot
be classified as Class II. The definition of a Class III (contaminated) procedure includes an “open, fresh wound.”1(p109) When a
Penrose drain is placed and the surgical wound is closed, the portion of the incision where the drain is inserted remains partially
open. This fresh, open wound increases the potential for postoperative infection, so Class III is the correct classification. If the
drainage from the wound is purulent, it is Class IV (dirty or infected).

Pilonidal cyst
If no inflammation or infection is present, the excision of a pilonidal cyst should be classified as Class I (clean). If acute
inflammation is present, it should be classified as Class III (contaminated); if existing clinical infection (ie, purulence) is present, it
should be classified as Class IV (dirty or infected).

Portacaval shunt
In this procedure, the hepatic vein is connected to the inferior vena cava. The GI tract is not entered. For this reason, a
portacaval shunt should be classified as Class I (clean).

Thoracoscopy and thoracotomy
When thoracoscopy and thoracotomy procedures are performed, the pleural space is entered but the respiratory tract is not
entered. These procedures should be classified as Class I (clean).

Vasectomy
During a vasectomy, the vas deferens, a part of the GU tract, is severed. For this reason, a vasectomy should be classified as
Class II (clean-contaminated).
Reference
1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guidelines for prevention of surgical site infection, 1999. Centers for Disease Control
and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27(2):99-134.

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September 2015, Vol. 102, No. 3
urinary tract is entered under controlled conditions and
without unusual contamination. Specifically, operations
involving the biliary tract, appendix, vagina, and oropharynx
are included in this category, provided no evidence of infection
or major break in technique is encountered [eg, spillage from
gastrointestinal tract].
[Class III] Contaminated wounds: These include open, fresh,
accidental wounds, operations with major breaks in sterile
technique [eg, procedure performed with unsterile instruments]
or gross spillage from the gastrointestinal tract, and incisions in
which acute, nonpurulent inflammation is encountered.
[Class IV] Dirty or infected wounds: These include old traumatic
wounds with retained devitalized tissue and those that involve
existing clinical infection or perforated viscera. This definition
suggests that the organisms causing postoperative infection were
present in the operative field before the operation.1(p109)
AORN developed the Surgical Wound Classification Decision
Tree (Figure 1) as a tool to assist perioperative RNs in accurately
classifying surgical wounds using the CDC surgical wound
classification system. This tool, included in the 2015 “Guideline
for prevention of transmissible infections,”2 can also be found on
the AORN web site at http://www.aorn.org by searching for
“Surgical Wound Classification Decision Tree.” The decision
tree is an algorithm that has organized, directed wound
classification questions designed to lead perioperative team
Storing and using small, prefilled containers of formalin in the OR
QUESTION:
Is it acceptable to store and use small, prefilled containers
of formalin in a procedure room or the OR?
ANSWER:
Formalin, including formalin in small, prefilled containers,
should be stored or used in an area other than a procedure
room or the OR unless ignition sources are not used and the
regulatory requirements for the locations for use and storage
have been met. Formalin is a combustible liquid, and ignition
sources (eg, electrosurgery) should not be used in the stor-
age area.1
Storage and use of formalin is regulated by the Occupational
Safety and Health Administration (OSHA) and other federal
and state health regulatory agencies.2,3 Locations where
formalin is used or stored must have
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Clinical Issues
members to the correct wound classification. Examples of
procedures that may cause confusion regarding their correct
wound classification are addressed in Table 1, and a rationale for


how the Surgical Wound Classification Decision Tree has been
used is provided.
Sharon A. Van Wicklin,
MSN, RN, CNOR, CRNFA(E),
CPSN-R, PLNC, is a perioperative
print & web 4C/FPO
nursing specialist in the Nursing
Department at AORN, Inc.
References
1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guidelines
for prevention of surgical site infection, 1999. Centers for Disease
Control and Prevention (CDC) Hospital Infection Control Practices
Advisory Committee. Am J Infect Control. 1999;27(2):99-134.
2. Guideline for prevention of transmissible infections. In: Guidelines
for Perioperative Practice. Denver, CO: AORN, Inc; 2015:419-451.

posted signs warning of formaldehyde use, the active
ingredient in formalin;

eyewash stations available within the immediate area; and

ventilation systems with adequate capacity to maintain
formaldehyde levels below the permissible exposure limits
(ie, eight-hour total weighted average of 0.75 ppm or 15-
minute short-term exposure limit of 2.0 ppm).2
Warning signs and adequate ventilation systems are necessary
because formaldehyde is a potential carcinogen that can cause
acute and chronic health conditions, including sensitization
leading to asthma and contact dermatitis. Formalin, even
when stored in small, prefilled containers, can be absorbed
through the skin and nasal passages, splashed in the eyes, or
ingested. Exposure can result in irritation, burns, or allergic
reactions.1-4 Formalin in a 10% buffered solution, as is
commonly used in the OR, contains approximately 4%
formaldehyde.4 Eye and skin contact with liquids containing
AORN Journal j 303
Van WicklindBrubaker
1% or more formaldehyde must be prevented by the use of
face shields and eye protection according to OSHA
requirements.2
Eyewash stations are necessary to provide emergency treatment
in the event that a perioperative team member splashes
formalin into his or her eyes. Eyewash stations located in the
immediate area means that travel time from the site of
chemical exposure to the eyewash station is no greater than 10
seconds.5 The eyewash station also should be located on the
same level as the formalin, and the travel route to the
eyewash station should be free of obstructions that may
delay the immediate use of the eyewash station.5 When
walking at a normal pace, the average person covers a
distance of 55 feet in 10 seconds5; however, a person who
has experienced a chemical splash to the eyes or face may be
visually impaired, in discomfort or pain, and in a state of
panic. For this reason, it is prudent to consider the physical
and emotional state of a person in these circumstances and
the availability of assistive personnel in the immediate area


when determining the location of eyewash stations in
relation to areas where formalin is used or stored.5
Latex-free environments for tissue recovery and organ procurement
procedures
QUESTION:
One of the surgeons I work with has asked that we provide
a latex-free environment during procedures where tissue is
recovered and organs are procured. Is this necessary?
ANSWER:
Currently there are no recommendations from any professional
organization for providing a latex-free environment during tissue
recovery and organ procurement; however, there is a potential
for tissue and organs to acquire latex protein deposits if not
recovered in a latex-free environment. Organ transplantation,
where fresh, refrigerated, viable, and functional cells are desired,
and allograft tissue transplantation, where a highly processed
nonviable matrix is the norm, are substantially different pro-
cedures. There are no reports of latex-induced anaphylactic
shock associated with transplantation of allograft tissues.
Researchers at one tissue bank evaluated the potential for latex
residue on finished tissue allografts and found it to be within
acceptable limits of exposure (ie, 200 mcg/dm2).1 In this study,
the researchers approximated the maximum amount of latex
304 j AORN Journal
September 2015, Vol. 102, No. 3
Sharon A. Van Wicklin, MSN, RN, CNOR,
CRNFA(E), CPSN-R, PLNC, is a perioperative nursing
specialist in the Nursing Department at AORN, Inc.
References
1. NIOSH Pocket Guide to Chemical Hazards. DHHS (NIOSH) Publi-
cation No. 2005-149 ed. Cincinnati, OH: National Institute for
Occupational Safety and Health; 2007.
2. xCFR 1910.1048: Hazardous substances. Formaldehyde.
Occupational Safety and Health Administration. https://www.osha.gov/
pls/oshaweb/owadisp.show_document?p_id¼10075&p_table¼
STANDARDS. Accessed May 8, 2015.
3. OSHA Fact Sheet: Formaldehyde. 2011. Occupational Safety and
Health Administration. https://www.osha.gov/OshDoc/data_General_
Facts/formaldehyde-factsheet.pdf. Accessed May 8, 2015.
4. Material Safety Data SheetdFormalin 10%. 2013. American
Master Tech. http://www.americanmas-tertech.com/PDF/SSFX
BFO.PDF. Accessed May 8, 2015.
5. ANSI/ISEA Z358.1-2009: American National Standard for Emergency
Eyewash and Shower Equipment. New York, NY: American National
Standards Institute; 2009.
protein that might adhere to an allograft when recovered in an
environment where latex gloves were worn. They calculated
that up to 90 mcg/dm2 of latex protein could be transferred to
an allograft during the recovery procedure. Based on the
researcher’s conservative assumption that approximately 10%
of leachable latex protein would remain adherent to the
allograft after processing, they estimated that the total amount
of latex protein remaining on a single allograft would be
approximately 10 mcg/dm2.1 This amount is much lower
than the 2001 ASTM International’s recommended limit of
200 mcg/dm2 for medical devices that are to be labeled latex-
free, including latex-free surgical gloves.2
In December 2014, the US Food and Drug Administration
(FDA) provided guidance for labeling products made with
natural rubber and recommended that products be labeled “Not
made with natural rubber latex”3(p4) with the explanation that
[The] FDA is concerned that statements submitted for inclu-
sion in medical product labeling, such as “latex-free,” “does not
contain natural rubber latex,” or “does not contain latex,” are
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September 2015, Vol. 102, No. 3
not accurate because it is not possible to reliably assure that
there is an absence of the allergens associated with hypersen-
sitivity reactions to natural rubber latex in the medical prod-
uct. Use of these terms may give users allergic to natural rubber
latex a false sense of security when using a medical product.3(p1)
Although the FDA recognizes that the complete absence of
all natural rubber latex allergens may not be necessary for
the safe use of medical products by individuals with natural
rubber latex allergies,3(p4) it is impossible to know how
much exposure to natural rubber latex might cause a
reaction in any specific person. Researchers have not been
able to establish that allograft processing procedures are
able to completely destroy or eliminate any latex proteins
that might be present in the allograft. Thus, the question
of whether allograft tissue recovered in a non-latex-free
environment is safe for transplantation into latex-sensitive
or latex-allergic patients remains unanswered.
Case reports in the literature describe latex-induced anaphylactic
shock during organ transplantation procedures.4,5 Shinoda et al4
reported the case of a 33-year-old female liver donor who
developed intraoperative latex-induced anaphylactic shock during
surgery for living donor transplantation. During the procedure,
her blood pressure dropped and her face and upper extremities
became warm and flushed. After treatment with epinephrine, she
seemed to recover and the procedure was continued; however,
she went into shock again within a few minutes. The surgical
team suspected latex-induced anaphylactic shock. They
administered epinephrine and hydrocortisone, changed to latex-
free gloves, and replaced the patient’s urinary catheter with a
latex-free catheter. The patient recovered a second time, but the
procedure was discontinued because an intraoperative x-ray
revealed mild pulmonary edema. Postoperative IgE-RAST
(immunoglobulin E radioallergosorbent test) blood levels showed
a strong positive result, suggesting that the anaphylactic reaction
was induced by latex. The authors recommended that latex
allergy should be considered as a potential donor risk. Although
the authors did not recommend using a latex-free environment
for organ recovery procedures, a hypothetical case could be made
that implementing latex precautions during this procedure might
have prevented the anaphylaxis.
Jacmarcq et al5 reported the case of a young man who developed
anaphylactic shock during a kidney transplantation procedure.
No latex-containing materials were used during the procedure;
however, the authors concluded that latex contamination in the
donor organ was the cause of the anaphylaxis. The authors
strongly recommended procuring donor organs in a latex-free
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Clinical Issues
environment to reduce the risk of anaphylactic shock in a
recipient with unknown latex allergy.
Preoperatively, the RN should assess both donor and recipient
patients for risk factors for latex sensitivity. Organ procure-
ment and tissue recovery professionals use donor risk assess-
ment forms when evaluating the donor’s medical condition
and history. These forms may include assessment questions
regarding the donor’s specific allergies. Uniform donor risk
assessment interview forms are available from the American
Association of Tissue Banks at http://www.aatb.org/DRAI
-Documents.6 Early recognition of risk factors for latex
sensitivity may prevent the progression of anaphylaxis.
Based on a consideration of the benefits versus potential harms
associated with this practice question, it seems that the benefits of
providing a latex-free environment during tissue recovery and organ
procurement procedures outweigh the potential harms. Recom-


mendations for providing a latex-free environment are provided in
the AORN “Guideline for a safe environment of care, part 1.”7
Acknowledgment: The authors thank Eric J. Davis, MS, RN,
CNOR, clinical nurse consultant, at Molnlycke Health Care,
Norcross, GA, for his assistance in writing this response.
Sharon A. Van Wicklin, MSN, RN, CNOR,
CRNFA(E), CPSN-R, PLNC, is a perioperative nursing
specialist in the Nursing Department at AORN, Inc.
Scott A. Brubaker, CTBS, is
senior vice president of Policy at
print & web 4C/FPO
the American Association Of
Tissue Banks, McLean, VA.
References
1. LifeNet HealthTM. Frequently Asked Questions: What Is the Risk That
an Allograft That Is Implanted Into a Patient Contains Latex?. Virginia
Beach, VA: LifeNet Health; 2014.
2. ASTM D3578-01e1. Standard Specification for Rubber Examination
Gloves. West Conshohocken, PA: ASTM International; 2001.
AORN Journal j 305
Van WicklindBrubaker
3. Recommendations for Labeling Medical Products to Inform Users
That the Product or Product Container Is Not Made With Natural
Latex. Guidance for Industry and Food and Drug Administration
Staff. Rockville, MD: US Department of Health and Human Services,
Food and Drug Administration; 2014. http://www.fda.gov/ucm/
groups/fdagov-public/@fdagov-meddev-gen/documents/document/
ucm342872.pdf. Accessed May 9, 2015.
4. Shinoda M, Tanabe M, Nagao K, et al. Discontinuation of
living donor liver transplantation due to donor’s intraoperative
Covering facial hair in semirestricted and restricted areas
QUESTION:
Why does the current AORN “Guideline for surgical
attire”1 recommend that perioperative team members
cover facial hair when in semirestricted and restricted
areas? Does longer facial hair present a greater risk of
surgical site infection than shorter facial hair?
ANSWER:
The AORN recommendation1 for covering facial hair is based
on a nonexperimental study that examined dispersal of
bacteria by men with and without beards and by women.
McLure et al2 placed blood agar plates 15 cm below the lips
of 30 seated subjects: 10 clean-shaven men, 10 bearded
men, and 10 women. The subjects wore surgical masks for
two 90-minute periods. Researchers placed an additional
agar plate 15 cm below the subjects’ lips to control for
environmental conditions. Following exposure, they
incubated the agar plates for 24 hours and a microbiologist,
blinded to the study sequence, counted and identified the
number of bacterial colonies present. The results of the
study showed there was significantly more bacterial shedding
by bearded men than by clean-shaven men or by women,
even when a mask was worn. The researchers suggested that
beards may act as a reservoir for bacteria and dead organic
material. The researchers did not specifically explore the
amount of bacterial shedding from longer beards compared
with shorter beards; however, they theorized that shorter
beards would disperse less bacteria than longer beards. Their
recommendation was that bearded men working near sterile
fields should consider beard removal.
In a quasi-experimental study, Wakeam et al3 investigated the
facial bacterial shedding of 408 health care workers: 199 with
facial hair and 209 without facial hair. Each subject rubbed his
306 j AORN Journal
September 2015, Vol. 102, No. 3
latex-induced anaphylactic shock. Int Surg. 2012;97(4):
356-359.
5. Jacmarcq O, Karila C, Carli P. Latex-induced anaphylactic shock
following graft reperfusion during renal transplantation. Ann Fr
Anesth Reanim. 2005;24(5):547-550.
6. Uniform DRAI Documents. American Association of Tissue Banks.
http://www.aatb.org/DRAI-Documents. Accessed May 9, 2015.
7. Guideline for a safe environment of care, part 1. In: Guidelines for
Perioperative Practice. Denver, CO: AORN, Inc; 2015:239-263.
or her cheek using a sterile culture swab while holding a blood
agar Petri dish 30 cm below the face. The researchers designed
this test to simulate the bacterial shedding that might occur
from the health care worker onto a sterile field or a patient
during patient care. Notably, researchers considered the
shedding test positive only if the same species of bacteria
grew in the Petri dish as grew on the culture swab from the
health care worker’s face.
The results of the study showed that although health care
workers with and without facial hair shed bacteria at high rates
(42% overall), those with facial hair shed bacteria at a higher
rate (50.8%) than those without facial hair (33.5%). The re-
searchers emphasized the importance of all health care workers
completely covering their faces during invasive procedures
performed under sterile conditions. The benefit of covering
facial hair in restricted and semirestricted areas is that it may
decrease patients’ exposure to microorganisms shed from the


skin and hair of perioperative personnel and thus reduce their
risk of surgical site infection.1
Sharon A. Van Wicklin, MSN, RN, CNOR,
CRNFA(E), CPSN-R, PLNC, is a perioperative nursing
specialist in the Nursing Department at AORN, Inc.
References
1. Guideline for surgical attire. In: Guidelines for Perioperative Practice.
Denver, CO: AORN, Inc; 2015:97-120.
2. McLure HA, Mannam M, Talboys CA, Azadian BS, Yentis SM. The
effect of facial hair and sex on the dispersal of bacteria below a
masked subject. Anaesthesia. 2000;55(2):173-176.
3. Wakeam E, Hernandez RA, Rivera Morales D, Finlayson SR,
Klompas M, Zinner MJ. Bacterial ecology of hospital workers’ facial
hair: a cross-sectional study. J Hosp Infect. 2014;87(1):63-67.
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September 2015, Vol. 102, No. 3
Covering ears in semirestricted and restricted areas
QUESTION:
Why does the current AORN “Guideline for surgical
attire”1 recommend that perioperative team members
cover their ears when in semirestricted and restricted areas?
ANSWER:
The AORN recommendation1 for covering ears is based on a
nonexperimental study that examined the source of bacteria
shed by perioperative team members from exposed areas of
the face not covered by surgical attire or personal
protective equipment. Owers et al2 systematically cultured
the foreheads, eyebrows, and ears of 20 surgical team
members. The researchers found that there was
significantly more bacteria isolated from the ears than from
the foreheads and eyebrows of the surgical team members
and recommended that the ears be covered by surgical
head covers during surgery, particularly if the team
member has pierced ears. Owers et al2 emphasized the
need for covering ears, and Bartlett et al3 recommended
that pierced ears specifically be covered. In this quasi-
experimental study,3 the researchers measured bacterial
counts on the earlobes of surgical team members wearing
pierced earrings. Each subject acted as their own control to
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Clinical Issues
negate the effect of differences in individual skin bacterial
loads. The researchers found that bacterial counts were 21
times greater on the skin behind the earrings worn by the
perioperative team members. The benefit of covering the
ears, regardless of whether they are pierced or not, in
restricted and semirestricted areas is that it may decrease
the patient’s exposure to microorganisms shed from the


ears of perioperative personnel and thus reduce the
patient’s risk of surgical site infection.2
Sharon A. Van Wicklin, MSN, RN, CNOR,
CRNFA(E), CPSN-R, PLNC, is a perioperative nursing
specialist in the Nursing Department at AORN, Inc.
References
1. Guideline for surgical attire. In: Guidelines for Perioperative Practice.
Denver, CO: AORN, Inc; 2015:97-120.
2. Owers KL, James E, Bannister GC. Source of bacterial shedding in
laminar flow theatres. J Hosp Infect. 2004;58(3):230-232.
3. Bartlett GE, Pollard TC, Bowker KE, Bannister GC. Effect of jewellery
on surface bacterial counts of operating theatres. J Hosp Infect.
2002;52(1):68-70.
AORN Journal j 307
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Continuing Education:
Clinical Issues 1.7 www.aorn.org/CE

T his evaluation is used to determine the extent to

which this continuing education program met
your learning needs. The evaluation is printed
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credit, you must complete the online Learner Evaluation at
5.

6.
To what extent were your individual objectives met?
Low 1. 2. 3. 4. 5. High

Will you be able to use the information from this article

in your work setting?
1. Yes 2. No
http://www.aorn.org/CE. Rate the items as described below.
7. Will you change your practice as a result of reading this
article? (If yes, answer question #7A. If no, answer
PURPOSE/GOAL
question #7B.)
To provide the learner with knowledge of AORN’s guidelines
related to surgical wound classification; storing and using 7A. How will you change your practice? (Select all that apply)
small, prefilled containers of formalin in the OR; latex-free 1. I will provide education to my team regarding why
environments for tissue recovery and organ procurement change is needed.
procedures; covering facial hair in semirestricted and restricted 2. I will work with management to change/implement
areas; and covering ears in semirestricted and restricted areas. a policy and procedure.
3. I will plan an informational meeting with physicians
to seek their input and acceptance of the need for
OBJECTIVES
change.
To what extent were the following objectives of this
4. I will implement change and evaluate the effect of
continuing education program achieved?
the change at regular intervals until the change is
1. Discuss practices that could jeopardize safety in the
incorporated as best practice.
perioperative area.
5. Other: __________________________________
Low 1. 2. 3. 4. 5. High

2. Discuss common areas of concern that relate to periop-

7B. If you will not change your practice as a result of
erative best practices.
reading this article, why? (Select all that apply)
Low 1. 2. 3. 4. 5. High
1. The content of the article is not relevant to my practice.
3. Describe implementation of evidence-based practice in 2. I do not have enough time to teach others about the
relation to perioperative nursing care. purpose of the needed change.
Low 1. 2. 3. 4. 5. High 3. I do not have management support to make a
change.
4. Other: __________________________________
CONTENT
4. To what extent did this article increase your knowledge 8. Our accrediting body requires that we verify the time
of the subject matter? you needed to complete the 1.7 continuing education
Low 1. 2. 3. 4. 5. High contact hour (102-minute) program: ______________

308 j AORN Journal www.aornjournal.org