In the name of patient safety, we have heard calls for “bare below the elbows” care in hospital wards, and now the American College of Surgeons (ACS) is strongly urging surgical workers to drop the common practice of wearing scrubs in public.

“Many different healthcare providers — surgeons, anesthesiologists, CRNAs, laboratory technicians, aides — wear scrubs in the OR setting,” the ACS stated in a recently issued policy.1 “The ACS strongly suggests that scrubs should not be worn outside the perimeter of the hospital by any healthcare provider. To facilitate enforcement of this guideline for OR personnel, the ACS suggests the adoption of distinctive, colored scrub suits for the operating room personnel.”

The ACS said the practice imbues such traits as professionalism and “introspection,” and builds rapport with patients. “In addition, insofar as clean and properly worn attire may decrease the incidence of healthcare-associated infections, it also speaks to a desire and drive for excellence in clinical outcomes and a commitment to patient safety,” the ACS noted.

To those uninitiated to the surgical culture, the ACS statements calling “skull caps” a symbol of the profession may seem a little bizarre.

“The skull cap can be worn when close to the totality of hair is covered by it and only a limited amount of hair on the nape of the neck or a modest sideburn remains uncovered,” the ACS states. “Like OR scrubs, cloth skull caps should be cleaned and changed daily. Paper skull caps should be disposed of daily and following every dirty or contaminated case. Religious beliefs regarding headwear should be respected without compromising patient safety. … Soiled scrubs and/or hats should be changed as soon as feasible, and certainly prior to speaking with family members after a surgical procedure.”

Surgical Attire Guidelines

Additional ACS surgical attire guidelines are summarized as follows:

  • Scrubs and hats worn during dirty or contaminated cases should be changed prior to subsequent cases, even if not visibly soiled.
  • Masks should not be worn dangling at any time.
  • Operating room scrubs should not be worn in the hospital facility outside of the OR area without a clean lab coat or appropriate cover-up over them.
  • OR scrubs should be changed at least daily.
  • During invasive procedures, the mouth, nose, and hair (skull and face) should be covered to avoid potential wound contamination. Large sideburns and ponytails should be covered or contained. There is no evidence that leaving ears, a limited amount of hair on the nape of the neck, or a modest sideburn uncovered contributes to wound infections.
  • Earrings and jewelry worn on the head or neck where they might fall into or contaminate the sterile field should all be removed or appropriately covered during procedures.
  • Clean appropriate professional attire — not scrubs — should be worn during all patient encounters outside of the OR.

Shirts and Skins

Another fashion-forward trend in healthcare is the so-called “bare below the elbows” approach that was popularized in the United Kingdom as a way to reduce Clostridium difficile infections. Similar to necktie bans, the idea is that pathogens could spread by contaminated sleeves and lab coats. The University of Iowa Hospital and Clinics adopted the practice this year at the urging of Michael Edmond, MD, MPH, hospital epidemiologist at the Iowa City facility.

“We use contact precautions for epidemiologically important organisms, placing patients in private rooms and wearing gowns and gloves when we go into the room,” Edmond said at last year’s IDWeek meeting in San Francisco. “This is based on evidence that clothing does become contaminated and the assumption that pathogens on contaminated clothing can be transmitted to patients.”

Thus, the logical extension of contact precautions concerned with clothing as a fomite is “bare below the elbows,” which means no sleeves, white coat, neckties, wristwatch, and no jewelry except a wedding band, he said.

“The intention of this is to allow a good hand- and wrist-washing and to avoid contamination of sleeve cuffs,” Edmond said. “I have personally practiced bare below the elbows consistently since 2009.”

The postulated role of clothing in the transmission of pathogens is based on the awareness that patient skin and the surrounding environment are contaminated with pathogens, he said.

“The clothing of the healthcare worker becomes contaminated by being in contact with the patient or the environment,” he said. “We add to that some pieces of clothing are infrequently laundered, particularly neck ties and lab coats, [which harbor] pathogens we presume may be transmitted from the healthcare worker clothing to the subsequent patient.”

The pathogens may be able to linger on lab coats in particular, which may be infrequently laundered. Edmond cited a study showing washing of lab coats occurs on average about every two weeks.2

“We found that about a third of people wash their white coats every week; about 40% every month, and most interestingly and quite appalling, almost 20% reported that they had never washed their lab coat,” he said. “They’re like Pigpen.”


  1. ACS. Statement on Operating Room Attire. August 4, 2016:
  2. Munoz-Price SL, Arheart KL, Lubarsky DA. Differential laundering practices of white coats and scrubs among healthcare professionals. AJIC 2013;41:513-516.