Greens could be bad for you: a study of the inappropriate use of theater greens.

To the Editor: Theater greens are a clean uniform for the theater suite. Their purpose is to help reduce the transfer of organisms from other hospital areas into the theater suite.

In the UK the NATN (National Association of Theater Nurses) recommend that "all personnel should change into outer clothes when leaving the perioperative environment and don a new set of theater attire upon their return." (1) Several studies have suggested that cover gowns or white coats ought to be worn over theater greens if they are used outside the theater suite. (2,3)

Regarding shoe wear, there is no clear link between floor contamination and wound infection, but studies indicate that a change of footwear should occur as far from the operating theater as possible and footwear should be cleaned after every use to keep floor contamination to a minimum. (4)

We performed a study to: 1) audit the use of theater greens outside the theater suite in three hospitals and 2) to determine the habits and attitudes of theater staff regarding the use of theater greens.

First, an observational study was performed in the three hospitals studied. We recorded the number of people wearing theater greens in locations around the hospital; the cleanliness of the greens worn outside theater; the use of white overcoats to protect greens outside the theater; the use of "outdoor" shoes outside the theater instead of theater shoes and the title of the staff involved. Observations were made during 5 one-hour periods on different days at peak times of staff leaving and entering the theater (lunch and breakfast times).

Second, to determine the attitudes of theater staff regarding theater greens, we circulated a questionnaire to staff working in the theater suite. The questionnaires were completed anonymously. Of 300 questionnaires handed out (100 at each hospital), 157 (52%) were returned completed.

Our results revealed no significant difference in the results between the three hospital studies, so the results were amalgamated for clarity and to increase the sample size.

We found that half of those using the theater entrance either to enter or exit do so in theater greens (555/1,100: 50%). Staff frequently use the canteen (105/421: 25%), library (12/91: 13%) and mess (50/222: 23%) wearing theater greens. Percentages listed are the total number of people, (visitors and nonstaff members included) found in a location during the observation period. Observations on the cleanliness of the greens demonstrated that 10% were visibly soiled with scrub solution or blood.

Of those wearing greens outside the theater, only 22% were found to be wearing both an overcoat and outdoor shoes. Far more, (41%) use theater greens outside the theater suite with both theater shoes and no overcoat.

The position of the person wearing theater greens while entering or leaving the theater was recorded and it was found that a higher proportion were anesthetists (32%) and surgeons (27%) than nurses (12%), porters (10%) or cleaners (2%).

The results of the questionnaire indicate staff attitude toward wearing theater greens and provide further information on the usage of greens: of the overall 157 respondents, 32% were surgeons, 29% were nurses, 14% were ODAs, 13% were anesthetists, 6% were HCAs, 4% were porters and 2% were cleaners. Of the staff surveyed, 85% admitted to wearing greens outside the theater suite. Most staff admitted to not always using an overcoat (69%) or changing to outdoor shoes (62%) when leaving the theater. Only 18% said that they always changed into fresh greens on re-entering the theater. Surprisingly, 39% thought greens should be reserved for theater use only. The respondents stated that greens were mostly worn to access wards; but also in the canteen (52% of respondents), in the car park (6%) or at home.

This study demonstrates that theater greens are widely used outside the theater suite. We gained the impression that theater greens are often seen as an alternative uniform worn for dirtier tasks. It has been suggested that staff in departments outside the theater should wear theater greens, as they can be easily changed should they become contaminated. (5) We suggest that theater greens be reserved for the theater suite. An alternative uniform (such as differently colored 'greens') ought to be found for staff undertaking dirty tasks elsewhere in the hospital.

Staff will fail to use outside lab coats and shoe wear if none are available at the theater door. Notices, physical barriers, staff education and enforcement of guidelines are also likely to reduce inappropriate use of greens outside the theater.

Jennifer K. O'Neill, MRCS 

Department of Orthopaedic Surgery

Princess Royal Hospital 

Haywards Heath, United Kingdom

Phillipa Rust, MRCS

Department of Orthopaedic Surgery

Northwick Park Hospital 

London, United Kingdom

Dominique Knight, MRCS

Department of Orthopaedic Surgery

Southend Hospital

Southend, United Kingdom

David M. Ricketts, FCRS ORTH 

Department of Orthopaedic Surgery

Princess Royal Hospital

Haywards Heath, United Kingdom

References

1. National Association of Theatre Nurses. Principles of safe practice in the perioperative environment. NATN Harrogate, 1989.

2. Copp G, Mailhot CB, Zaler M, et al. Cover gowns and the control of operating room contamination. Nursing research 1986;35:263-268.

3. Woodhead K, Taylor EW, Bannister G. et al. Behaviours and rituals in the operating theatre. A Report from the Hospital Infection Society Working Party on Infection Control in Operating Theatres. J Hosp Inf 2002;51:241-255.

4. Nagai I, Kadota M, Takechi M. Studies on the mode of bacterial contamination of an operating theatre corridor floor. J Hosp Inf 1984;15:50-55.

5. McGrath B. Prize Letter. BMA News 2003, July 12. Letters to the Editor