Surgical gowns: a survey of wearer and purchaser satisfaction with protection.

The medical profession's first priority has always been patient safety and well being. One infection control practice includes the wearing of surgical gowns to protect patients from microorganisms carried by healthcare workers. With the advent of AIDS into the healthcare arena, a new concern and focus has resulted: the protection of medical personnel from patient's blood and body fluids.

Guidelines developed by the Centers for Disease Control (CDC) and the Occupational Safety and Health Administration (OSHA) are designed to protect medical personnel from blood and body fluid infectious agents, including HIV and the hepatitis B virus. CDC recommended universal precautions are classified into two categories--those for all medical personnel and those applying particularly to medical personnel performing at-risk tasks.

At risk tasks include invasive procedures, dental procedures, autopsies, renal dialysis and laboratory work[1]. Surgical gowns, masks, protective eyewear and gloves are recommended for at-risk procedures to prevent blood strikethrough, which is the route for viral and bacterial transmission. As the medical profession recognizes the dangers of at-risk procedures and the importance of protection from patient blood and body fluids, attention turns to the scope of gown protection provided[2].

A survey was undertaken to assess satisfaction with surgical gown protection. Specific objectives were to provide a description of current operating room gown design, fabric and cost and to determine the level of satisfaction with gowns as to patient and staff protection and safety.

Two sample categories, purchasers (P) and wearers (W) of surgical gowns at randomly selected state university teaching hospitals throughout the U.S. were sent self-administered questionnaires. The four page questionnaire consisted of 27 questions asking for information on demographics of the respondent, surgical gown usage in the OR, cost, operating room conditions and satisfaction with gowns. Information requested regarding the surgical gowns included gown design and fabric, fit, comfort and protection provided to patients and surgical staff.

The population of each of the two sample categories was 150, for a total of 300 questionnaires. Forty seven P's and 41 W's returned questionnaires for a 31% and 27% return rate, respectively. Data was collected from a total of 88 returned questionnaires and analyzed with the Statistical Analysis System (SAS). A descriptive analysis, which consisted of frequency distributions and mean scores and t-tests, was used to analyze W and P responses.

Results Of Survey

Statistical analysis revealed no significant differences in P and W responses. Unless otherwise stated, all percentages are reported as combined response frequencies of P's and W's. Sample demographics revealed that most respondents worked in mid-sized hospitals having 100-150 beds to large-sized hospitals having 200+ beds. Of these, 26% of the hospitals were located in the eastern U.S., 34.1% in the midwest, 19.5% in the west and 19.5% in the south. None of the respondents in the W sample were surgeons; 65% were surgical nurses and 35% were other administrators, including nurse supervisors and directors. Respondents in the P sample included purchasers of hospital supplies (38%) or OR directors, coordinators, supervisors and managers (62%).

Gowns were worn in all general surgeries, implant and heart by-pass operations. Of the various types of protective clothing generally worn in the operating room (Figure 1), respondents wore surgical gowns 98.9%), scrubs (85.1%), shoe covers (85.1%), hoods (89.7%), gloves 98.9%), caps (85.1%), face masks 98.9%), goggles/glasses (93.1%), and hoods with face shields (42.5%). From this data, surgical gowns, hoods, face masks, goggles and gloves were the most frequently worn protective apparel in the OR. This coverage is in agreement with the recommended guidelines from the CDC for at-risk procedures. Open-ended responses from W's indicated that plastic aprons, knee-high shoe covers, hood and helmet systems, water resistant paper boots and laser gloves were also worn during surgery.

Gown design was described as knee or full length with snap, tie or Velcro gown closures, collarless and having long raglan sleeves with elastic cuffs. Gowns were usually randomly selected for size or one size fits all. Gown fabrics were 28.9% reusable wovens (13.8% cotton, 10.8% cotton/polyester, 4.3% synthetic), 41.3% disposable nonwovens, 4.3% reusable microporous membrane constructions, 23.9% paper and 1.6% other (Figure 2).

Gown comfort according to the W's was high, with 82% responding positive and 17% negative. W's also reported that gowns did not impair surgical team performance. The reasons cited for discomfort of gowns were thermal discomfort and size; nurses reported that gowns were too large. The average operating room temperature was 68 [degrees] F for nearly half of the hospitals responding (47.5%) and the OR temperature range for all hospitals in the survey was 60-78 [degrees] F.

Gown cost was reported reasonable by 90% of the P's. Over half of the P's bought gowns costing between $0-15 60%), 25% bought gowns costing $15-20 (28.6%), and over one tenth (11.4%) used gowns costing in excess of $20 per gown (Figure 3). Less than half of the P's (44.2%) were willing to pay more for a gown with improved patient safety features to protect patients; however, over half (66.7%) would consider purchasing a more expensive gown if features to improve surgical team safety were incorporated into gowns.

Satisfaction with gown design in terms of patient safety and protection was high, with 86.7% satisfied. There was a lower level of satisfaction with gown design when considering healthcare worker safety from patient blood and body fluid contamination (78%). The features most cited to improve gown design to protect healthcare workers were incorporating a double fabric front (13%) and double fabric sleeves (12.6%). Increased comfort was cited by W's as a desirable improvement in gown design, but no specifics were mentioned as to what features were needed to increase comfort.

There was a high level of satisfaction with gown fabric in terms of patient safety (90.6%) and a slightly lower satisfaction level for healthcare worker safety (81.1%). Suggested changes in gown fabric properties to increase satisfaction included improved barrier protection to liquids (92.3%) and bacteria (75.7%) and increased comfort (91.9%). Open ended responses indicated the need for recyclable and biodegradable fabrics.

This study indicates that at present more surgical gowns worn in operating rooms in the U.S. are disposable nonwovens as compared to reusables. Usage of disposable gowns appears to be related to the low initial cost per gown.

There is now increasing concern that surgical gowns protect medical personnel from viral contamination and infection. This was demonstrated by purchasers reporting they would pay more for a gown with increased safety for surgical teams but would not pay more for gowns with improved protective features for patient safety. Furthermore, satisfaction with surgical gowns to protect healthcare workers was reported as lower than the satisfaction with gowns for patient safety and protection.

In reporting satisfaction with gowns for healthcare personnel safety, respondents indicated a higher level of satisfaction with gown fabric than with gown design. This response may be connected to a false sense of security that may exist concerning the barrier effectiveness of currently available surgical gown fabrics[3]. As more testing of fabrics is carried out and standardized methods of testing are established, differences in the protective qualities of commercially available gowns will become known and the satisfaction level of both wearers and purchasers with surgical gown fabrics may change. Additional research is needed to determine why a lower level of satisfaction was reported for gown design. The identification of additional factors besides offering gowns with specific protection features may lead to other improvements in gown design and increased satisfaction. Perhaps fit and sizing are such factors to be investigated.

Survey data also suggest that satisfaction with, both gown design and fabric is related to comfort. Even though 82% of respondents considered current surgical gowns to be comfortable, desired changes and improvements to both gown design and fabrics included comfort.

References

[1.] Crutcher, J.M., Lamm, S.H., and Hall, T.A., "Procedures to Protect Health-Care Workers From HIV Infection: Category I (Health-Care) Workers," American Industry Hygiene Association Journal, 52(2)A100-A103 (1991). [2.] Smith, J.W., and Nichols, R.L., "Barrier Efficiency of Surgical gowns: Are We Really Protected From Our Patients' Pathogens?", Archives of Surgery, 126:756-763 (1991). [3.] Lovitt, S.A., Nichols, R.L., Smith, J. W., Muzik, A. C., and Pearce, P.F., "Isolation Gowns: A False Sense of Security?" American Journal of Infection Control, 20:185-191 (1992).