EXHIBIT 5

2:15-cv-12101-DML-DRG Doc # 24-6 Filed 08/27/15 Pg 1 of 3 Pg ID 625
Central Sterile 

Reprocessing

HENRY FORD 

HOSPITAL

Subject: Central Sterile Reprocessing Attire Policy

Effective: January, 2010 

 

Revised: February, 2014

Policy No.: 

Page: 1 of 2

Page 1 of 2

Purpose

To describe practices to maintain and control the introduction or spread of contamination in the operating room. 

To promote the appearance of professionalism for the Surgical Services Team utilizing dress attire.

 

Scope 

All persons entering the Surgical Services areas are responsible for adherence to the Attire Policy.

All persons employed by Surgical Services are responsible for reporting noncompliance to their supervisor.

The Surgical Services management team is responsible for taking corrective action as necessary.

Policy

Uniforms

1. Hospital provided scrub attire should be worn by personnel who enter the Surgical Services area. A

 protective jumpsuit is suitable for visitors to the area.

2. Hospital laundered surgical scrubs are available for Surgical Services staff. Home laundering of surgical

 scrubs is permitted, provided they are donned after arrival at the hospital

3. Scrub attire must be laundered in adherence to ICM 8.16. Scrub attire grossly contaminated with blood

 and/or body fluid must remain and be laundered by facility laundry service.

4. Laundered surgical attire should be protected from contamination during transport to the Surgical

 Services area.

5. Vendors must follow the Attire policy. They must transport and change into their own plain black clean

 scrubs using the hospital provided locker rooms. No other color of scrubs is allowed.

6. Fluid resistant gowns must be worn over scrub attire whenever there is anticipation of possible

 contamination with blood/body fluids.

7. Scrub attire must be changed daily and /or when it becomes visibly soiled, contaminated or wet.

8. Cover jackets must be worn by non-scrubbed personnel over scrub attire when leaving the surgical area.

 Jackets should be long-sleeved and buttoned or snapped closed during use. When worn in the Surgical

 Services areas, cover jackets must be approved, non-linting, non-shedding material. 

9. Lab coats must be removed prior to crossing the designated area (red line) into the sterile core.

10. Long sleeved shirts and pants are not permitted to be worn under scrub clothing when in the Surgical

 Services areas. A non-shedding crew neck short sleeved T-shirt that can be contained completely within

 or covered by the surgical attire maybe worn.

11. In accordance with HR policy 5.06, stocking or socks must be worn with shoes. Perforated shoes are

 not permitted. Shoe covers are optional, but recommended when shoes have been worn outside the

 health care facility. They should not be worn outside the operative area and must be changed whenever

 visibly soiled or wet.

12. Bags, carry-alls and other totes that are not for clinical use carried in from outside of the Surgical

 Services areas are not permitted. 

13. No food or drink beyond the designated area (red line).

 Head and Facial Coverings

1. Head and facial hair must be completely contained using lint-free caps or hoods. Bald/shaved

 heads should also be covered to prevent shedding of squamous cells.

2. Homemade caps may be worn only if laundered daily. Disposable caps must be worn within the surgical

 (invasive) field, to maintain asepsis and in decontam.

3. Bearded personnel must wear a hood that completely covers the hair.

4. Religious headwear must be covered by a hood in the surgical area.

2:15-cv-12101-DML-DRG Doc # 24-6 Filed 08/27/15 Pg 2 of 3 Pg ID 626
Central Sterile 

Reprocessing

HENRY FORD 

HOSPITAL

Subject: Central Sterile Reprocessing Attire Policy

Effective: January, 2010 

 

Revised: February, 2014

Policy No.: 

Page: 2 of 2

Page 2 of 2

 Masks and Personal Protection Equipment

1. High efficiency filtration masks must be worn by all personnel in the Intraoperative restricted area.

2. Surgical masks must be properly placed on the face to prevent venting at the sides.

3. Surgical mask must be discarded immediately after use and /or when visibly soiled or wet.

4. Never wear surgical mask on top of the head or around the neck.

5. Protective eyewear must be worn by personnel within the surgical field and whenever performing tasks

 where there is potential for splash (refer to ICM Section 4)

6. No additional eye protection is required when laser-safe protection is worn. Refer to Laser Safety

 Manual for employee and patient laser safety requirements.

7. Face shields may be worn over the surgical masks.

8. Sterile gloves must be worn when performing sterile procedures and discarded after use or when

 damaged. (refer to ICM section 4)

9. Double gloving is permitted. Both gloves must be discarded after use or when damaged/torn.

10. Sterile fluid resistant gowns must be used by all personnel with the sterile field (see below- Sterile

 aseptic technique) completely impervious gowns must be worn when the complexity of the procedure

 places personnel at high risk of body fluid contamination. Sterile gowns must be disposable or

 reprocessed using manufacturer’s guidelines.

11. Petroleum products must never be used with latex gloves, unless a vinyl/plastic line is utilized.

 Personal Items

1. Jewelry should be confined or removed before entering the surgical field. Earrings, necklaces and other

 dangling jewelry must not be exposed over the surgical field. Rings watches and bracelets should be

 completely removed if scrubbing.

2. In accordance with HR policy 5.06 nails should not extend more that 1⁄4 inch beyond the finger tip. Nail

 polish must be free of chips and not peeling. Any visible nail under polish – polish should be removed.

 Artificial nails, tips, wraps, tapes, bands, rhinestones, and/or appliqués are NOT permitted, even if under

 gloves, anywhere in the clinical area

 

 Aprons

1. Fluid-proof (full front) aprons or impervious gowns must be worn when body fluids are anticipated. If

 aprons are disposable, they are to be disposed of after use and between patients.

Approved by: Shelley Hagan, RN, BSN, CNOR

Manager, Central Sterile Reprocessing

Reviewed by: Karla Zarb, RN, BSN, MSN 

Surgical Services Administrator

 

2:15-cv-12101-DML-DRG Doc # 24-6 Filed 08/27/15 Pg 3 of 3 Pg ID 627