Wednesday, August 31, 2016

OR head covering controversy: ACS vs. AORN

In early August, the American College of Surgeons (ACS) issued a statement on operating room attire. Much to my surprise and delight, it said this about headgear:

The skullcap is symbolic of the surgical profession. The skullcap 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. Like OR scrubs, cloth skullcaps should be cleaned and changed daily. Paper skull caps should be disposed of daily and following every dirty or contaminated case.

The Association of periOperative Registered Nurses (AORN) responded with a statement of its own:

Several types of evidence exist that support recommendations that perioperative personnel cover their head and ears in the OR. This evidence includes the fact that human skin and hair is naturally colonized with many bacteria, and perioperative personnel shed microorganisms into the air around them. We know airborne bacteria in the OR can fall into the operative field, contribute to the overall air contamination of the OR, and place patients at risk of surgical site infections. Completely covering the hair can reduce the number of bacteria introduced into OR air by perioperative personnel.

Unfortunately, the "evidence" cited by the AORN is all circumstantial. Yes, human hair and skin may be colonized with bacteria. There is no proof whatsoever that a single surgical patient has ever been infected by a hair or skin droppings from OR personnel. If you want to extend this logic to its inevitable conclusion, the entire neck and face should be covered too. Eyebrows and eyelashes could be deadly. Maybe all OR personnel, including circulating nurses and anesthesia, should wear helmets like those used by astronauts or deep-sea divers.

Some say it is impossible to do a study about this, but one of my Twitter followers came up with a perfectly reasonable suggestion. Simply have several teams of operating room personnel, some of whom are wearing bouffant caps and some wearing skullcaps, stand over an OR table. Instead of a patient, culture media could be placed in strategic locations. The OR teams should move about in scripted ways for an hour or two. Let's see whether there's any difference in the amount of bacteria grown in the cultures.

Perhaps the AORN should get its own house in order first. Many of the OR nurses and techs that I have worked with over the years wear their supposedly fully covering headgear like this:


Korhomme said...

There was a trend years ago for orthopods to wear astronaut type suits; I'm not sure if they were any use.

And if you're bald, are you excused wearing a head covering?

Skeptical Scalpel said...

Yes, I know about the ortho space suits. Funny how you don't see them any more.

Bald is no excuse. Don't you know that SKIN BACTERIA! could fall off a bald head?

artiger said...

Thank you for getting to this. I respect the AORN, as I feel they have been a high quality organization over the years, but this latest attempt at a power grab is silly. I really doubt that their rank and file members really support this. Any OR nurses out there who feel differently, please feel free to correct me.

Then again, their leadership may be in cahoots with ours in the ABMS, AMA, Joint Commission, etc...i.e., justifying their existence by creating more problems to solve.

I have to say that the ACS came off sounding pretty silly using the symbolism argument, but I credit them otherwise with standing up for their members. I mean, really, suggesting that the surgeons are not in charge? You got to stick by your principles.

Anon said...

As a junior registrar draining a perianal abscess late one night, I wore a scrub dress to theatre. There were no regular scrubs left (and in the Australian system, the hospital provides the scrubs en masse without vending machines involved). I was wearing TEDS which I wore under my regular scrubs, so this evening my knees were bare. I had no choice, there was nothing else available other than the dress.

To my horror I was immediately accosted by the Nursing Theatre Floor co-ordinator who demanded I change (not possible) or wear stockings (also not possible - it was 11pm). When I asked why, I was told that the risk of "pubic shed" would lead to surgical site infections. In my patient with a perianal abscess.

Yes. Pubic shed.

Dr Umesh Bilag said...

I think if exposed skin of consultant is also source of infection can we paint the surgeon with antiseptics.

Skeptical Scalpel said...

Artiger, I agree the symbolism argument was weak. They should have simply said there is no evidence that skullcaps cause infections--end of story.

Anon, I had heard the "pubic shed" claims many years ago. That is why nurses and techs no longer wear dresses. Of course, one could ask, wouldn't one's underwear contain most of the dreaded pubic shed. How did anyone survive an operation in the old days with all that pubic shed going on?

Umesh, good suggestion. Paint the skin and the hair of all personnel in the OR with Betadine, no chlorhexidine.

Anonymous said...

There actually have been a few pilot studies on scrub attire and hats which do not show any increased risk (cloth vs disposable, hospital laundered vs personal/home
laundered); AORN guidelines however are not informed by data. Guidelines like these seem to be in place to show who's boss...

Skeptical Scalpel said...

If you have links or references to those pilot studies, please send them to me.

For some reason OR nurses and the AORN are particularly prone to creating arbitrary rules. See

Libby said...

Maybe the Nursing Theatre Floor person thought Anon was going commando in the OR?

Skeptical Scalpel said...

That must have been it. Question: What does one store in the pubic shed?

George Gasman said...

Pubic hares?

pamchenko said...

"I'm just being a patient advocate..."

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