Everything you ever wanted to know about operating room head coverings

In case you might want to challenge your hospital’s policy on the subject, I have gathered all of the recent research I could find on surgical head wear.

In response to a 2013 question from a reader, I blogged about the complete lack of evidence that OR staff hair caused wound infections or any other problem. After a similar question from another reader three years later, I pointed out nothing had changed.

Finally a 2017 paper in the journal Neurosurgery appeared online comparing the incidence of wound infections in clean cases for the 13 months before and the 13 months after the institution of a ban on the wearing of the traditional surgeons’ ca`p. Over 15,000 patients were included in the study which found no statistically significant difference in the rate of wound infections.

Controversies in OR infection control

Like professional athletes, Skeptical Scalpel sometimes talks about himself in the third person. A recent article in Clinical Infectious Diseases [CID] confirms what Skeptical Scalpel has said about a couple of controversial topics in infection control.

The article by surgeons from the University of Washington was published online in late May of this year and gives historical context to some of the standard operating room practices we currently argue about.

Regarding operating room headgear, the authors dissect and refute the positions endorsed by the Association of periOperative Nurses (AORN) that hair and airborne bacteria cause infections. In fact, they say wearing of any kind of hat in the OR may actually disperse more bacteria due to the effect of the hat rubbing against the hair and causing an increase in bacterial shedding.

They conclude “there is little reason to support the AORN recommendations regarding head covering.”

Who really did the case?

According to the Residency Review Committee for Surgery, "A resident may be considered the surgeon only when he or she can document a significant role in the following aspects of management: determination or confirmation of the diagnosis, provision of preoperative care, selection, and accomplishment of the appropriate operative procedure, and direction of the postoperative care."

In nearly all instances, resident "determination or confirmation of the diagnosis, provision of preoperative care, selection of the operative procedure, and direction of the postoperative care" happen only in emergencies. For the majority of elective patients and same day operations, the residents do not play significant roles in most components of perioperative management.

What about "accomplishment of the appropriate operative procedure"? Are the residents really doing the cases they scrub on?

A recent paper from the University of Texas Medical Branch in Galveston, called "Who did the case? Perceptions on resident operative participation," looked at this question in a surprisingly candid way. The authors asked residents and faculty to independently assess what percentage of the operation the resident performed.

For the 87 cases for which responses from both resident and attending surgeon were available, agreement on percent of the case performed by resident (< 25%, 25 to 50%, 50 to 75%, > 75%) occurred in 61%, agreement of the role the resident played (first assistant, surgeon junior year, surgeon chief resident, teaching assistant) occurred 63% of the time, and agreement on both percent and role occurred only 47% of the time.

This reminds me of a story from when I was a resident. In the surgeons' locker room one day, someone asked a senior attending if the resident who scrubbed with him had done the case. The attending replied, "He thinks he did."

That's what the authors from Texas found too. In about two-thirds of the cases with disagreement about the percent of a case the residents did, the residents felt they performed larger portions of the case than did the faculty.

What constitutes "a significant role" is open to interpretation.

A resident once came to me and said, "I'm not really sure I should claim I was the surgeon for a case I scrubbed on today. Should I log myself as 'surgeon' anyway?"

I said, "If you have to ask, you probably shouldn't claim it."

Surgical residents are supposed to enter the cases they do in an online database, and the RRC uses these data in its accreditation process. The American Board of Surgery mandates that residents perform specific numbers of various types of cases in order to be eligible to take their boards.

A 2016 study in the Journal of Surgical Education surveyed 82 residents from various surgical specialties at UC Irvine and found only about half of the responding residents were told how to assess what their role was, and they were often delinquent [for more than one year at times] in logging their procedures leading to inaccuracies in the logs.

The authors concluded that the way cases were being logged raised "concerns about the use of the system for assessing surgical preparedness or crediting training programs."

The two papers cited above are small studies from single institutions, but in my opinion, probably reflect the reality in most residency training programs.

Submitted case log numbers may be misleading. This may be a previously unidentified factor in the crisis in confidence afflicting some graduating chief surgical residents.

Would competency-based training be better? The buzz about competency-based training has died down, and there are skeptics including the authors of this thoughtful editorial from the Journal of Graduate Medical Education.

Starting in the 2017-2018 academic year, the American Board of Surgery will require a minimum of 850 operative procedures for the five-year training period and 200 operations in the chief resident year—increases from 750 and 150, respectively.

Will competency-based training or increasing the number of operations required help?

Not if the residents aren't really doing the cases.

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:

It's time to discuss surgeon headgear again

I received this email last week:

My state has recently banned the time-honored surgical cap,

Timed-honored cap

in favor of the “bouffant” cap.

"Bouffant" is French for "doofus"

I have been wearing the disposable surgical caps for my entire career, and have one of the lowest infection rates of any surgeon at my hospital.

Not only are the bouffant caps uncomfortable, I have now developed a severe allergy to them, making them unwearable. Now they say I must wear a full head/beard cover type cap in order to satisfy their requirements...REALLY? 

Head and beard cover even more uncomfortable than bouffant

I asked the hospital to show me a study that proves that the use of a bouffant cap has ANY advantage at all. Of course they can't, because no such study exists.

OR delays: Who's responsible and what can be done?

Every two or three years, someone, usually a hospital administrator, decides that delays in operating room turnover time need to be looked into. A committee of 20 or 30 stakeholders (love that term) is appointed and assigns someone the job of measuring the time between cases and identifying reasons for delays. In years when turnover time is not being studied, first case starting delays are on the agenda.

In my nearly 24 years as a surgical department chair, one or the other of these issues was investigated at least 10 times. We were never able to conclusively determine the exact causes of delays or solutions to the problem, and we returned to business as usual.

An article in Anesthesiology News about a paper that looked at causes of operating room delays in over 15,500 cases at a single hospital got my attention.

The number one reason for delays was that the nurses did not have the operating room ready for the patient. Nursing also was responsible for the third most common cause "preop prep (IVs, meds, etc.)."