Monday, May 22, 2017

Finally, evidence clarifies the surgical caps controversy

A study of clean surgical cases found no significant difference in wound infection rates for 13 months before and 13 months after the use of bouffant surgical caps became mandatory. Infection rates for the 7513 patients operated on when surgeons were allowed to wear traditional skullcaps, was 0.77%, and for the 8446 patients who had surgery after the bouffant cap mandate, the infection rate was 0.84%. Subgroup analyses of only patients having spine or cranial operations showed similar insignificant differences in wound infection rates.

The study, from a group in Buffalo, New York, was published online in the journal Neurosurgery.

At the 2017 Americas Hernia Society meeting, Dr. Michael Rosen, director of the Cleveland Clinic Comprehensive Hernia Center, presented the results of a survey of 86 surgeon members of the society's quality collaborative.

Ventral hernia repairs were done in 6210 patients with a 4.1% incidence of wound infection. Risk factors for surgical site infection were obesity, hypertension, width of hernia, operation duration greater than two hours, and female sex. The type of cap worn was not associated with the occurrence of a wound infection or any other surgical site complication such as seroma, wound dehiscence, or enterocutaneous fistula.

Of the 79% of surgeons who responded, 48% said they wore disposable skullcaps, 9% wore cloth skullcaps, 29% wore bouffant caps with ears exposed, and 16% wore bouffant caps covering their ears.

[I know that adds up to 102%, but that's what the General Surgery News article about the paper said.]

The report mentioned a series of postoperative infections caused by a mycobacterium at an Israeli hospital in 2004. At the time, a newspaper account of the 15 breast plastic surgery patients said an investigation found the source was a surgeon whose hair and eyebrows were colonized from his home Jacuzzi.

In 2016, the surgeon published a paper about the incident. The organism had never been identified before and was christened M. jacuzzii. Several patients suffered persistent infections and required removal of implants. In the paper, the surgeon revealed he wore a standard paper cap [presumably a skullcap] and the organism was also found on his facial skin.

While some might suggest this paper justifies the use of bouffant caps, the surgeon could still have contaminated the operative field with organisms from his facial skin or eyebrows. Other than with a space helmet, complete coverage of the eyebrows and facial skin is impossible.

The paper from Buffalo had some limitations. It was from a single hospital and was not a randomized trial. However, it was sufficiently powered to detect a difference in infection rates.

The hernia study was not as scientifically rigorous as the Buffalo study, but enough procedures were analyzed to detect a difference in infection rates had one been present.

In the GSN story, the Association of periOperative Registered Nurses (AORN) response to the American College of Surgeons statement supporting the use of skullcaps was quoted. “Wearing a particular head covering based on its symbolism is not evidence-based [nor is the AORN's bouffant cap rule] and should not be a basis for a nationwide practice recommendation.”

Now that we have evidence that skullcaps are not linked to increased infection rates, will the AORN at last get over its obsession with bouffant caps?

My previous posts on this topic can be found here and here.


George Gasman said...

(I'm *so* glad to be retired...)

But, science be damned. It's POLICY, dontcha know?

Korhomme said...

I thought that most post-op infections were caused by the patients' own germs, so that what sort of caps surgeons wore was largely irrelevant. Is this no accepted today?

Skeptical Scalpel said...

Yes, George, it's policy.

Korhomme, the patient's skin is a common source of infection, but infections can be caused by unsterile instruments, breaks in sterile technique, technical errors by the surgeon and other factors. What type of cap is worn or how much hair is exposed? Nope.

George Gasman said...

The bean-counters and policy-makers don't care about anything *other* than policy. Patient safety comes second.

To wit: We had a "surprise" visit from our state public health department. They dropped in to see how the OR functions, and one inspector was watching a case get set up. During setup, an x-ray tech wheeled her machine into the room, and the back of her unsterile gown brushed against the sterile table. NO ONE SAW THIS OTHER THAN THE INSPECTOR.

Guess what happened? We got cited for a break in sterile technique. That's probably legit.

Guess what else happened? The case proceeded as though nothing had happened.

In other words, a break in technique, seen by the inspector, was enough to cause a citation, but not enough to notify the staff that such a break occurred.

Gotta keep that clipboard filled with checkmarks.

Skeptical Scalpel said...

George, great story. In a few words, it tells you a lot about what is wrong with bureaucracies. I bet the inspector felt pretty good about catching that mistake too.

Anonymous said...

I sent this to the director of the OR at my institution and was told to piss off.

Skeptical Scalpel said...

I assume the director will not be signing up to receive email notifications of my new blog posts. Are you from the U.K. or Ireland? Piss off is what they say over there.

artiger said...

I'm really surprised that AORN was willing to fall on a sword without some sort of credible evidence. I've known them (via their members) to be a much more reputable organization than what they have displayed. Same could be said about the ACS, with their "symbolism" nonsense. Still, although I don't think this battle is necessarily over, the surgeons certainly struck a serious blow. If AORN has any sense, they'll quietly back away from this one.

Oldfoolrn said...

A long time ago the bureaucratic agencies were obsessed with containing perineal fallout. We were carefully monitored for snug fitting rubber bands on our scrub pant cuffs. I have a post on my blog about this nonsense-

I don't which sounds more goofy. In depth studies of surgical cap usage or crotch confinement studies

Skeptical Scalpel said...

Artiger, I'll be shocked if the AORN gives up on this. It's not their style.

Old, I remember when the perineal fallout business started. OR nurses used to wear dresses. One day they were banned.

Korhomme said...

There were some in UK a while back who didn't wear face masks; this didn't seem to catch on.

Is there any evidence for their use?

Skeptical Scalpel said...

I do not believe there is any evidence that wearing a facemask reduces surgical site infection rates. Having been splashed in the face on many occasions, I think everyone at the table should wear a mask to protect themselves.

George Gasman said...

I don't have the studies at hand, but iirc, one study on the effectiveness of face masks showed that there was indeed a higher incidence of infection - among those not wearing the masks, not the patients!

My understanding is that in Great Britain, the only people in the OR wearing masks are those at the table: surgeon, assistant, scrub nurse. No one else is.

However, returning to headgear. Other than the issue of comfort (and I for one always found the "cap" more comfortable than any hood or shower-cap) is there any other reason for the objection besides the vanity of the wearer? Before you jump on me, note that I have a full beard, and I *always* wore a cap, until the clipboard carriers killed it.

No question that, yeah, it "looks better," but should vanity be the deciding factor it OR attire?

If there's no evidence that one's better than the other from a patient standpoint, let them wear whatever they wish. Everyone has a bit of vanity and comfort preferences. All I'm saying is that we should acknowledge that and do as we please, clipboard carriers be damned.

Skeptical Scalpel said...

There's no evidence that one cap is better than another so it shouldn't be an issue at all. I think surgeon comfort is important especially in a long case. I hated the way a bouffant cap felt. It was irritating and at times distracting.

George Gasman said...

Yup. I didn't wear the shower-cap either, until it was mandated. The elastic always annoyed me, and *I* was able to scratch!

Agreed - no evidence? Go away, clipboard lady.

Skeptical Scalpel said...

Yes, no evidence that the bouffant is better.

Oldfoolrn said...

One good clip with a St. Mayo scissors solves that irritating elastic band on the bouffants. You can even obscure the cut elastic with the lower mask tie. My favorite cap was a bouffant with the annoying elastic band excised.

Anonymous said...

Anonymous Europe: I have been shaving my head bald for the past 10 years every day.:) Does not matter what I wear.:D

artiger said...

What little hair I have remaining is kept very short...a cap has no problem covering it.

I'm sure AORN has some counter studies underway to attempt to save face. It's just another attempt at wrestling control. I wish they'd find a better use of their time, and their members' dues.

Skeptical Scalpel said...

Anon Europe, I shaved my head for years. The rule still was I had to wear a bouffant cap. I got around it though. The story is in one of the posts I linked to.

Artiger, I doubt these two studies will change the AORN's position. As you noted, it's also about power and who is in charge.

Unknown said...

I'm a CST of 15 years and my hospital has now mandated we all wear the disposable bouffant hats OVER our cloth hats no matter the type of cloth hat. The reason I went to a bouffant cloth hat was because my 3 foot long hair could no longer be contained in the skull cap comfortably. The disposable bouffant hats not only can not hold my hair but they also break my skin out. I break out from the "hypoallergenic scrubs" we are made to wear so I take some clean ones home to wash and I bring them back in in a sealed bag. Now my issue is I have to cover my cloth scrub hat with a disposable bouffant hat that breaks me out because the "cloth hat might not be clean enough" I wash it with the scrubs I bring in but I don't have to cover the scrubs? Having a CST with boils on her from the disposable bouffant hats is better than pissing off AORN apparently.

Skeptical Scalpel said...

Codi, welcome to a world where there is no nuance, no room for extenuating circumstances, and no deviation from a rule because "it's a rule." Never mind that the rule is not based on any evidence. Yes, welcome to the world of modern medicine.

William J. Williams said...

Anyway,the doctor is fully armed when performing surgery on the patient. Hats, masks, gloves, disposable surgical gowns are essential

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