Another chapter in “Surgical Cap Wars”

No one expected the AORN [Association of periOperative Registered Nurses] to meekly accept the conclusion of the paper which found no difference in infection rates when surgeons wore surgical skullcaps or a bouffant-style head coverings.

The AORN recently fired back with a letter to Neurosurgery, the journal that published the paper. It has not yet printed the letter or a response to it by the authors of the paper. I look forward to seeing both.

Meanwhile, Becker’s Infection Control and Clinical Quality revealed some tidbits an article entitled and “AORN experts respond to study on bouffant use and SSI rates.” [SSI = surgical site infection]

The AORN claims that it never mandated the use of bouffant headgear. It merely called for “a clean surgical headcover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn” because “hair carries bacteria that could [emphasis mine] cause an SSI.”

Lisa Spruce, the director of evidence-based practice for the AORN, said, “It’s up to the facility to determine what’s the best way to get everyone’s hair covered.” This is rather disingenuous as everyone knows the only way to cover every single hair on the head is to wear a bouffant or a hood.

The AORN did not offer any evidence that hair causes infections. Instead Spruce and the other AORN experts chose to nitpick the Neurosurgery study by pointing out a single scatter plot that showed what they said was a decrease in SSI rates after bouffants were worn.

They claim the figure below indicates fewer infections occurred late in the 13 month period of bouffant usage because it took some time for everyone to comply with bouffant use.

Blue is skullcap. Red is bouffant. Time in months

They offer no proof that adoption of the bouffant took several months. In my experience, when hospitals go from skullcaps to bouffants, the transition is abrupt. On the day the mandate takes effect, skullcaps are no longer available. And by the AORN's logic, one could argue that the plot shows a spike in bouffant-associated SSIs at months 4 and 5 of use.

What about statistical significance? The table directly above the figure they cited clearly shows that there was no significant difference in the SSI rate between the two types of headgear for all operations in the hospital, spine cases, or craniotomy/craniectomy procedures.

Click on table to enlarge it.

In fact if you believe in trends, there were slightly more infections for overall operations and spine cases in the bouffant group.

The AORN wants all hair covered. What about the eyebrows? As I mentioned in a post back in May, an outbreak of SSIs that occurred after some plastic surgery operations in Israel was traced to an organism found in the surgeon’s eyebrows.

Bottom line: If the AORN cannot cite evidence proving that scalp or facial hair causes infections, its experts should do their own research and publish it—otherwise stop damaging the organization’s already marginal credibility.

Thanks to Artiger, a loyal reader of my blog posts, for sending me the link to the Becker's article.