Friday, July 13, 2018

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.

Also in 2017 at the Annual Clinical Congress of the American College of Surgeons, investigators from the Gundersen Health System in Wisconsin presented an observational study of 1543 surgical patients whose surgeons wore bouffant caps in 39% of cases and surgeons’ caps 61% of the time. After adjusting for the type of procedure, there was no significant difference in the rate of surgical site infections between the two groups.

Another study presented at that ACS meeting measured the amount of microbial contamination of a simulated surgical field when participants were wearing either type of cap. Using passive settle plate analysis, the investigators found significantly higher microbial shedding when bouffant caps were worn. Bouffants were also more permeable than either disposable or cloth surgeons’ caps.

A paper presented at the 2018 meeting of the Association for Academic Surgery/Society of University Surgeons involved patients at Thomas Jefferson University in Philadelphia who underwent non-vascular clean or clean-contaminated procedures before and after ban on the wearing of traditional surgeons’ caps. For the more than 3000 patients, the rate of surgical site infections was not significantly different between groups.

Two Rochester, New York teaching hospitals were subjected to new regulations mandating coverage of ears and facial hair after a visit from the state Department of Health. A before-and-after study involving over 6500 patients found no significant differences in wound infections, other complications, length of stay, or deaths for the two time periods.

Purists will complain that none of these studies were prospective randomized double-blind trials. However, the number of cases that would have to be done in order for a study to have enough statistical power to legitimately show no difference between the two types of headgear would be prohibitively large. The authors of the Rochester paper calculated it would take a sample size of 485,000 patients to show a 10% reduction in surgical site infections in patients with clean or clean-contaminated wounds. That study is not going to happen.

Proponents of the bouffant cap—the Joint Commission and the Association of periOperative registered Nurses—must now produce evidence showing bouffant caps are more effective in preventing surgical site infections or admit they were wrong.

Thanks to  @hassler_ken for suggesting this post


Unknown said...

In the majority of SSI cases, the pathogen source is the native flora of the patient’s skin, mucous membranes, or hollow viscera. maybe we should keep using them to protect ourselves from them

Just a thought said...

So the AORN said that they did not push to change what we wear in the OR. Here is the article that they updated.

I guess they can’t say they are wrong, but would you expect them too?

artiger said...

And, not surprisingly, both AORN and Joint Commission (aka Dumb and Dumber) remain silent since EVIDENCE has been presented. Could it be that, I don't know, they don't have any evidence, and never did?

Korhomme said...

Fascinating, Skepto, thank you! To think that the quasi-religious indoctrination that we had over the years simply isn't borne out when examined.

It's common to see people in the butchery counter of the supermarket wearing 'hair nets', though I usually thought of this as cosmetic. People who work in ultra-clean environments making computer chips, for example, are usually shown in full surgical gear with bouffant caps. Is there any evidence that any of this is actually effective, rather than just a means of reminding the workers to be careful?

Anonymous said...

What a great resource!
While a ban of the traditional paper surgical cap has not yet made it to any of the hospitals I operate in, there are rumblings from some AORN partisans. Is there even a single study they could "cherry pick" that I may have to be ready to address?

Oldfoolrn said...

Back in the Day, AORN had credibility and was proudly known as Association of Operating Room Nurses. I suspect some upstart, office sitting youngsters changed their name to sound more sophisticated and exclude LPNs. Before the advent of OR techs, LPNs were commonly utilized as scrub nurses. They were very proficient and taught me many tricks of the scrub nurse trade.

Years ago surgeons always won any argument with a nurse because they were captain of the ship and the apex predator in the OR food chain. Things are different today, Dr. Skeptical. Good luck getting "professional" nurse youngsters to admit they are wrong about anything.

Skeptical Scalpel said...

Artiger, yes they never had hard evidence.

Korhomme, I just don't want hair in my food--not because I could get sick. It's more of an aesthetic thing. I think there may be some evidence that dust and hair in your hard drive could be an issue.

Anon, I believe there are some theoretical studies suggesting there could be a problem, but I can't cite them for you.

Old, I agree. I would be shocked if the AORN concedes anything on this subject.

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