Surgical Caps Get Clean Bill of Health
Large Study Reveals No Link to Surgical Site Infections
By Christina Frangou
Cancun, Mexico—At last, in one of the most hair-raising debates in surgery in the last year, some data you can hang your hat on.
In an analysis of more than 6,200 ventral hernia repairs carried out by 68 surgeons, investigators could not identify any association between the type of surgical hat worn by surgeons and the risk for surgical site infection (SSI) or surgical site occurrence (SSO) requiring procedural intervention.
“Surgeons should be allowed to wear the hat of their choice without concern for negatively affecting their patients’ outcomes,” said Michael Rosen, MD, director of the Comprehensive Hernia Center at the Cleveland Clinic and medical director of the Americas Hernia Society Quality Collaborative.
“The bottom line is you should feel comfortable wearing whatever hat makes you comfortable, and you are not harming your patients. There are other things you can do to optimize your surgical outcomes, but the surgical hat has nothing to do with it.”
Dr. Rosen presented the data, along with an entertaining slideshow including photos of him modeling various types of surgical headwear, at the 2017 annual meeting of the Americas Hernia Society.
The presentation was warmly received in the room of surgeons, many of whom have been frustrated by the campaign to convince surgeons to give up their skullcaps for bouffants. One attendee, who didn’t give his name, said his hospital and surgical center had been reprimanded because the surgeons wore cloth skullcaps.
The study was designed to settle an ongoing debate about patient safety and the type of headwear worn by operating room personnel—a debate that has elicited an unusually emotional response from surgeons.
It began when the Association of periOperative Registered Nurses (AORN) recommended that all hair should be covered in the OR, which would preclude surgeons wearing a traditional surgical cap. The missive led to a crackdown on OR staff in hospitals throughout the United States, with surgeons at a number of institutions receiving reprimands for leaving hair around their ears exposed during surgery. After a protest from surgeons, the American College of Surgeons responded with guidelines of its own, stating that 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.”
AORN countered with a response that reviewed the ACS statement in detail, noting where they believed the ACS statement was supported or not supported by evidence. The group criticized the surgical organization’s stance on skullcaps: “Wearing a particular head covering based on its symbolism is not evidence-based and should not be a basis for a nationwide practice recommendation.”
It continued: “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.”
In the same month, surgeons at the Cleveland Clinic received an email stipulating that all skullcaps be removed from the OR and that all surgeons should wear a bouffant. The policy lasted an hour before it was retracted due to an outcry from surgeons.
Frustrated with the lack of data to support either position, Dr. Rosen set out to use the AHSQC data to examine the issue. He sent out a survey to 86 surgeons in the AHSQC, to which 79% responded. The surgeons had performed 6,210 ventral hernia cases with an SSI rate of 4.1%, an SSO rate of 12% and 5.8% SSOs that required procedural intervention.
The respondents’ preferred cap was a disposable surgical skullcap, worn by 48%. Nine percent wore a cloth surgical skullcap, 29% preferred a disposable bouffant with their ears exposed, and 16% wore a disposable bouffant with their ears covered. No surgeons who responded to the survey wore a cloth bouffant or beard-covering bonnet.
In a multivariate analysis, no single type of skullcap or surgical cap predicted SSIs or SSOs requiring procedural intervention. It did identify factors associated with a higher risk for an SSI or SSO requiring intervention: patient female gender, obesity, hypertension, hernia width, modified Ventral Hernia Working Group grade and OR time over two hours (P<0.05).
The study is already being used by surgeons to defend their choice to wear a skullcap or bouffant. Two days after the presentation at AHS, surgeons at Greenville Health System were asked to consider a policy that would prohibit the wearing of skullcaps.
“I used this study to say there appears to be absolutely no difference over what headgear you wear. The research cited by AORN and others who want to scrap surgical skullcaps is outdated and fails to link infections to any particular headgear,” said Alfredo Carbonell, DO, one of the co-directors of the Hernia Center at the Greenville Health System in Greenville, S.C.
The AHSQC data only cover one type of surgery and may not be applicable in other fields, but it is “many times better than anything that’s been published to date,” Dr. Carbonell said.
“These kinds of decisions—to get surgeons to give up skullcaps—are things that decrease morale. If we are making decisions based on non science, that’s a dangerous decrease to morale.”
Dr. Rosen said he hopes this analysis will put to rest some of the concerns about surgical skullcaps. But it does not dispel all of them. While it is the largest study of the issue to date, it does not address some of AORN’s chief concerns. The surgeons who were involved with the study were not cultured for bacteria. But AORN cites several small studies, dating between 1965 and 2004, that show that OR personnel can carry bacteria on their hair. While there is no evidence in the scientific literature that links these bacteria to wound events or shows that particular surgical headwear may prevent transference of bacteria, AORN argues that headwear that completely covers the hair can reduce the number of bacteria introduced into OR air by perioperative personnel.
There is one case from Israel, reported in the lay press, in which 15 women developed bacterial infections after undergoing breast surgery at Atidim Medigroup Hospital, in Tel Aviv. The infections were linked to a bacterial organism that appeared in the whirlpool bath of the plastic surgeon who’d performed all the operations. The Israeli newspaper Haaretz reported that an investigation undertaken by the Health Ministry traced the source of the infection to the surgeon, who carried the mycobacterium in his hair and his eyebrows (www.haaretz.com/?the-jacuzzi-bug-1.134323).