Skull Cap or Bouffant Cap: Why It Matters

In 2014, the Association of periOperative Registered Nurses (AORN) published guidelines on operating room attire. The guidelines stated: “A bouffant hat should be worn to cover all of the hair, scalp, and ears to minimize skin and hair shedding and protect surgical patients from bacteria.”¹ A related article from the AORN stated to: “prohibit personnel from wearing skull caps altogether unless they are completely covered by a bouffant hat.”² The guidelines also stated that health care providers’ arms should be covered with long-sleeve apparel while in the OR.

What followed was a de facto prohibition on skull caps. Virtually overnight, OR managers across the United States removed skull caps from locker rooms, forbade personal skull caps made of cloth, and mandated the use of jackets within the OR areas. Surgeons and anesthesiologists were caught off guard and became upset as these top-down mandates were suddenly implemented with little or no physician input. The medical community was doubly frustrated to find that these guidelines were not based on rigorous scientific evidence, but rather “a number of studies showing that hair can be a source of bacterial organisms and potential surgical site infection.”³

Surgical attire mandates were quickly incorporated into local hospital policies and Joint Commission surveys, facilitated by AORN guidelines which provided OR managers with ready language.

The surgical community took umbrage at the skull cap prohibition. The American College of Surgeons released a statement that “the skull cap is symbolic of the surgical profession … [it] may be worn when close to the totality of hair is covered by it,”⁴ to which the AORN responded that “wearing a particular hair covering based on its symbolism is not evidence-based … our emphasis is on patient safety.” This exchange between the AORN and ACS eventually spilled into the lay press.⁵

The American Society of Anesthesiologists (ASA), for its part, assembled a working group in response to the AORN guidelines and actively met with the ACS, AORN and other stakeholders to ensure that anesthesiologists’ voices were heard and that future guidelines would be based on medical science.

Recent studies have shed light on the head covering issue. Two studies found no difference in rates of surgical site infections (ssI) before and after implementation of the AORN guidelines in over 40,000 combined patients.^6,7 Another study found that disposable bouffant hats performed inferiorly to skull caps (both disposable and cloth) with regard to “permeability, particulate contamination, and greater microbial shed.”⁸ A reanalysis of data from a hair clipping and ssI study found no relationship between the surgeon’s type of hair covering and rate of ssI.⁹ Mandated use of long-sleeved jackets cost one university medical center an extra $1 million annually; this translates to more than one-half billion dollars for all the hospitals in the United States.⁷

Fast forward to the present. The AORN recently released updated guidelines for surgical attire. Perhaps in response to recent studies and the input from the ASA and ACS, the AORN appears to have backtracked on the more contentious points in the previous guidelines. The new proposed guidelines state that “no recommendation can be made” regarding head covers, clothing underneath scrubs, and arm coverage; decision making is largely deferred to the local institution. To its credit, the AORN held a 60-day open comment period which closed on Feb. 22, 2019, and more than 200 comments were submitted. Final guidelines are scheduled to be published this summer.

The debate over surgical attire raises troubling questions regarding the roles of societies and individuals working in health care, the promulgation of policies, and the level of scientific evidence behind these policies. What is the authority of AORN, and how did its guidelines come to have such widespread influence? Why did the Joint Commission include the AORN surgical attire guidelines in its surveys with little or no physician input? How many other Joint Commission standards have dubious scientific justification? What other latent opportunities exist for nonphysicians to influence physician practice?

Prior to this episode, many physicians would have deemed a study of OR head covering an amusing sideshow—perhaps even a waste of time—but this controversy demonstrates that any issue, no matter how trivial, can become an opportunity for nonphysicians and regulators to influence physician practice. Only by taking proactive ownership of all things in the perioperative arena can we ensure that policies are held to the same “burden of proof” as our clinical practices. Ample opportunities exist for us to establish medical evidence and best practices in scientific, regulatory and policy areas. If we don’t do it, others will do it for us.

Dr. Chi is also a clinical instructor (affiliated), Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, in Stanford, California. Dr. Chi reported no relevant financial disclosures.

Editor’s note: The views expressed in this article belong to the author and do not necessarily reflect those of the publication.

References

1. Bartek M, Verdial F, Dellinger EP. Naked surgeons? The debate about what to wear in the operating room. Clin Infect Dis. 2017;65(9);1589-1592.
2. Spruce L. Back to basics: surgical attire and cleanliness. AORN J. 2014;99(1):138-146.
3. Association of periOperative Registered Nurses. www.aorn.org/ about-aorn/ aorn-newsroom/ health-policy-news/ 2017-health-policy-news/ aorn-guideline-for-surgical-attire. Accessed January 29, 2019.
4. American College of Surgeons. http://bulletin.facs.org/ 2016/ 10/ statement-on-operating-room-attire/ . Accessed January 29, 2019.
5. Kowalczyk L. No more surgical caps for surgeons? https://www.bostonglobe.com/ business/ 2016/ 08/ 31/ hat-wars-flaring/ abr7FuB9EZna1FRtECDR1K/ story.html. Accessed January 29, 2019.
6. Shallwani H, Shakir HJ, Aldridge AM, et al. Mandatory change from surgical skull caps to bouffant caps among operating room personnel does not reduce surgical site infection in Class I surgical cases: a single-center experience with more than 15,000 patients. Neurosurgery. 2018;82(4):548-554.
7. Elmously A, Gray KD, Michelassi F, et al. Operating room attire and healthcare cost: favoring evidence over action for prevention of surgical site infections. J Am Coll Surg. 2019;228(1):98-106.
8. Markel TA, Gormley T, Greeley D, et al. Hats off: a study of different operating room headgear assessed by environmental quality indicators. J Am Coll Surg. 2017;225(5):573-581.
9. Kothari SN, Anderson MJ, Borgert AJ, et al. Bouffant vs skull cap and impact on surgical site infection: does operating room headwear really matter? J Am Coll Surg. 2018;227(2):198-202.