Abstract
The current medical, political, and social environments create substantial challenges for healthcare providers. As healthcare delivery grows increasingly more complex, however, there remains a robust, albeit appropriate, emphasis on reducing morbidity and mortality while simultaneously lowering costs. One major focus has been to identify and mitigate risk factors for surgical site infections (SSI), which account for one-third of all hospital-acquired infections and are the most costly to treat [1,2]. Several published guidelines provide evidence-based practice recommendations to minimize this complication within the operating room setting [3—5]. Unfortunately, universal agreement on specific guideline recommendations is lacking. As a result, physicians, nurses, and other caregivers struggle to implement the most effective strategies for optimal patient care.
Founded in 1981, the Surgical Infection Society comprises more than 540 active members, including surgeons, scientists, physicians, pharmacists, nurses, and advance practice providers. Its primary mission is to educate healthcare providers and the public about infection in surgical patients and promote research in the understanding, prevention, and management of surgical infections. The society's Therapeutics and Guidelines Committee is tasked with reviewing pertinent literature and preparing guidelines and scholarly reviews regarding prevention and management of surgical infections. Our goal here is to comment on the most recent iteration of the AORN Guideline for Surgical Attire, and specifically the topic of appropriate head coverings in the operating room.
First, we support recommendation 5.2 under the Head Coverings section, which states that, “No recommendation can be made for the type of head or beard covers worn in the semi-restricted and restricted areas.” As mentioned, current evidence, “does not demonstrate any association between the type of surgical head covering material or extent of hair-coverage and the outcome of SSI rates.” In addition to the articles cited, we recommend including studies by Rios-Diaz et al. [6], Shallwani et al. [7], and most recently, Elmously et al. [8] that all demonstrate no decrease in SSI rates after implementation of a bouffant-only, no surgical cap policy for head covering in the operating room. Elmously et al. [8] also performed a cost analysis for implementing this policy, which includes caps with beard covers and disposable operating room jackets and found substantially higher costs associated with the policy change.
Second, we support recommendation 5.3 under the Head Coverings section, which states that, “No recommendation can be made for covering the ears in the semi-restricted and restricted areas.” As discussed, although the ears are a “potential reservoir for pathogens,” current evidence “has not demonstrated any association between covering the ears and SSI rates.” Indeed, the previously cited article by Markel et al. [9] demonstrated that compared with disposable surgical caps, bouffant hats result in substantially higher microbial shed and particulate contamination at the sterile field. Taken together, covering the ears with bouffant caps may, in fact, be counterproductive. Moreover, this recommendation is important because bouffant caps can interfere with the proper fit and function of surgical headlamps and protective eyewear.
In summary, lack of universal agreement on patient care guidelines is one of many challenges for front-line practitioners in today's complex healthcare environment. Multiple reports from the Institute of Medicine highlight the critical juncture of communication with quality and safety [10–12]. Interprofessional collaboration with health professionals working together to deliver the highest quality of care clearly results in improved quality and safety [13–15]. To this end, we commend AORN for its substantial efforts to minimize risk factors for SSI and appreciate the opportunity to review and comment on the updated guidelines. We support the revised recommendations that do not specify any advantage for particular head coverings or covering the ears for the prevention of SSI in the operating room environment. Last, we welcome future collaborations with AORN and other relevant societies and regulatory bodies that can help ensure the most efficacious and safe treatments for our patients.