#BanTheBouffant

By Mary L. Brandt

If you don’t work in an operating room, you may not be aware of the controversy going on about OR caps.  To get right to the point – the surgeons think they should be allowed to wear the cloth hats they have worn forever.  The Association of Operating Room Nurses (AORN) developed guidelines which included covering the ears and all hair (which means a bouffant paper hat). These guidelines were then implemented by JACHO which means they became “law” in every hospital in the United States.

Anonymous surgeons demonstrating extremely effective covering of all hair with bouffant hats.

I’m a real believer in evidence based medicine (and policies) so I decided, like others, to look into what is really known about the issue.  Because it is a conflict of interest, I need to disclose that I can’t stand the bouffant hats and I really, really miss my (clean and washed) cloth hats. (which BTW cover all my hair!)

What do the data say about the use of bouffant hats and infection rates?  

• In a review of NSQUIP data of 6,517 patients, there was no difference in infection rates after the rules were put in place that required the use of bouffant hats.
• In a very satirical, but evidence based review, which looked at the used of bouffant hats (no evidence they reduce infections), the authors also pointed out that naked surgeons would shed less bacteria than surgeons wearing scrubs.
• In a review of 15,000 cases, half done before the rule was implemented and half after, there was no change in surgical site infections (SSIs)
• The American College of Surgeons task force on operating room attire recommended the following: “During invasive procedures, the mouth, nose, and hair (skull and face) should be covered to avoid potential wound contamination. Large sideburns and ponytails should be covered or contained. There is no evidence to suggest that leaving ears, a limited amount of hair at the nape of the neck, or modest sideburns uncovered contributes to wound infections.”
• A study of 6210 patients undergoing hernia repair showed no difference in rate of infections based on the type of cap their surgeon wore during surgery.
• In a study of bearded surgeons vs clean shaven surgeons there was no difference in bacterial shedding, suggesting that the new requirement for “beard hats” is not necessary.

Why don’t surgeons like bouffant hats?

It’s harder to keep them in place when wearing loupes or headlamps. If the goal is to keep the hair covered, this is a real problem.  When moving headlamps, operating microscopes or loupes, the bouffant hat often moves substantially – or even comes off entirely.

They are hot. Many surgeons feel (me included) that the bouffant hats are uncomfortable and are hot.  One can argue that anything that increases surgeon discomfort could affect concentration, which might be reflected in less focus on the operation.

Bouffant hats are expensive and bad for the environment.  On Amazon, 100 bouffant hats cost $7.45.  There were 48 million inpatient operations performed in 2009.  When you add the 48 million outpatient procedures performed, that means there are roughly 100 million operations performed per year.  (Mind you, these data are almost 10 years old, so it’s likely to be more now).  If we assume an average of 4 cases/day by an average surgical team (nurses, CRNA, anesthesiologist, assistants/resident) and they all wear their hat for the day, the number of hats needed per year would be 100 million cases x 6 members of the team = 600 million hats/yr. 600 million hats divided by 100/box = 6 million boxes x $7.45 = $44,700, 000.  Over 44 million dollars a year for the bouffant hats… all of which (600 million/year) end up in a land fill or are incinerated.  p.s. Given that hats are often changed during the day, this number is probably on the low side.

It affects morale.  In a survey of young (<45 years of age) surgeons, 71.2% stated that the new rules had affected surgeon morale.

They are inferior in blocking bacteria when compared to other caps.  In a study of bouffant hats, disposable skull caps and cloth hats, the bouffant hat was the worst in preventing airborne bacterial contamination in the operating room.  “I expect our findings may be used to inform surgical headgear policy in the United States,” he said. “Based on these experiments, surgeons should be allowed to wear either a bouffant hat or a skullcap, although cloth skull caps are the thickest and have the lowest permeability of the three types we tested.” Troy A. Markel, MD, FACS

Photo credit

I’m confident that in the very near future we will be back to wearing our clean, cloth hats.   When you look at the data, and weigh the pros and cons, it seems pretty obvious what needs to be done….

This article was originally posted on Wellness Rounds on March 17, 2018.

Mary L. Brandt, M.D. is Professor of Surgery, Pediatrics, and Medical Ethics at Baylor College of Medicine and a practicing pediatric surgeon at Texas Children’s Hospital. She has held numerous educational roles including Program Director of General Surgery and Senior Associate Dean of Student Affairs. She actively blogs and tweets about medical education and self-care for students, residents and practicing physicians. 

 

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