In Reply: Mandatory Change From Surgical Skull Caps to Bouffant Caps Among Operating Room Personnel Does Not Reduce Surgical Site Infections in Class I Surgical Cases: A Single-Center Experience With More Than 15 000 Patients

To the Editor: As the senior authors of our study,1 we appreciate the opportunity to respond and hopefully further the dialog that is underway regarding recent issues in surgical attire, specifically regarding the surgical cap. Surgical staffs around the nation would be surprised to hear that the Association of periOperative Registered Nurses (AORN) has not taken a position banning the surgical cap. Site surveyors at numerous hospitals believe and have acted otherwise. The full guidelines may not specifically ban the cap, but the language (“A clean surgical headcover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn”2) effectively does ban the cap. And the online summaries as to head covering, provided by the AORN in 2014 and 2015 (and accessed then), were specific in the need to eliminate access to and availability of the cap. Further, presentations and publications by AORN leadership in the AORN’s own journal with AORN-sponsored continuing education credits are very clear. In an article by Dr Spruce entitled “Back to Basics: Surgical Attire and Cleanliness,”3 the need to “wear appropriate attire” is specified: “bouffant hair coverings.” In the same article, the means of successful implementation are also specified: “Emphasize the importance of the policy with regard to patient safety,” while being “aware of barriers to practice change,” such as by “providing skull caps.”3 And in the continuing education post-test, question 2 begins: “One reason that it is important for perioperative personnel to cover their hair with a bouffant hat rather than a skull cap…” A 2012 article in the AORN Journal by Drs Braswell and Spruce entitled “Recommended Practices: Implementing AORN Recommended Practices for Surgical Attire”4 states “Skull caps are not recommended…Perioperative nurses can talk with their department managers and materials management department personnel to eliminate the availability of skull caps.” The end result of this policy and its implementation into practice are emblematic of the core problem of the regulatory state: a top-down exercise of power, however well intended, with significant unforeseen consequences. In our case, our hospital system, which is the largest nongovernmental employer in our region, was faced with immediate jeopardy with the Centers for Medicare & Medicaid Services over surgical head coverings. This threatened more than 60 postgraduate training programs and 700 plus residents. The time and energy expended by senior administration, nursing and physician leadership, down to all levels of the organization, was immense—and, in our view, wasted. And this occurred at an institution with surgical site infection rates already well below the national average. We are in agreement with the need to work as a team to continually improve patient safety. However, different members of the team do have particular perspectives that should not be dismissed. And theoretical benefits should not be claimed when the evidence shows no benefit. The close of the letter from the AORN leadership states “covering and containing hair is a reasonable and prudent measure. There is no harm in doing so…” and further cites a theoretical benefit of reduced exposure to potential pathogens and a presumed theoretical lower rate of infection.5 We again emphasize that there is harm in having an uncomfortable surgeon with a headlight and loupes out of proper position, with a bouffant hat that will not stay in place, and that our study of almost 16 000 patients shows no benefit in eliminating the surgical cap to reduce surgical site infections. Disclosures Dr Levy is a shareholder/has ownership interests in Intratech Medical Ltd, Bloc Medical LLC, and NeXtGen Biologics; he is Principal investigator for Covidien US SWIFT PRIME Trials; he receives honoraria from Covidien; he is a consultant for Pulsar and Blockade Medical; he is on the Advisory Board for Stryker, NeXtGen Biologics, and MEDX; and he receives financial support from Abbott for carotid training sessions. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.