The surgical cap debate: 7 things to know

To bouffant or not to bouffant — that is the question at many hospitals now reexamining the traditional surgeon's cap. The headgear controversy has reached such heights it hit the pages of The Boston Globe Thursday morning.

Here are seven things to know about what the argument is about, who is taking sides and why.

1. At issue is whether surgical caps are sufficient in the operating room or if full coverage with a shower cap-like bouffant is necessary for patient safety. The American College of Surgeons is pro-surgical caps while the Association of periOperative Registered Nurses resides in camp bouffant.

2. The back-and-forth began when AORN updated its guidelines earlier this year, according to MedPage Today. Among its updated rules, AORN stated, "Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears and facial hair," according to the report.

3. Shortly after, ACS issued its own updates on what to wear in the OR based on "professionalism, common sense, decorum and the available evidence." In these guidelines ACS defended the classic surgeon's cap, which may leave a limited amount of hair on the nape of the neck or sideburn uncovered. "The skullcap is symbolic of the surgical profession," ACS stated in its new guidelines. The specific updates pertaining hats were as follows:

  • 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 that leaving ears, a limited amount of hair on the nape of the neck or a modest sideburn uncovered contributes to wound infections.
  • Soiled scrubs and/or hats should be changed as soon as feasible and certainly prior to speaking with family members after a surgical procedure.
  • Scrubs and hats worn during dirty or contaminated cases should be changed prior to subsequent cases even if not visibly soiled.

4. AORN fired back with a point-by-point critique of ACS' new guidelines."Wearing a particular head covering based on its symbolism is not evidence-based, and should not be a basis for a nationwide practice recommendation," AORN stated. It said evidence exists that human skin and hair naturally contain bacteria and shed microorganisms into the air, which can fall into the operative area. "There is no risk to perioperative personnel to cover their skin and hair, while the benefit of doing so to patients is that it reduces the patient's exposure to potentially pathogenic organisms and helps to protect them from harm," AORN said.

5. The disagreement has hit mainstream media, as evidenced by Thursday's article in The Boston Globe. David Hoyt, MD, executive director of ACS, told the Globe surgeons find the bouffants uncomfortable and they don't understand why they would be required to wear them when they never have before.

6. Now the Joint Commission plans to weigh in. It told the Globe it is in the process of analyzing the various guidelines and will provide its position when the analysis is complete.

7. AORN took issue with a few other recommendations by ACS as well, however most of the brouhaha remains centered on OR hats, as The Boston Globe notes. See a full listing of AORN's concerns with the ACS guidelines here.


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