AORN experts respond to study on bouffant use and SSI rates

Experts from the Association of periOperative Registered Nurses sent a letter to the editor of the journal Neurosurgery in response to a study published in the journal that found use of bouffant caps does not impact surgical site infection rates.

In the study, researchers tracked SSI rates in one hospital 13 months before and 13 months after it banned surgical skull caps from its operating rooms. They concluded the "elimination of traditional surgeon's cap did not reduce infection rates."

The study's authors wrote that AORN's Guideline for Surgical Attire "mandated the use of bouffant caps to prevent SSIs" and urged organizations to stop using skull caps.

In the letter to the editor, AORN calls these statements "unequivocally incorrect" and goes on to say AORN "does not specify the type or style of head covering that should be worn."

Instead, the guidelines say, "A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn," as hair carries bacteria that could cause an SSI.

"We don't specify how you do it, we just say cover your hair, all of your hair," Lisa Spruce, DNP, RN, AORN's director of evidence-based perioperative practice, tells Becker's. "It's up to the facility to determine what's the best way to get everyone's hair covered."

Dr. Spruce, one of the letter's authors, says it's a "myth" in some facilities that AORN mandates the use of bouffants over skull caps. Some organizations have stopped allowing skull caps in the OR because they are not always efficient at covering all of a person's hair.

And while the study's authors concluded eliminating use of the skull cap did not reduce SSI rates, AORN experts looked at the data and came to a different conclusion — there was a slight improvement in SSI rates after seven weeks of bouffant use in all class I OR cases and five weeks of bouffant use in spine procedures.

"If you look at the scatter plot they provided, it shows SSI rates went down when everyone started wearing a bouffant," Dr. Spruce says. "They misinterpreted the evidence."

The reason for the delay in SSI rate reduction indicates it can take weeks or months to get everyone compliant with a new mandate, according to Dr. Spruce. "It takes a few months for everyone to be compliant, and then you naturally see improvement," she says.

In the future, Dr. Spruce and AORN would like hospitals to form multidisciplinary teams when deciding what kind of head covering can be used in the facility, rather than handing down a mandate with no discussion. Everyone who wears hair covering in the OR — surgeons, nurses, anesthesia professionals — should be consulted before a decision is made.

AORN experts also noted SSI prevention needs a bundled approach and "covering and containing hair is a reasonable and prudent measure."

"There is no harm in doing so, but the benefit to all patients is a reduced risk of exposure to potentially pathogenic organisms that live on the hair, skin, ears and facial hair of perioperative team members," the letter concludes.

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