Articles and resources regarding perioperative attire (including head coverings) and infection risks

The topic of head coverings for operating theatre staff has garnered much attention in recent years for a number of reasons. These include:

Hospital policies banning the use of cloth caps (for infection control reasons) impeding the take up and effectiveness of the “Theatre Cap Challenge”
A controversial policy in the USA mandating a particular style of theatre cap over that preferred by many surgeons
Increasing concerns about the environmental impact of healthcare, and a desire to shift away from single use to reusable items with a move towards cloth theatre caps being part of that
Covid related shortages forcing some hospitals to go back to reusable caps and gowns where previously they’d mandated disposable versions.

This has prompted a lot of research and debate, and i thought it would be helpful to collate some of the articles for easy reference/access. Below are number links to each article, with the full reference list at the bottom. I will continue to add more references as I come across them.

Discussions, reviews, editorials etc

This is a blog post I wrote looking at the references cited in the ACORN standards regarding head coverings.

A Challenge to Cloth Theatre Caps?

A review and discussion of the topic of perioperative attire. Includes reference to two studies showing naked staff contaminate theatres less than clothed staff!

Naked Surgeons? The Debate About What to Wear in the Operating Room. - Clinical Infectious Diseases

Editorial looking at the infection control concerns compared with the benefits of having staff names and roles on head coverings

Competing patient safety concerns about surgical scrub caps – Infection control vs. breakdowns in communication. - Journal of Patient Safety and Risk Management

This is the joint statement put out by the American College of Surgeons, the American Society of Anesthesiologists, the Association of peri-Operative Registered Nurses , the Association for Professionals in Infection Control and Epidemiology, the Association of Surgical Technologists, and the Council on Surgical and Perioperative Safety after they finally all got together to discuss head coverings

Recommendations for Operating Room Attire

Review article looking at a variety of “specialised garments” intended to reduce sugical site infections, including head coverings.

Surgeon’s garb and infection control: What’s the evidence? - Journal of the American Academy of Dermatology

A review looking at a variety of physical and environmental interventions, including head coverings, to reduce surgical site infections.

Protection of the patient in the operating suite - The Journal of Hospital Infection

Before-and-After studies following mandated changes to head coverings +/- other aspects of perioperative attire.

Study based on prospectively collected NSQIP data following introduction of AORN Guidelines on head coverings.

Have Recent Modifications of Operating Room Attire Policies Decreased Surgical Site Infections? An American College of Surgeons NSQIP Review of 6,517 Patients. - Journal of the American College of Surgeons

Another study utilising NSQIP data, this time specifically looking at abdominal surgery following mandating of long sleeve jackets and bouffant head coverings.

New barrier attire regulations in the operating room: A mandate without basis? - American Journal of Surgery

Yet another NSQIP based study looking at surgical site infections after mandated change to bouffant head coverings.

The art and science of surgery: Do the data support the banning of surgical skull caps? - Surgery

Before-and-study following the change from “skull caps” to “bouffant caps”, specifically within the neurosurgical setting.

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. - Neurosurgery

As well as surgical site infections this study also includes data on the financial cost of implementing the AORN Guidelines.

Operating Room Attire Policy and Healthcare Cost: Favoring Evidence over Action for Prevention of Surgical Site Infections. - Journal of the American College of Surgeons

Before-and-after study looking at surgical site infections following mandating use of disposable jackets and bouffant-style head coverings. Also includes data on the financial cost of the change.

Association of Surgical Jacket and Bouffant Use With Surgical Site Infection Risk. - JAMA Surgery

Other studies related to the “Bouffant Scandal”

Comparison of surgeons head covering preferences with incidence of hernia surgical site infections recorded in a prospectively collected database.

Is there an association between surgeon hat type and 30-day wound events following ventral hernia repair? - Hernia

Re-analysis of data from a previous randomised controlled trial looking at surgical site infections, and comparing it to surgeon theatre cap preference.

Bouffant vs Skull Cap and Impact on Surgical Site Infection: Does Operating Room Headwear Really Matter? - Journal of the American College of Surgeons

Microbiological studies assessing factors influencing bacterial shedding, dispersal, contamination etc.

Quantitative study of disposable and cloth head coverings and their impact on various markers of operating theatre contamination.

Hats Off: A Study of Different Operating Room Headgear Assessed by Environmental Quality Indicators. - Journal of the American College of Surgeons

Assessing individual variation in shedding of Staphylococcus aureus and the impact of clothing. This is one of the two studies mentioned above that found less bacteria is shed when naked compared to clothed!

Effect of clothing on dispersal of Staphylococcus aureus by males and females. - The Lancet

Another study showing that bacterial dispersal is less when naked than when clothed!

Dispersal of non-sporeforming anaerobic bacteria from the skin - Epidemiology & Infection

Looking at the effect of head coverings on airborne contamination.

The effect of surgical theatre head-gear on air bacterial counts. - Journal of Hospital Infection

Microbiological study looking at the effect of perioperative attire, including head coverings, on air and surface contamination in conventional and laminar flow operating theatres.

Clothing in laminar-flow operating theatres - Journal of Hospital Infection

Assessment of a number of combinations of “surgical garb”, including a variety of different head coverings, including the impact of using hairspray!

The Surgeon's Garb - Clinical Orthopaedics and Related Research

Miscellaneous

Before-and-after study looking at surgical site infections after they switched from disposable head coverings, shoe covers, and masks to reusable items due to covid induced shortages.

Pandemic Operating Room Supply Shortage and Surgical Site Infection: Considerations as We Emerge from the Coronavirus Disease 2019 Pandemic. - Journal of the American College of Surgeons

Rae, A., Provan, D., Aboelssaad, H. & Alexander, R. A manifesto for Reality-based Safety Science. Safety Science 126, 104654 (2020).

Salmon, P. M. et al. The big picture on accident causation: A review, synthesis and meta-analysis of AcciMap studies. Safety Science 126, 104650 (2020).

Zippel, C., Börgers, A., Weitzel, A. & Bohnet-Joschko, S. Many critical incidents could be avoided by preanaesthesia equipment checks: Lessons for high reliability organisations. European Journal of Anaesthesiology 31, 289–291 (2014).

Zippel, C., Borgers, A., Weitzel, A. & Bohnet-Joschko, S. Many critical incidents could be avoided by preanaesthesia equipment checks: Lessons for high reliability organisations. [Letter]. Journal of Anaesthesiology 31, 289–291 (2014).

Wilkes, A. R., Pandit, J. J. & O’Sullivan, E. The history of anaesthetic equipment evaluation in the United Kingdom: lessons for developing future strategy. Anaesthesia 66, 34–39 (2011).

Cook, T. M. et al. Multicentre clinical simulation evaluation of the ISO 80369-6 neuraxial non-Luer connector. Anaesthesia 74, 619–629 (2019).

Cassidy, C. J., Smith, A. & Arnot‐Smith, J. Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006–2008*. Anaesthesia 66, 879–888 (2011).

Checklist for anaesthetic equipment. 2.

Chair et al. Safe management of anaesthetic related equipment. https://www.anaesthetists.org/Home/Resources-publications/Guidelines/Safe-management-of-anaesthetic-related-equipment (2009) doi:10.21466/g.SMOAREA.2009.

Association of Anaesthetists of Great Britain and, Ireland et al. Checking Anaesthetic Equipment 2012: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia 67, 660–668 (2012).

Bourgain, J. L., Coisel, Y., Kern, D., Nouette-Gaulain, K. & Panczer, M. What are the main “machine dysfunctions” to know? Annales Françaises d’Anesthésie et de Réanimation 33, 466–471 (2014).

Orihara, M. Comparison of incidence of anaphylaxis between sugammadex and neostigmine: a retrospective multicentre observational study. 10.

Xie, A. & Carayon, P. A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety. Ergonomics 58, 33–49 (2015).

Wilkes, A. R. Measuring the filtration performance of breathing system filters using sodium chloride particles. 7 (2002).

Merry, A. F., Shipp, D. H. & Lowinger, J. S. The contribution of labelling to safe medication administration in anaesthetic practice. Best Practice & Research Clinical Anaesthesiology 25, 145–159 (2011).

Shultz, J. et al. Standardizing anesthesia medication drawers using human factors and quality assurance methods. Canadian Journal of Anesthesia/Journal canadien d’anesthésie 57, 490–499 (2010).

Holloway, C. M. & Johnson, C. W. Reducing our ignorance: finding answers to certain epistemic questions for software systems. in 6th IET International Conference on System Safety 2011 D12–D12 (IET, 2011). http://doi.org/10.1049/cp.2011.0269.

Arthmar, R. VILFREDO PARETO. Manual of Political Economy. A critical and variorum edition. Edited by Aldo Montesano, Alberto Zanni, Luigino Bruni, John Chipman and Michael McLure. Oxford: Oxford University Press, 2014, 664 p. Estudos Econômicos (São Paulo) 45, 459–470 (2015).

Donzelli, F. Pareto’s Mechanical Dream. 47.

Muschara, T. Critical Steps: How to Identify and Manage the Most Important Human Performance Risks in Operations. Performance Improvement 53, 11–21 (2014).

Keijzer, C., Perez, R. S. G. M. & de Lange, J. J. Compound A and carbon monoxide production from sevoflurane and seven different types of carbon dioxide absorbent in a patient model. Acta Anaesthesiologica Scandinavica 51, 31–37 (2007).

Saito, M. Brown Adipose Tissue as a Regulator of Energy Expenditure and Body Fat in Humans. Diabetes & Metabolism Journal 37, 22 (2013).

Razzouk, R. & Shute, V. What Is Design Thinking and Why Is It Important? Review of Educational Research 82, 330–348 (2012).

Lally, P., Potts, H. W. W. & Wardle, J. Research article How are habits formed: Modelling habit formation in the real worldy. Eur. J. Soc. Psychol. 13 (2009).

Catchpole, K., Bell, M. D. D. & Johnson, S. Safety in anaesthesia: a study of 12 606 reported incidents from the UK National Reporting and Learning System. Anaesthesia 63, 340–346 (2008).

Nedergaard, J., Bengtsson, T. & Cannon, B. Unexpected evidence for active brown adipose tissue in adult humans. American Journal of Physiology-Endocrinology and Metabolism 293, E444–E452 (2007).

Kothari, D. & Agrawal, J. Colour-coded syringe labels: a modification to enhance patient safety. British Journal of Anaesthesia 110, 1056–1058 (2013).

Furniss, D., Dean Franklin, B. & Blandford, A. The devil is in the detail: How a closed-loop documentation system for IV infusion administration contributes to and compromises patient safety. Health Informatics Journal 146045821983957 (2019) http://doi.org/10.1177/1460458219839574.

Langer, T. et al. Intravenous balanced solutions: from physiology to clinical evidence. Anestezjologia Intensywna Terapia 47, 78–88 (2015).

Berkes, Z. et al. MODE-SWITCHING IN AIR TRAFFIC CONTROL. 88.

Standards Association of Australia & Standards New Zealand. User-applied labels for use on syringes containing drugs used during anaesthesia. (Standards Australia ; Standards New Zealand, 1996).

Dellamonica, J., Boisseau, N., Goubaux, B. & Raucoules-Aimé, M. Comparison of manufacturers’ specifications for 44 types of heat and moisture exchanging filters. British Journal of Anaesthesia 93, 532–539 (2004).

Frankenfield, D. C. On heat, respiration, and calorimetry. Nutrition 26, 939–950 (2010).

Wears, R. L. & Hettinger, A. Z. The Tragedy of Adaptability. Annals of Emergency Medicine 63, 338–339 (2014).

Webster, C. S., Merry, A. F., Larsson, L., McGrath, K. A. & Weller, J. The Frequency and Nature of Drug Administration Error during Anaesthesia. Anaesthesia and Intensive Care 29, 494–500 (2001).

Ogawa, Y., Abe, K., Sakoda, A., Onizuka, H. & Sakai, S. FDG-PET and CT findings of activated brown adipose tissue in a patient with paraganglioma. European Journal of Radiology Open 5, 126–130 (2018).

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Boon, M. R. & van Marken Lichtenbelt, W. D. Brown Adipose Tissue: A Human Perspective. Handb Exp Pharmacol 233, 301–319 (2016).

Frankenfield, D. C. On heat, respiration, and calorimetry. Nutrition 26, 939–950 (2010).

Kaiyala, K. J. What does indirect calorimetry really tell us? Molecular Metabolism 3, 340–341 (2014).

Mostert, L. & R Coetzee, A. Central oxygen pipeline failure. Southern African Journal of Anaesthesia and Analgesia 20, 214–217 (2014).

Schumacher, S. D., Brockwell, R. C., Andrews, J. J. & Ogles, D. Bulk Liquid Oxygen Supply Failure. Anesthes 100, 186–189 (2004).

Wilkes, A. R. Measuring the filtration performance of breathing system filters using sodium chloride particles. 7 (2002).

Merry, A. F. & Webster, C. S. Medication error in New Zealand—time to act. 121, 5 (2008).

Asai, T., Matsumoto, S. & Shingu, K. Incidence of blood-borne infectious micro-organisms: would you still not wear gloves? Anaesthesia 55, 591–592 (2000).

Marshall, S. D. & Chrimes, N. Medication handling: towards a practical, human-centred approach. Anaesthesia 74, 280–284 (2019).

Orser, B. A., Chen, R. J. B. & Yee, D. A. Medication errors in anesthetic practice: a survey of 687 practitioners. Canadian Journal of Anesthesia/Journal canadien d’anesthésie 48, 139–146 (2001).

Lally, P., van Jaarsveld, C. H. M., Potts, H. W. W. & Wardle, J. How are habits formed: Modelling habit formation in the real world. European Journal of Social Psychology 40, 998–1009 (2010).

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