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


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


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


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


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


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.


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


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


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


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


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.

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.


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


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.


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!


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


Looking at the effect of head coverings on airborne contamination.


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


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


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.



Benediktsdóttir, E. & Hambraeus, A. Dispersal of non-sporeforming anaerobic bacteria from the skin. J Hyg (Lond) 88, 487–500 (1982).
Hubble, M. J. et al. Clothing in laminar-flow operating theatres. Journal of Hospital Infection 32, 1–7 (1996).
Thomas, R. A Challenge to Cloth Theatre Caps? – Doctor Getafix. (2018).
Hambraeus, A. & Laurell, G. Protection of the patient in the operating suite. Journal of Hospital Infection 1, 15–30 (1980).
Shallwani, H. et al. 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 82, 548–554 (2018).
American College of Surgeons et al. Consensus Statement: Recommendations for Operating Room Attire. (2018).
Humphreys, H., Russell, A. J., Marshall, R. J., Ricketts, V. E. & Reeves, D. S. The effect of surgical theatre head-gear on air bacterial counts. Journal of Hospital Infection 19, 175–180 (1991).
Kuritzkes, B. A. et al. New barrier attire regulations in the operating room: A mandate without basis? The American Journal of Surgery 218, 447–451 (2019).
Farach, S. M. et al. 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 226, 804–813 (2018).
Bartek, M., Verdial, F. & Dellinger, E. P. Naked Surgeons? The Debate About What to Wear in the Operating Room. Clinical Infectious Diseases 65, 1589–1592 (2017).
Rios-Diaz, A. J. et al. The art and science of surgery: Do the data support the banning of surgical skull caps? Surgery 164, 921–925 (2018).
Elmously, A. et al. Operating Room Attire Policy and Healthcare Cost: Favoring Evidence over Action for Prevention of Surgical Site Infections. Journal of the American College of Surgeons 228, 98–106 (2019).
Wills, B. W. et al. Association of Surgical Jacket and Bouffant Use With Surgical Site Infection Risk. JAMA Surg 155, 323–328 (2020).
Kothari, S. N., Anderson, M. J., Borgert, A. J., Kallies, K. J. & Kowalski, T. J. Bouffant vs Skull Cap and Impact on Surgical Site Infection: Does Operating Room Headwear Really Matter? Journal of the American College of Surgeons 227, 198–202 (2018).
Katrina C, D. & Elliott R, H. Competing patient safety concerns about surgical scrub caps – Infection control vs. breakdowns in communication. Journal of Patient Safety and Risk Management 24, 224–226 (2019).
Haskins, I. N. et al. Is there an association between surgeon hat type and 30-day wound events following ventral hernia repair? Hernia 21, 495–503 (2017).
Malhotra, G. K. et al. Pandemic Operating Room Supply Shortage and Surgical Site Infection: Considerations as We Emerge from the Coronavirus Disease 2019 Pandemic. J Am Coll Surg 234, 571–578 (2022).
Eisen, D. B. Surgeon’s garb and infection control: What’s the evidence? Journal of the American Academy of Dermatology 64, 960.e1-960.e20 (2011).
Ritter, M. A., Eitzen, H. E., Hart, J. B. & French, M. L. The surgeon’s garb. Clin. Orthop. Relat. Res. 204–209 (1980).
Markel, T. A. et al. Hats Off: A Study of Different Operating Room Headgear Assessed by Environmental Quality Indicators. Journal of the American College of Surgeons 225, 573–581 (2017).

Reusable, Customised, Theatre Cap Suppliers

There is currently a big push towards the use of reusable, cloth theatre caps instead of disposable versions, driven partly by discussions around environmental sustainability, but also because cloth caps are the most effective way to display your name and role to improve communication and teamwork (AKA Theatre Cap Challenge. See video here“).

This website is my attempt to provide a list of retailers were you can purchase personalised cloth hats. It is likely incomplete, and i will review it periodiciallty, but apologies if any of the links no longer work

Customisable Cloth Hats

For some of the sites, the customise option is shown once you select a specific hat.

Theatre Caps:

Hunter Scrubs:

Mum Made Scrub Hats:

Royal Australian and New Zealand College of Obstetricians and Gynaecologists:



Scrub’d Up:

Tims Hats:

Comfy Caps:

Skrub Hedz:


Etsy have a large range available that changes quite frequently, so rather than trying to list them all,  this link will take you to a Search using “Personalised Scrub Caps”.



Fresh Gas Flows, Filters, HMEs and Humidification

I recently submitted a “Letter to the Editor” of the BJA in response to the clever study by Zhong and colleagues demonstrating that the use of high fresh gas flows (FGF) during TIVA produces a cost-saving with, importantly, no adverse environmental consequences. My letter was responding to their conclusion regarding the impact of high FGFs on humidification of inhaled gases, and specifically the issue of heat and moisture exchangers (HMEs).

The letter was edited and shortened significantly during the review process, so much so that I felt some important discussion around a commonly misunderstood device was missing. The published letter is now available here,  but I felt it might be helpful to make the full text of the original letter (with some minor corrections) publicly available, so I have presented it below.

Continue reading “Fresh Gas Flows, Filters, HMEs and Humidification”

Juno Pre-filled Syringes

Juno recently released a TGA-approved pre-filled syringe containing metaraminol. However, not long after release, multiple issues were identified by anaesthetists who were using them. There was a fair bit of discussion and sharing of information and experiences on Twitter, and many anaesthetists have stopped using them, and some hospitals have now withdrawn them. Several people have contacted me regarding the syringes, and I thought I would aggregate some of the information I’ve collected in one place to make it easy for people to access it if they want to.

Continue reading “Juno Pre-filled Syringes”

Sorting the #DudScrubs Laundry

This is where I’ll be picking my way through all the dirty #DudScrubs laundry. Tighten those side-ties, because there’s a lot to get through!

For an explanation of what #DudScrubs is all about, read my more detailed post on it here.

Below I’ve started organising the various tweets into different categories to make them easier to find, and because different aspects may be of more interest or importance to different people. But I think it is the overall picture that makes the case for change so compelling, and that hospitals need to sit up, take notice, and start asking their staff what they can do to make their scrub provisioning system more fit-for-purpose. Continue reading “Sorting the #DudScrubs Laundry”

It’s Time to #ScrubOut #DudScrubs

An unavoidable part of working in operating theatres is the requirement to wear what is formally known as “Perioperative Attire”, but casually known as “scrubs”. While the term “scrubs” is now used to refer to similar clothing worn anywhere in the hospital, the primary purpose of theatre scrubs is to reduce the introduction of environmental pathogens into the theatre environment, thereby reducing the incidence of surgical site infections. Most hospitals require staff to wear scrubs supplied and laundered by the hospital. So essentially, scrubs are a mandatory workplace uniform, supplied by the hospital, to be worn by staff to improve patient outcomes.

Continue reading “It’s Time to #ScrubOut #DudScrubs”

Day-to-Day Living in Suva c.2012

I spent three months at the end of 2012 working in Suva, Fiji as the ASA Pacific Fellow, which was a position they created and funded in order to help prepare anaesthetic trainees for their exams. At the end of the stay I wrote a short piece describing some of the practical aspects of living there with my young family, in case it proved helpful to other Fellows that came after me. I thought I’d re-post here for similar reasons, but also as an historical snapshot as a significant part of my medical career that has had a lasting impact on me and my family. Fiji is a strategic hub for training doctors working all around the South Pacific, so if you get the chance to contribute in some way, I highly recommend you do.

Continue reading “Day-to-Day Living in Suva c.2012”

A Purple Patch for a Power Problem

Part of my job as an Anaesthesia Quality and Safety Fellow is to monitor reports made though our Anaesthesia Safety Monitoring Project, which allows staff to report latent safety threats, near-misses, faulty or badly designed equipment and pretty much anything that might pose a threat to patient safety. Below is the text of a “Letter to the Editor” that I wrote explaining how we were able to quickly and cheaply respond to an issue highlighted by one of these reports. The letter was published in the Canadian Journal of Anesthesia, and it can be accessed here (login required) or viewed online here by anyone.

Continue reading “A Purple Patch for a Power Problem”

Vale Professor Geoff Cutfield

I was deeply saddened to hear of the passing of Professor Geoff Cutfield earlier this year. He’s had a lasting impact on me as a doctor, anaesthetist and a  human being. Following his death, people who were unable to make the funeral in New Zealand were given the opportunity to provide something to be read out at the service to help celebrate the phenomenal life he lead. Below is my contribution to that celebration.

Continue reading “Vale Professor Geoff Cutfield”

ANZCA Primary Exam Tutorials & Resources

I occasionally give some tutorials to anaesthetic trainees sitting the ANZCA Primary Exam. I thought it would be worth collecting some of the resources I use into one location so that I can provide a link for pre-reading, revision etc, but also in case anyone else outside my hospital network might find them useful. I may well add additional content and links to post over time, so it may be worth checking in again at some point.

Click here to go straight to the tutorial resources.

Continue reading “ANZCA Primary Exam Tutorials & Resources”