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!

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.

 

 

1.
Rae, A., Provan, D., Aboelssaad, H. & Alexander, R. A manifesto for Reality-based Safety Science. Safety Science 126, 104654 (2020).
1.
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).
1.
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).
1.
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).
1.
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).
1.
Cook, T. M. et al. Multicentre clinical simulation evaluation of the ISO 80369-6 neuraxial non-Luer connector. Anaesthesia 74, 619–629 (2019).
1.
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).
1.
Checklist for anaesthetic equipment. 2.
1.
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.
1.
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).
1.
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).
1.
Orihara, M. Comparison of incidence of anaphylaxis between sugammadex and neostigmine: a retrospective multicentre observational study. 10.
1.
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).
1.
Wilkes, A. R. Measuring the filtration performance of breathing system filters using sodium chloride particles. 7 (2002).
1.
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).
1.
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).
1.
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.
1.
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).
1.
Donzelli, F. Pareto’s Mechanical Dream. 47.
1.
Muschara, T. Critical Steps: How to Identify and Manage the Most Important Human Performance Risks in Operations. Performance Improvement 53, 11–21 (2014).
1.
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).
1.
Saito, M. Brown Adipose Tissue as a Regulator of Energy Expenditure and Body Fat in Humans. Diabetes & Metabolism Journal 37, 22 (2013).
1.
Razzouk, R. & Shute, V. What Is Design Thinking and Why Is It Important? Review of Educational Research 82, 330–348 (2012).
1.
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).
1.
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).
1.
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).
1.
Kothari, D. & Agrawal, J. Colour-coded syringe labels: a modification to enhance patient safety. British Journal of Anaesthesia 110, 1056–1058 (2013).
1.
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.
1.
Langer, T. et al. Intravenous balanced solutions: from physiology to clinical evidence. Anestezjologia Intensywna Terapia 47, 78–88 (2015).
1.
Berkes, Z. et al. MODE-SWITCHING IN AIR TRAFFIC CONTROL. 88.
1.
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).
1.
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).
1.
Frankenfield, D. C. On heat, respiration, and calorimetry. Nutrition 26, 939–950 (2010).
1.
Wears, R. L. & Hettinger, A. Z. The Tragedy of Adaptability. Annals of Emergency Medicine 63, 338–339 (2014).
1.
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).
1.
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).
1.
Boon, M. R. & van Marken Lichtenbelt, W. D. Brown Adipose Tissue: A Human Perspective. Handb Exp Pharmacol 233, 301–319 (2016).
1.
Frankenfield, D. C. On heat, respiration, and calorimetry. Nutrition 26, 939–950 (2010).
1.
Kaiyala, K. J. What does indirect calorimetry really tell us? Molecular Metabolism 3, 340–341 (2014).
1.
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).
1.
Mostert, L. & R Coetzee, A. Central oxygen pipeline failure. Southern African Journal of Anaesthesia and Analgesia 20, 214–217 (2014).
1.
Schumacher, S. D., Brockwell, R. C., Andrews, J. J. & Ogles, D. Bulk Liquid Oxygen Supply Failure. Anesthes 100, 186–189 (2004).
1.
Wilkes, A. R. Measuring the filtration performance of breathing system filters using sodium chloride particles. 7 (2002).
1.
Merry, A. F. & Webster, C. S. Medication error in New Zealand—time to act. 121, 5 (2008).
1.
Asai, T., Matsumoto, S. & Shingu, K. Incidence of blood-borne infectious micro-organisms: would you still not wear gloves? Anaesthesia 55, 591–592 (2000).
1.
Marshall, S. D. & Chrimes, N. Medication handling: towards a practical, human-centred approach. Anaesthesia 74, 280–284 (2019).
1.
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).
1.
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).
1.
Gardner, B. & Rebar, A. L. Habit Formation and Behavior Change. in Oxford Research Encyclopedia of Psychology (Oxford University Press, 2016). doi:10.1093/acrefore/9780190236557.013.129.

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: https://theatrecaps.com/collections/caps

Hunter Scrubs: https://hunter-scrubs.gorgias.help/en-US/articles/embroidery-&-customisation-86759

Mum Made Scrub Hats: https://www.mummadescrubhats.com.au/embroidery

Royal Australian and New Zealand College of Obstetricians and Gynaecologists: https://shop.ranzcog.edu.au/products/personalised-theatre-caps

KimCaps: https://kimkaps.com/

Infectious: https://www.infectious.com.au/collections/scrub-hats-and-caps

Scrub’d Up: https://www.scrubdup.com/embroidered-scrub-caps

Tims Hats: https://www.facebook.com/TimsHats.1

Comfy Caps: https://www.comfycaps.com/custom-caps

Skrub Hedz: https://skrubhedz.square.site/embroidery

Medicus: https://medicuscaps.com/en-au/products/personalised-scrub-caps-with-embroidery

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”