Local Surgeons Enter National Debate On Surgical Headwear

They did so with a scientific study published in Neurosurgery last spring, the largest published study on the effect of headgear upon rates of surgical site infections, and more recently with an invited commentary published in the October Bulletin of the American College of Surgeons (ACS).

The ACS and the Association of periOperative Registered Nurses (AORN) are the key organizations that have been involved in a public debate on headwear for surgeons and the teams that care for surgical patients.

Kevin J. Gibbons, MD, senior and lead author on both publications, is senior associate dean for clinical affairs at UB and associate professor of neurosurgery. He is also chief of neurosurgery at Kaleida Health, physician director of surgical services at Buffalo General Medical Center (BGMC) and executive director of UBMD Physicians’ Group.

He describes the controversy thusly:

“AORN’s position is that any head covering that doesn’t cover all hair, as well as the surgeon’s ears, should be banned from the operating room. The rationale was that since hair harbors bacteria, leaving some of a surgeon’s hair and ears uncovered — as traditional surgical skullcaps do — could put patients at higher risk of surgical site infections,” Gibbons says.

The leadership of AORN argues there is no harm in eliminating the cap and says there may be benefit in terms of reduced surgical site infections.

“The result of this interpretation resulted in hospitals around the country being cited by outside reviewers for poor infection control practice if anyone in the OR was seen wearing a surgical cap,” he notes.

Hospitals, Gibbons says, responded by outlawing caps to comply with the mandate. That’s what happened in 2015 at BGMC, the largest training site for the medical school.

“This ban on the cap provided us with an opportunity to examine infection rates in so-called ‘clean’ cases before and after the ban,” he says. “The study demonstrated no change in infection rates in almost 16,000 surgical cases.”

At the time the study was published in spring 2017, it was the journal’s most widely read paper, according to its website. But despite the findings, the debate has continued.

“There were accusations that surgeons just wanted to hold onto this symbol of the profession, that surgeons were just being macho while disregarding what was thought to be a patient safety issue,” Gibbons says.

“Surgeons responded that this was a power grab by the AORN, that there are performance and comfort issues that shouldn’t be disregarded and that there was no good evidence supporting the ban on the cap,” he adds. “Our study found that there is no basis for banning the cap.”

Gibbons notes that the ban was disruptive at the local hospital and at others around the country and that BGMC already had a surgical infection rate well below the national average.

He explains that the availability of the cap is particularly important to surgeons who wear tools, such as surgical telescopes and headlights, mounted on their heads for hours during surgery.

Many surgeons maintain such tools are more likely to stay in place with the skullcap versus the bouffant.

The debate is important to those in the surgical field, but it also has a wider impact as well, Gibbons says.

“Within medicine as a whole, we are really trying to become more evidence-based. There are certain things proved beyond a doubt, and those should be the standards,” he says. “There are other things that are not exactly evidence-based, but which the vast majority of experts agree on.”

“And then there is opinion. The problem was that the banning of skullcaps was enforced at the level of a standard, and it shouldn’t have been. The rationale, not the evidence, suggested that banning the cap would reduce infections; the evidence is it did not.”

The article authored by Gibbons and his UB colleagues, titled “The Surgical Cap: Symbol, Science, Argument, and Evidence,” reviews the debate, cites the lack of evidence and the need to be evidence-based whenever possible.

It also cites the deleterious effect the ban and debate have had on surgical teams and teamwork, and the need to do better.

According to Gibbons, advocates for the ban on skullcaps kept insisting there was no harm in enforcing the ban and maintained it may result in fewer surgical site infections.

“Our response is, there is harm in a top-down mandate that is not evidence-based, that disregarded surgeons’ concerns and, most importantly, did not reduce surgical site infections,” he says.

The Bulletin article calls for both organizations to coordinate and cooperate on a new system that takes into account all aspects of the debate for all the professionals involved.

Co-authors on the article are:

• Kenneth V. Snyder, MD, PhD, assistant professor of neurosurgery
• Steven D. Schwaitzberg, MD, professor and chair of surgery
• Elad I. Levy, MD, professor and chair of neurosurgery