The skullcap feud

There's a feud brewing between two professional societies on appropriate attire in the operating room. Earlier this year, AORN (the Association of periOperative Registered Nurses) issued updated guidelines on OR attire. The guideline forbids the wearing of skullcaps because the head covering should cover the head, hair, ears, facial hair, and nape of neck when personnel enter the semi-restricted and restricted areas of the OR. This didn't sit well with some surgeons, and the American College of Surgeons (ACS) issued their own statement on OR attire earlier this month. With regards to the skullcap, they state, "the skullcap is symbolic of the surgical profession. The skullcap can be worn when close to the totality of hair is covered by it and only a limited amount of hair on the nape of the neck or a modest sideburn remains uncovered. Like OR scrubs, cloth skull caps should be cleaned and changed daily. Paper skull caps should be disposed of daily and following every dirty or contaminated case."

From AORN's perspective, the issue with skullcaps is the exposed ears and exposed hair at the base of the head, from which pathogens may contaminate the surgical field as hair and skin squames are shed. The counterargument, of course, is that there is no evidence to suggest that skullcaps have been associated with surgical site infections. And now we find ourselves in essentially the same quagmire as with white coats.

This week, AORN shot back, and they punched the good old boys right in the gonads. Says AORN, "head coverings based on symbolism and a personal attachment to historical norms have no place in the patient benefits analysis expected of guidelines developers." AORN rightly took the moral high ground and called out the ACS for using a professionalism argument to justify their stance. As I have argued before with regards to the white coat, professionalism exists to protect the profession, not the patient. So while the surgeons' argument with regards to lack of evidence has validity, the professionalism argument does not. And my thinking about the skullcap is the same as for the white coat: the biologic plausibility for causing infection should lead to a suggestion to avoid the skullcap but not a mandate. While AORN may argue that their recommendations are guidelines, the reality is that the Joint Commission enforces them as mandates.

I'm not a surgeon, but if I were, I'd give up my skullcap, just in case bacteria were falling off my earlobes. And I think these issues are much easier to resolve if we simply follow the dictum, the patient comes first in everything that we do.

While I'm on my moral high horse, and since I'm an equal opportunity critic, I'd be remiss if I didn't point out an issue with the AORN. You may have noticed that there is no link to the AORN attire guideline in this post, and that's because AORN sells their guidelines for $225. It seems to me that when any professional society has something so important to say that it is written into a guideline, they have a moral imperative to make the guideline accessible free of charge to everyone, particularly when the guideline impacts patient safety. This is but another example of the ugly side of professionalism, a decrepit concept that continues to haunt us.


  1. Great write-up, Mike, and I agree whole-heartedly. Much like with white coats, the data on head coverings will never rise to the level of conclusive proof of harm for the majority of the surgical community to agree to eliminate them. However, this is yet another gravitational challenge parachute argument. As you have noted, if biologic plausibility exists, as it clearly does here, and there is little risk of harm, then it should an easy decision.

    Unlike white coats, however, where you have argued it should be an individual decision and not a mandate, the inclusion of this recommendation into the AORN guidelines ensures it becomes a mandate. It is hard to justify this to surgeons on the basis of published evidence, and we know how compelling "because it's in the guidelines" is. I wonder if, like with white coats, we would have more success with a slow shift in culture by modeling correct behavior rather than mandating it "because TJC says so."

    We have let surgeons wear skull caps - as long as they also cover them with a standard bouffant cap that covers their ears and neck hair.

    1. Agree Dan--a recommendation, some encouragment, and let it diffuse would be a better way to go.

  2. AORN: Pay us to read guidelines and their tenuous basis, so you can argue the point coherently with us, otherwise just shut up and end your silly tradition. It may sound superficial but guys look silly in bouffant caps. Those were designed for 1950's, Philly and Balto, Hairspray-worthy big hair women's hairdos, not short hair most surgeons and OR nurses/techs have. If you look at most surgeons, we naturally wear our hair short. Some of is traditional, some of it is because its easier to manage with our busy schedules, and most of it, I would say, is because its gonna get flattened under a hat most of the day in the OR, why spend money on product and lift. There is just no way that you are ever going to show that there is a difference in infections between a stupid bouffant cap and a skull cap. Neither covers the ears. Neither covers normal male sideburns. AORN also argues that you can't tell when the cloth caps were last washed. Duh. I could wear the same set of scrubs everyday and no one could tell when they were last washed (for a few weeks). We wear the same shoes every day in the OR, and no one obsesses about when they were cleaned last (anymore, used to be they had us cover with stupid paper covers...)

    To prove a point while staying in compliance with the wear-the-bouffant-Nazis in my OR, I have been defiantly wearing my skull cap everywhere (red white and blue patriot baby!) outside the OR (and getting much praise), then covering it with a stupid "disposable" bouffant cap I have been re-using for 6months. No difference in infection rates. Big difference in garbage generated, which is my point for using a cloth cap in the first place. Saving the planet form all the toxic garbage we generate in US ORs is a much more important problem to fix than hair covering, IMHO.

    Oh, and if you have stuff falling off your head into patients wounds: You are leaning too much. You are going to hurt your back. Stand up straight, like your mother told you!

  3. "No difference in infection rates." This is the unfortunate part: you have no data to support this statement. As noted above, since following the process of using a disposable bouffant won't harm anyone (you only note your offended sense of self-image), why not?

    1. There actually is data and there is literature to support that covering your hair (among many other things) does not decrease infections rates, and there is in fact, no difference. I personally do not like wearing the bouffant in the OR.

      How often do professional men wash their ties? How many items (including patients) does a persons tie collide into on a daily basis? Even though this might not increase infection/contamination rates, we should ban them because its plausible it can happen.

  4. When the germ theory was first being advance, a surgeon in the US by the name of Charles Meigs dismissed the entire concept of transmission of bacteria causing infection, famously stating "a gentlemen's hands are clean". I guess the surgeons today believe this extends to their hair as well.

  5. This argument is ridiculous. Why do the ears need to be covered but not the forehead? What about the neck? Must I remind everyone that bacteria do not jump. Bacteria are not completely removed with any amount of prep. Bacteria are aerosolized and do come out of the sides of a surgical mask. Unless we start wearing biocontainment Ebola type hazmat suits in the OR and make the OR a negative pressure clean room there will be bacteria in the OR. Covering a little hair on the neck and sideburns will not make a difference.

  6. Unfortunately, there are several issues here which center on circular logic.
    1. It is a fools paradise to think that bouffants cover the hair on the neck and ears better than a scrub cap on a person with short hair. Anyone who says so hasn't worked in an OR. The number of female nurses with long hair hanging out their bouffant is readily apparent.

    2. Room traffic has a much higher impact on infectious risk by disturbing airflow, but you don't see the nursing organization recommending that their dues paying members attempt to stay throughout the entire case to limit room air flow rather than taking breaks, lunch, etc.

    3. The ACS recommended changing scrubs between contaminated cases. In the AORN's reply to the ACS they stated, "Evidence shows that perioperative team members who are following standard precautions, using personal protective equipment (PPE) and conducting hand hygiene should not need to change scrubs and hats between cases." This would say that a contaminated patient can not contaminate the surgeon. Yet, wouldn't this be true in the reverse? See when we use circular logic like the AORN, then laundering scrubs at home, wearing them outside, etc. shouldn't matter because the patient is protected by standard precautions and PPE. Before the AORN supporters show up, yes I know that is an OSHA violation.

    4. If bouffants are so good for preventing infections why isn't the AORN recommending space suits? There is not exposure to any facial hair, skin, eyebrows, etc? If we use them wouldn't it be safer for the patients????? That seems to be the argument for bouffants.

    5. Why didn't AORN disclose that Kimberly Clark is a major supporter of them?

    6. Why did the British come up with the exact opposite recommendation for covering arms? They felt that jackets interfered with appropriate handwashing.

    7. Randomzied trials show that not wearing a surgical mask has no impact on surgical sight infections yet AORN didn't make that a recommendation.

    Why????? Because the data is horrible. You can quote the gravitational challenge without a parachute argument but that is a straw man argument. I could say if one parachute is good then you should use 20. Even though that in reality would raise cost, likely render your one parachute ineffective, etc. However, it sure sounds safe.

  7. BariatricSurgeon nailed it. No data to support AORN. I for one do not recognize them as an unbiased expert on anything. You can carry this to totally ridiculous extremes. What about eyeglasses? Are they sterile or cleaned before cases? What about your eyebrows? Must be some bugs lurking in there. If there's a long case, and your mask gets moist from humidity, should the circulator change it for you intraoperatively? I know for a fact that my infection rates are way below the national average, even when I was "allowed" to wear cloth caps. It's just more bureaucratic nonsense perpetuated by people who have to justify they're jobs. If there was data to support this nonsense from AORN, we would not be having this dialogue at all.

  8. BariatricSurgeon and Urohawk are spot on. And it's even more ridiculous when you consider that the same "ruling" applies to Sterile Processing. Has anyone ever worn a bouffant when you have NO hair? There is no way to keep it out of your eyes decently, even when stretched below the earlobes. I am bald, and where I am not, I shave. I also exfoliate my scalp regularly and follicle scrub my eyebrows daily. I take my job as CST "Mr. Clean" very seriously.

    Yet even with all that, I am hundreds of times more likely to lose an eyelash (or drop a tear) into a Set than I am to have something drip out of/off my ears. The very idea is ludicrous.


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