The skullcap feud (Part 2)

Several months ago I posted on the feud between the surgical community and the Association of periOperative Registered Nurses (AORN). This turned out to be a wildly popular post that generated a great deal of discussion on our blog and other websites. You'll recall that AORN outlawed the surgeon's skullcap in its latest guideline on surgical attire. This caused an uproar among surgeons who noted that there was no substantial evidence on which to make this rule.

In a new paper in Neurosurgery, a surgical group at University of Buffalo took matters into their own hands and decided to generate some evidence after their own hospital banned the skullcap and mandated that all OR personnel don bouffant caps. They compared surgical site infection rates for Class I (clean) procedures 13-months before and after the skullcaps were outlawed. During the study period, approximately 16,000 surgical procedures were performed. There was no difference in SSI rates between the two time periods.

So, my hat's off (no pun intended) to the authors. The score now is Surgeons 1, AORN 0. And I suspect that more studies are on the way.

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.

You are what you wear

Mike has posted extensively on appropriate attire in clinical settings and perhaps folks are starting to notice. This month's ACP Hospitalist has a balanced piece by Charlotte Huff on the subject and quotes extensively from the good doctor Edmond. The most compelling part of the article for me was how much ideas and standards of what attire is considered appropriate change over time AND can be changed through education.  For example, a highlighted 1987 JAMA study reported that 34% of patients wanted female physicians to wear skirts. Can you imagine that in 2013? - makes 1987 seem almost Victorian. What was most encouraging to me was the 2008 JHI study Mike mentioned in the article. That study found that a simple education session could shift the proportion of patients preferring their surgeons wear scrubs from 24% to 62%. Hopefully soon, we will all be wearing scrubs... and black vests.

The well-dressed surgeon

AORN, the Association of periOperative Registered Nurses, has developed new draft guidelines on surgical attire available for public comment. The document can be viewed here.

Some highlights:

• Fresh scrubs are to be donned on entry or re-entry to the OR
• Hands should be washed prior to donning scrubs
• Surgical scrubs should not be laundered at home (believe it or not, some hospitals do not currently provide laundered scrubs to OR personnel as a cost-savings measure)
• All undergarments must be covered by the scrubs (e.g., no crew neck t-shirt or turtleneck with v-neck scrubs)
• Shoes with holes on the tops or sides (i.e., traditional Crocs) are not permitted