AORN to Change Recommendations in Heated Bouffant Hat vs. Skull Cap Debate

Nurse Leader Insider, August 9, 2018

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This article first appeared in the August issue of Patient Safety Monitor Journal.

Ears. Do you cover them while conducting surgery?

This simple question has fueled a bitter fight ever since The Association of periOperative Registered Nurses (AORN) officially recommended that bouffant hats be worn in the OR by all surgical team members. Since then, there’s been a back-and-forth of testy statements and unsatisfying studies.

Over the past couple of years, AORN, while still claiming all ears needed to be covered in the OR, has insisted it never explicitly declared that skull caps should be banned. Then a new study last fall hit bouffant-backers with an uppercut and pushed AORN to reconsider its stance on headwear.

After participating with other healthcare heavy-hitters this winter in a task force that met to discuss recommendations for OR attire, specifically ear and hair covering, AORN expects to make changes to its Guideline for Surgical Attire in 2019.

Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, director of evidence-based perioperative practice for AORN, says the organization will still recommend complete hair coverage in that revised guideline, but “there’s not going to be a recommendation on which head covering.”

As for the coverage of ears, AORN is “probably going to come out in our new guideline and say the ears don’t need to be covered,” notes Spruce, because the task force feels the research focusing on its necessity has been inconclusive. “However,” she says, “our guideline stands as is until it’s revised.”

It is significant that AORN will likely be changing its stance. While the organization is the world’s largest professional association for perioperative nurses, it is a tone-setter for issues affecting all healthcare workers who enter the OR. CMS and subsequently The Joint Commission followed AORN’s lead on headwear and has cited healthcare organizations accordingly.

The study that seems to have ended this battle was led by Troy Markel, MD, assistant professor of surgery at Indiana University, who examined the effectiveness of disposable bouffant hats and skull caps as well as newly laundered cloth skull caps in preventing airborne contamination.

Not only did Markel and his peers observe no significant differences between the disposable bouffant hats and the disposable skull caps “with regard to particle or actively sampled microbial contamination,” they also determined that the disposable bouffant hats had greater permeability, penetration, and greater microbial shed compared to both disposable and cloth skull caps.

Thus, the researchers concluded last October that disposable bouffant hats “should not be considered superior to skull caps in preventing airborne contamination in the operating room.”

That study made the strongest case to date in the contentious debate over OR headwear.

Several years ago, AORN began, depending on who you ask, either promoting the use of bouffant hats among surgical staff or advocating for skull caps to be banned. The organization encouraged full coverage of the ears in the OR, one of the reasons why AORN favored bouffant hats.

In 2016, the American College of Surgeons (ACS), who see the skull cap as “symbolic of the surgical profession,” came out and said skull caps “may be worn when close to the totality of hair is covered by it and when only a limited amount of hair on the nape of the neck or modest sideburns remains uncovered.” Executive director David Hoyt, MD, FACS, stated that ACS’ new guideline for appropriate attire was “based on professionalism, common sense, decorum, and the available evidence.”

As Priya Nori, MD, medical director of the antibiotic stewardship program at the Montefiore Health System and associate professor at Einstein School of Medicine, puts it, people were ticked.

“Surgeons said, ‘Where’s the evidence? We’ve been doing this for generations,’ ” says Nori.

Last year, surgeons from the University of Buffalo and Kaleida Health also challenged AORN’s stance with a study published in Neurosurgery, arguing that according to research, wearing bouffant hats in the OR didn’t influence surgical site infection rates for Class 1 cases.

Lead researcher Kevin Gibbons, MD, senior associate dean for clinical affairs with the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, said last year, “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.”

That included Kaleida Health, which had previously received a letter placing the organization in immediate jeopardy because CMS considered the skull cap to be inadequate OR headwear.

AORN fired back, saying “there were too many assumptions in that study.” But the organization also claimed the researchers “repeatedly misrepresented the AORN recommendation throughout the article” and later issued a statement to correct “misrepresentation” and “misinformation” of its position, noting that “there is no recommendation that bouffant caps should be worn.”

By doing the latter, AORN appeared to be softening its stance, though the organization notes that its current Guideline for Surgical Attire, revised in 2014, does not explicitly recommend bouffant caps. AORN will revise its guideline again in 2019 following the study from Markel and his peers that found that the requirement for ear coverage is not supported by sufficient evidence.

“It was the first, if only, [study] that I have seen that looked at the effectiveness of those types of hats as far as whether they were doing what they were designed to do,” says Spruce, speaking on behalf of AORN. “I think it just sparked everybody’s interest and opened up this discussion.”

AORN and others felt the evidence was enough to revisit the controversy and, according to Spruce, ACS assembled the task force, which included the Council on Surgical and Perioperative Safety, the American Society of Anesthesiologists, the Association for Professionals in Infection Control and Epidemiology, the Association of Surgical Technologists, and The Joint Commission.

The task force met in February and the organizations released, in early May, a joint statement that read: “Over the past two years, as recommendations were implemented, it became increasingly apparent that in practice, covering the ears is not practical for surgeons and anesthesiologists and in many cases counterproductive to their ability to perform optimally in the OR.”

The group determined that “available scientific evidence does not demonstrate any association between the type of hat or extent of hair coverage and [surgical site infection] rates.”

The statement added that “in reassessing the strength of the evidence for this narrowly defined recommendation,” the task force concluded that “evidence-based recommendations on surgical attire developed for perioperative policies and procedures are best created collaboratively, with a multi-disciplinary team representing surgery, anesthesia, nursing, and infection prevention.”

Spruce says AORN had already decided “that it was time to revise that guideline” but “it was valuable” to hear the thoughts among that multidisciplinary group. She adds, “The perioperative setting has always been a team environment and we’ve always promoted that, so we want the teams to come together and agree on issues that are important to patient safety.”

AORN’s Guideline for Surgical Attire will be reviewed by AORN’s advisory board, which includes representatives from organizations that formed the task force, plus the Society for Healthcare Epidemiology of America (SHEA), the International Association of Healthcare Central Service Material Management, and the American Association of Nurse Anesthetists. That revised guideline will be available for public comment early next year and will be ready for publication in April 2019.

In the meantime, Spruce recommends that healthcare organizations “convene all of the relevant stakeholders”—an all-inclusive, interdisciplinary team—“to discuss their current facility policy and either confirm that it’s going to stay the same until the guideline comes out or go ahead and institute changes based on the consensus of [the task force].”

She notes that The Joint Commission was part of the consensus, so allowing the use of skull caps “should be fine.”

However, Steven A. MacArthur, a senior consultant with The Greeley Company in Danvers, Massachusetts, believes that healthcare organizations should proceed with caution.

“Until CMS provides some relief or guidance or recapitulation relative to the skullcap issue, you have to go by what has been documented in the process, which is in this case, ‘Thou shalt not wear skull caps as the only protection,’ ” says MacArthur. “Until CMS tells their surveyors not to chase this, then … they are increasing their vulnerability relative to the survey process.”

Regardless of whether CMS again follows AORN’s lead on OR headwear, Nori, who in April at SHEA’s spring conference discussed this topic and other controversies in OR equipment and attire, doesn’t anticipate widespread policy changes among U.S. healthcare organizations.

“Even if AORN dials things back, for us to implement another cultural change, it’s a big undertaking to then change all of our equipment and share new information,” says Nori. “It’s engrained in people to do it a certain way. The most important thing is just standardization to avoid errors in the OR. So even if they make a 180-degree change in their recommendation, I don’t think my hospital system … would tell all of our surgeons, ‘Hey, you don’t have to do that anymore.’ ”

Asked which headwear she recommends, Nori says that “based on what we know about the mechanics of shedding the bacteria and skin cells and hair and all that, I think as much of that stuff you can cover as possible, that’s great. I think whatever is comfortable, whatever breathes, and whatever doesn’t alienate people by forcing people to wear one thing. I think you have to have different options for different types of people. And it just kind of has to make sense scientifically.”

Adds Nori, “I think it would be good for [AORN] to finally put a statement out assuaging people’s previous objections, because that part in particular was pretty controversial. … There shouldn’t be any kind of very strong national recommendation unless there’s good evidence behind it.”

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