Skullcap vs. bouffant: Evidence should determine whether surgeons hold onto their caps

If you’re about to undergo brain surgery, you likely aren’t thinking about what your surgeon is wearing on his or her head.

But headwear for surgeons and the teams that care for surgical patients is the subject of a serious, public debate between two key organizations: the Association of periOperative Registered Nurses (AORN) and the American College of Surgeons (ACS), both of which are dedicated to improving the care of surgical patients.

Surgeons from the Jacobs School of Medicine and Biomedical Sciences and Kaleida Health have entered the national discussion. They did so with a scientific study published in Neurosurgery last spring, the largest published study on the effect of head gear upon rates of surgical-site infections, and last week with an invited commentary published in the October Bulletin of the ACS.

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

“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. The leadership of AORN argues there is no harm in eliminating the cap and 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.”

Hospitals, he says, responded by outlawing caps to comply with the mandate. That’s what happened in February 2015 at Buffalo General, Kaleida Health’s biggest hospital and the largest training site for the Jacobs School of Medicine and Biomedical Sciences.

“This ban on the cap provided us with an opportunity to examine infection rates in so-called ‘clean’ cases before and after the ban,” Gibbons 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 the journal’s 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 continues. “Our study found that there is no basis for banning the cap.”

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

He explains 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, while important to those in the surgical field, has a wider impact as well, he points out. “Within medicine as a whole, we are really trying to become more evidence-based. There are certain things proven beyond a doubt and those should be the standards. 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.”

Gibbons and his UB colleagues authored an article, titled “The surgical cap: Symbol, science, argument, and evidence,” published this week in The Bulletin of The American College of Surgeons. It 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 this 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 Ken Snyder, assistant professor of neurosurgery at UB and director of physician quality for Kaleida Health; Steven Schwaitzberg, chair of the Department of Surgery and president of UBMD Surgery; and Elad Levy, chair of the Department of Neurosurgery, president of UBNS, co-director of Kaleida Health Stroke Center and Cerebrovascular Surgery, and medical director of neuroendovascular services at Gates Vascular Institute.