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Changes in Surgical Attire Did Not Reduce Surgical Site Infections

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Study Authors: Bradley W. Wills, Walter R. Smith, et al.; Radwan Dipp Ramos, Kamal M.F. Itani

Target Audience and Goal Statement: Surgeons, anesthesiologists

The goal of this study was to evaluate whether the combination of mandated surgical jackets and bouffants (head covers) in the operating room is associated with the risk of surgical site infection.

Question Addressed:

  • Is the combination of surgical jackets and bouffants in the operating room effective in reducing the risk of surgical site infection?

Study Synopsis and Perspective:

Despite state-of-the-art aseptic approaches, bacterial contamination of a surgical wound is inevitable. There are as many as 300,000 surgical site infections every year in the U.S. These infections account for about 20% of all hospital-acquired infections and increase hospital length of stay by an average of 9.7 days.

Action Points

  • There was no significant difference in risk of surgical site infections following the mandate of surgical jackets and bouffants for all operating room personnel in a retrospective cohort study of over 34,000 inpatient surgical encounters at a single large academic hospital.
  • Be aware that the study hospital spent more than $300,000 annually on surgical jackets and, according to the researchers, use of surgical jackets in all U.S. hospitals would cost the healthcare system $540 million per year.

Surgical site infection risk factors can be related to patient (e.g., colonization with pathogenic bacteria, perioperative hyperglycemia), procedural (e.g., break in sterile technique, operating room ventilation), and other (e.g., surgical technique, improper application of skin antisepsis) factors. Decolonization strategies, proper hair removal, and sterile attire are some of the ways to reduce microbial inoculation into the wound.

Wearing proper surgical attire to limit patient exposure to any reservoir that could harbor pathogenic organisms seems to be an act of common sense. Indeed, many healthcare organizations have begun to recommend the use of surgical jackets for OR staff who are not scrubbed in and bouffants for all staff. This is in addition to traditional protective attire commonly used during surgical procedures.

In JAMA Surgery, Brent Ponce, MD, of the University of Alabama at Birmingham (UAB) Hospital, and colleagues performed the first data-driven examination of the effectiveness of these recommendations.

Their retrospective cohort study was conducted over a 22-month period and included 34,042 inpatient surgical encounters (48% women) at UAB Hospital. Surgical site infection data came from the institutional infection control monthly summary reports. Order invoices provided clear dates of implementation and cost.

The study period was split into three periods based on changes in hospital policy regarding mandatory OR attire. The first period covered 8 months when bouffants and surgical jackets were not required, followed by 6 months with mandated surgical jackets. For the final 8-month period, surgical jackets and bouffants were mandated.

The primary study outcome was surgical site infections according to the National Healthcare Safety Network definitions for superficial incisional, deep incisional, and organ/space surgical site infections. Wound dehiscence, postoperative sepsis, death, and cost of interventions were listed as secondary outcomes.

There was no significant difference in risk of surgical site infections among the three successive groups (1.01% vs 0.99% vs 0.83%, P=0.28). Adjusting for potentially confounding variables had minimal effect on the difference in this risk over time.

Similarly, there were no differences in death (1.83% vs 2.05% vs 1.92%, P=0.54), sepsis (6.60% vs 6.24% vs 6.54%, P=0.54), and wound dehiscence (1.07% vs 0.84% vs 1.06%, P=0.20) among the three groups.

The hospital spent more than $300,000 annually on surgical jackets. According to the researchers, use of surgical jackets in all U.S. hospitals would cost the healthcare system $540 million per year.

Fans of medical dramas may know that types of surgical head wear include skull caps or the loose-fitting bouffants with elastic to keep the cover on a surgeon’s head. The American Association of Perioperative Registered Nurses (AORN) and the American College of Surgeons have been engaged in a debate about the most suitable head cover for the OR, since a recent AORN guideline recommended the use of bouffants. Additionally, the AORN stated that all personnel present in the OR and not scrubbed wear surgical jackets to cover their arms at all times.

While Ponce’s study did not show infection effects as a function of headgear, the researchers pointed out that bouffants were found to be 57.14% less expensive than surgical skull caps.

“Bouffants cost $0.04 per unit ($2.72 for a box of 75) while surgeon caps cost $0.07 per unit ($7.44 for a box of 100),” they wrote.

Study limitations included a lack of data on degree of compliance, an inability to control for different surgeons’ skin preparation techniques, Surgical Care Improvement Project bundle compliance, surveillance beyond 30 days for implanted prostheses, duration of surgery, and emergency operations.

Source References: JAMA Surgery 2020; DOI: 10.1001/jamasurg.2019.6044

Editorial: JAMA Surgery 2020; DOI: 10.1001/jamasurg.2019.6023

Study Highlights and Explanation of Findings:

Despite significant advances in surgical techniques, modern technologies in the operating room, and preemptive measures such as perioperative intravenous antibiotics and preoperative skin antisepsis, surgical site infections remain a problem in surgery. The CDC has incorporated this knowledge into surgical wound classification grades (I-IV). Prevention of infection is a priority for the entire healthcare team.

Over the past few years, regulatory recommendations in this regard have included suggestions that OR personnel cover their arms with surgical jackets and wear “a clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck.” Although not directly stated, this has been understood to mean a recommendation for bouffants and against surgical caps in an effort to lower the risk of surgical site infections.

“Interestingly, one article that took a more basic science approach to this issue found that bouffants were more permeable and had greater microbial shed than skull caps, concluding that bouffants ‘should not be considered superior to skull caps in preventing airborne contamination in the OR,'” Ponce and team wrote.

The current study findings demonstrated that risk of surgical site infections remained relatively constant throughout the study period. The researchers did not observe significant differences in the risk of infections, postoperative mortality, sepsis, and wound dehiscence among the three groups. Simply put, their data add support to a growing body of literature suggesting that these well-intentioned regulations have not been shown to have an effect on risk of surgical site infections.

Unlike the U.K.’s “bare below the elbow” policy, the other recommendation focused on wearing jackets in the OR. Theoretically, this would decrease bacterial shedding from the arms.

A 2016 study showed that there was no significant difference in surgical site infection rates 1 year prior to and 1 year after the University of Minnesota Medical Centers’ policy of mandating cover jackets in the OR.

In 2019, the AORN updated their guidelines on surgical jackets, stating “no recommendation can be made for wearing long sleeves in the semi-restricted and restricted areas other than during performance of preoperative patient skin antisepsis,” adding that further research would be needed to evaluate benefits and risks.

Although they did not observe an effect on infection, the researchers did see an impact on hospital expenses. According to a separate study, the cost of attire for one person entering the OR rose from $0.07 to $0.12 before the AORN policy change to $1.11 to $1.38 after the policy change.

“Ultimately, institutions should evaluate their own data to determine whether recommendations by outside governing organizations are beneficial and cost-effective,” they wrote.

Bouffant-versus-cap is not even the most important infection-control issue for surgical teams, wrote Radwan Dipp Ramos, MD, and Kamal Itani, MD, both of Veterans Affairs Boston Healthcare System, in an invited commentary.

“There are other common-sense recommendations regarding attire that we unfortunately disregard,” including frequent laundering of cloth caps, not wearing scrubs home, and, when leaving the restricted area of the OR, removing headgear, mask, and shoe covers and changing or covering scrubs, they noted.

“Short of having best evidence in any of those areas, myth and reality will continue to coexist, and our common sense augmented by available evidence should prevail over emotions and careless practices,” Ramos and Itani concluded.

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