Buffalo doctors are at the center of a national debate among surgeons: Skullcap or bouffant?
It's a question that has embroiled the medical community in a heated controversy over whether the head attire surgical teams wear could pose a risk of infection.
Influenced by recommendations from the Association of periOperative Registered Nurses, hospitals have been banning the traditional tight-fitting, skullcap-style cap that sits above the ears in favor of the puffy shower-cap style bouffant that covers the ears, sideburns and nape of the neck. The change has drawn pushback from surgeons.
A study by Buffalo doctors published in May in the journal Neurosurgery fueled the controversy further. It compared infection rates in nearly 16,000 procedures at Kaleida Health's Buffalo General Medical Center in the 13 months before and after the hospital system banned surgical caps in early 2015 and found no significant difference.
The nurses' association questioned the interpretation of the study results and contended the doctors misrepresented its recommendation for surgical head attire. Then the American College of Surgeons in August countered with a defense of the skullcap, saying surgical attire should be based on "professionalism, common sense, decorum, and the available evidence." The college's statement, in turn, prompted a detailed rebuttal by the nurses' association.
Now, Kaleida Health physicians have followed up with a commentary in the latest Bulletin of the American College of Surgeons, arguing that the evidence is lacking to support the bans on the head wear preferred by many surgeons.
“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," said Dr. Kevin Gibbons, lead author on both publications. “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," said Gibbons, senior associate dean for clinical affairs at the University at Buffalo, chief of neurosurgery at Kaleida Health, and executive director of UBMD Physicians’ Group.
The issue is no small matter for health care facilities because of the potential for citations by government reviewers or accrediting agencies that may consider the skullcap a problem in surveys.
The study by the Buffalo physicians was prompted by a government hospital survey that interpreted a Kaleida Health surgeon’s use of a skullcap as a failure to implement standards to minimize surgical site, an "immediate jeopardy" citation that could have risked Medicare reimbursement.
"The time and energy expended by senior leadership, including administration, nursing, and physician leadership, down to all levels of the organization, was immense – and, in our view, wasted. And this occurred in an institution with surgical site infection rates already well below the national average," the physicians wrote in their commentary.
Kaleida Health recently reversed its ban on skullcaps based on a review of the evidence and its overall infection-control policies, Gibbons said.
The other large hospital system in the region – Catholic Health – requires its surgical staff to wear hospital-provided bouffant-style surgical caps. The requirement is based on recommended infection prevention practices and state regulations designed to reduce the risk of surgical infections, officials said in a statement.
During an unrelated visit to one of Catholic Health's operating rooms earlier this year, a Health Department representative noticed a surgical staff member wearing a tie-style cap and brought it to the attention of the surgery department manager. The issue was quickly resolved, officials said. The hospital system's surgical cap requirements allow staff to wear tie-style caps if they are covered by a bouffant cap.
Prior to 2015, the nurses' association guideline recommended bouffant caps for surgical personnel, citing research showing that the scalp and hair harbor bacteria, and could potentially pose a danger to a patient. The guideline was then revised without mention of specific head attire to say, “A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn,” although critics say the language effectively bans the caps.
There is no randomized, controlled trial that might settle whether different types of surgical head coverings affect surgical site infection rates.
The physicians involved in the Buffalo study see their work as large and solid enough to offer direction on surgical attire. But the nurses association questioned whether the study was strong enough to capture a difference between the head gear.
Meanwhile, the nurses association cites more than two dozen articles related to bacterial shedding from skin and hair, pathogenic organisms present on the hair and ears, and case reports of infectious organisms passed from health care providers to patients. But the group acknowledges that the articles don't offer conclusive evidence, and the Kaleida Health/UB physicians characterized the research as "weak" compared to their study.
Regardless, the nurses' association argues that covering and containing hair is a reasonable and prudent measure that poses no harm and may benefit patients by reducing the risk of exposure to potentially pathogenic organisms.
"Our conclusions are based on the best that we know at this time. It can't hurt and might help," said Gayle Davis, director of corporate communications for the group. "More studies need to be done."
The American College of Surgeons in a 2016 statement on operating room attire maintained that there is no evidence that leaving ears, a limited amount of hair on the nape of the neck or a modest sideburn uncovered contributes to wound infections. The group also stated that, "The skullcap is symbolic of the surgical profession," a line that had critics responding that policies should not be based on looks.
In the latest commentary, Gibbons and his colleagues said that surgeons who work for many hours wearing head-mounted devices need a level of comfort and confidence that the tools will stay in proper position, and that surgeons who wear skullcaps have preferences that should not be summarily dismissed.
Gibbons said the American College of Surgeons statement could have been better worded. And, in their commentary, the physicians also said the at-times polarizing surgical cap debate can come across as a "battle of the sexes."
"For many years, the surgical skullcap may have been a symbol of the surgical profession, favored more by surgeons than nurses or scrub technicians. And it may have been favored more by men than women. Those divisions and assumptions about gender, surgeon versus nurse, and male versus female should no longer exist in our ORs," they wrote.
Davis of the nurses' association said representatives of the American College of Surgeons asked to meet to talk about the research evidence on head gear. Gibbons said there needs to be greater cooperation between the groups, and a meeting may provide an opening to find consensus on the issue.