Which Operating Theatre Caps Should I Use When I Operate?

I love wearing scrubs and whole operating theatre attire.  I also love having a fancy reusable operating theatre cap.  I prefer using it to the ones that hospitals provide.  Hospitals usually provide single-use ones, so they do not need to wash them.  And the claim was that they are more sterile and less likely to lead to infections.  But I do not like those.  

They are not pretty or personal, but most importantly they are not sustainable and they produce a lot of CO2 emissions in production and delivery.  They also contribute to the large amount of hospital rubbish that we produce.  But it is always hard to argue with hospitals when they said that this single-use attire is leading to fewer infections for our patients.  We doctors never want to cause more complications for our patients.

Where did all this come from?

In 2015 Association of periOperative Registered Nurses (AORN) published revised guidelines, including one that called for complete coverage of scalp, hair and ears.  Soon after this, many hospitals started receiving non-compliance complaints about people not wearing these single-use caps.  

So far in NZ hospitals, multiple single-use hats are still not compliant with this statement as they do not cover all of the hair and ears.  What about beards and masks? Most masks will not completely cover some beards.

But is this actually making any difference in the number of the infections that we are seeing?  We often take these guidelines as gospels, but we do not assess whether they make any difference or not for our patients and our hospitals and how much implementing these guidelines costs for not just hospitals, but also the environment.

Recently there was an Operating Room (OR) summit which published it's proceedings and recommendations from the OR attire summit: A collaborative model for guideline development.
They looked at all the research that has come out about the OR attire, including surgical hats.  They involved several prominent OR (Operating Room) organisations, from the American College of Surgeons to American College of Anaesthetists to AORN.  Members of these organisations have found 80 studies.  Out of this number they have excluded few (around 20) that were published before 1990 unless they were a landmark (very important) paper.  Only 5 studies evaluated the relationship between infections and use of hats (coverage of hair and scalp).

Two studies have been published on the effectiveness of OR hats including the extent of coverage (scalp and hair) in preventing surgical site infections.   These 2 studies included patients from 21, 000 operations.  Neither of these studies has found that there was a decrease in surgical site infection, in contrary, there was s slight increase in the number of infections (this was not significant).

I also have a problem with studies that look at the permeability, or the particle transmission and pore size of disposable hats.  I think this is a bad replacement (but easier to perform) for clinical relevance.  It does not matter how porous hats are.  The question is: does wearing different hats lead to less infection to our patients or not? And this may not be universal for the whole hospital.  

Maybe we need to look at different patient groups, different types of operations, different situations (like how acute the operation is, which country it is performed, can this country or state afford all this for a change vs other areas that need improvement), how much does all this cost to implement, what is impact on the environment.

I believe that we are going to be looking more and more on the impact of healthcare on our environment.  Single-use hats are not only increasing our rubbish production, but they are also increasing our carbon footprint and lead to increasing temperatures and global warming.   Bacteria that cause many infections prefer (on average) to live in warmer environments.  As the temperatures rise there may be an increase in the surgical site infections just because of the increase in environmental temperatures and exposures to increased temperatures may lead to different infections due to presence of bacteria that thrive in these warmer environments.

In the end, I think that we should evaluate single vs multi-use OR hats in our own hospitals and see what effect this has for our patients.  The part of the study should also include the cost (both environmental as well as monetary) of both types of OR hats.  This way we can make informed decisions and also inform patients why we are using certain hats and why not in certain situations.