Everything You Ever Wanted To Know About Operating Room Head Coverings

In case you might want to challenge your hospital’s policy on the subject, I have gathered all of the recent research I could find on surgical head wear.



In response to a 2013 question from a reader, I blogged about the complete lack of evidence that OR staff hair caused wound infections or any other problem. After a similar question from another reader three years later, I pointed out nothing had changed.

Finally a 2017 paper in the journal Neurosurgery appeared online comparing the incidence of wound infections in clean cases for the 13 months before and the 13 months after the institution of a ban on the wearing of the traditional surgeons’ ca`p. Over 15,000 patients were included in the study which found no statistically significant difference in the rate of wound infections.

Also in 2017 at the Annual Clinical Congress of the American College of Surgeons, investigators from the Gundersen Health System in Wisconsin presented an observational study of 1543 surgical patients whose surgeons wore bouffant caps in 39% of cases and surgeons’ caps 61% of the time. After adjusting for the type of procedure, there was no significant difference in the rate of surgical site infections between the two groups.

Another study presented at that ACS meeting measured the amount of microbial contamination of a simulated surgical field when participants were wearing either type of cap. Using passive settle plate analysis, the investigators found significantly higher microbial shedding when bouffant caps were worn. Bouffants were also more permeable than either disposable or cloth surgeons’ caps.

A paper presented at the 2018 meeting of the Association for Academic Surgery/Society of University Surgeons involved patients at Thomas Jefferson University in Philadelphia who underwent non-vascular clean or clean-contaminated procedures before and after ban on the wearing of traditional surgeons’ caps. For the more than 3000 patients, the rate of surgical site infections was not significantly different between groups.

Two Rochester, New York teaching hospitals were subjected to new regulations mandating coverage of ears and facial hair after a visit from the state Department of Health. A before-and-after study involving over 6500 patients found no significant differences in wound infections, other complications, length of stay, or deaths for the two time periods.

Purists will complain that none of these studies were prospective randomized double-blind trials. However, the number of cases that would have to be done in order for a study to have enough statistical power to legitimately show no difference between the two types of headgear would be prohibitively large. The authors of the Rochester paper calculated it would take a sample size of 485,000 patients to show a 10% reduction in surgical site infections in patients with clean or clean-contaminated wounds. That study is not going to happen.

Proponents of the bouffant cap—the Joint Commission and the Association of periOperative registered Nurses—must now produce evidence showing bouffant caps are more effective in preventing surgical site infections or admit they were wrong.

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