What surgeons need to know about the skull cap, bouffant debate

Editor's Note

The debate over surgical cap attire has grown from a patient-safety issue to a platform for emotionally driven arguments, unflattering logic, and failed leadership by all parties involved, according to this Viewpoint article in JAMA Surgery.

The 2014 guidelines from AORN never explicitly endorsed the bouffant hair cover, but those familiar with options knew that the bouffant met the recommendations better than the skull cap. Those AORN guidelines became a benchmark for CMS and the Joint Commission surveys, and hospitals were cited for poor infection control practices if staff had hair exposed.

This led the American College of Surgeons (ACS) to publish their own guidelines in October 2016, noting that: “The skull cap is symbolic of the surgical profession. The skull cap may be worn when close to the totality of hair is covered by it and when only a limited amount of hair on the nape of the neck or modest sideburns remains uncovered.”

In February 2018, the ACS, AORN, ASA, APIC, AST and Joint Commission met to discuss findings of recent studies on the skull cap vs bouffant hair covering, which showed no change in SSI rates since the banning of skull caps and no association of SSI rates with the choice of hair covering. The summit came to the conclusion that there was no clear evidence linking the type of cap or extent of hair coverage with SSI rates.

This meeting led to AORN guideline revisions that came out in July 2019, which made no recommendation for the type of surgical head covering or extent of hair coverage. However, AORN added that an interdisciplinary team at each healthcare organization may determine the type of head covering to be worn.

The authors do not believe this was appropriate for AORN to defer to a committee at each institution because it allows the dilemma to remain a controversial issue. They say they “cannot see how this updated guideline could be viewed as anything other than a failure from leadership on all fronts to come to a more definitive consensus.”