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Where is the Science Behind the Rules We Follow?

hsGuest post from Marshal D. Peris, MD, FAAOS
Co-Chief Spine Surgery and Medical Staff President, Northern Westchester Hospital
Director of Spine Surgery, Mount Sinai Health System at CareMount Medical

As a surgeon, my goals in surgery include achieving excellent patient outcomes and reducing complications. We have been taught to be rigorous in our evaluation of research and to practice evidence-based medicine. In this ever-changing health care environment, I was ready to embrace change when my highly efficient hospital became part of a large, metropolitan hospital system. Recently, however, the hospital system that acquired my hospital altered the rules for operating room (OR) attire — with the purported goal of reducing infections. This included minor changes like forcing staff to wear socks and shoe covers and remove all earrings that dangle. However, two of the rules stood out as unnecessarily burdensome and nonscientific:

  • All OR personnel must wear a jacket with long sleeves buttoned all the way up over their scrubs; and
  • A surgeon’s scrub cap, whether disposable or reusable, was to be banned, leaving men to wear a bouffant cap or a full hood/ear/beard cover.

What makes wearing a jacket or a full head cover even more intolerable is the rule that the OR room temperature remains between 68 and 75°F degrees at all times.

The scrub jacket requirement stems from a concern that arm hairs carry microorganisms, and somehow these bacteria may find their way onto the surgical field and into the wound. All I can say, however, is since this rule went into effect, the loose sleeves and jackets can now inadvertently and unknowingly swipe against surgically prepped skin and sterile drapes.

Both the jacket and head cover mandate stems from an OR attire recommendation in the Association of periOperative Registered Nurses’ perioperative nursing guidelines. Nowhere is there a recommendation in the guidelines about what a surgeon standing at the operative field should wear. Additionally, there is no scientific reference given about surgical head covers and associated infection rates or patient outcomes. Finally, the guidelines carry no recommendation for those with shaved heads or no hair. For bald people, a bouffant cap is actually unsafe for both the patient and the staff member wearing it because such a cap:

  • Allows skin cells to easily pass through (try pouring baby powder into one to envision what I mean); and
  • Allows blood or OR field splash to pass through onto the scalp where it will sit until the surgery is over, or force the surgeon or nurse to scrub out and leave the OR to wash off and change hats.  

For the surgeon, a head cover is primarily for the surgeon’s protection, not the patient’s. Covering a surgeon’s ears decreases the ability to hear and does not allow for a surgeon to wear surgical loupes or lead glasses that have a securing headband. After much discussion, my hospital OR and system agreed with my assessment and will allow disposable surgeons caps and is not forcing me into wearing the dreaded bouffant or hood.

WTSWho is responsible for the nonsense? I have yet to find one person to stand up and admit responsibility for making the rule and explain the science behind it. My hospital blames the system of which they are now part. The system blames the department of health or the Joint Commission. The department of health blames Washington DC. The fear of all hospitals is an inspector with an agenda and interpretation of the “rules” that could levy a fine or close down an OR for failing to comply. The hospitals act out of fear and nothing else and are not willing to question the rules. Clearly, as large hospital systems mandate such protocols, these will rapidly become the norm — whether they are correct or not.

Now let’s consider the OR temperature requirement. After an extensive investigation, the only supporting reference on this topic is from an article in the Journal of Architecture from the 1960’s. The OR air temperature has never been shown to correlate with patient core body temperature or patient outcomes. Surgeons sweat while operating under hot lights, standing up against a heated cover over the patient because some architect wrote those recommended numbers in an article 50 years ago. Furthermore, I am now also forced to wear a particular head cover because someone wrote an OR attire recommendation for perioperative personnel. Where is the science? Can it be shown that my patients will have worse outcomes and more infections if the room temperature is 63°F and I wear a reusable freshly washed cloth surgeon’s cap? What am I asking for? No more than is asked of me every day as a surgeon: for the regulators and administrators to take responsibility and be guided by science. Will the person or committee responsible for these nonscientific rules please stand up and explain?

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