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August 28, 2019

What Surgeons Need to Know About the Bouffant Scandal

Author Affiliations
  • 1Cleveland Clinic Center for Abdominal Core Health, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
JAMA Surg. 2019;154(11):989-990. doi:10.1001/jamasurg.2019.2107

There are few topics that generate more heated debate than guidelines for appropriate surgical cap attire. Specifically, the recent point of contention is that the skull cap, for most people who wear it, leaves some hair uncovered, exposing patients to more bacterial shedding and potentially higher rates of surgical site infection (SSI). But the controversy has percolated into more than a patient-safety issue; it has become a platform for emotionally driven arguments, unflattering logic, and failed leadership by all parties. There is plenty of blame to go around and a silver lining in the attempted collaboration to resolve the controversy, but ultimately the pending resolution suffers from ambiguity and indecision. Before we look forward, we should start with a quick summary of the dispute.

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    1 Comment for this article
    Levels of Evidence still matter
    Steven Zeitzew, M.D. | West L.A. VA Healthcare Center
    It is premature to issue guidelines without sufficient scientific evidence.

    Any physician knows that the best clinical scientific evidence does not always support the conclusions reached based on prior theoretical discussions. This article discussed recommendations for and against specific hair covers without citing high level clinical scientific evidence supporting those recommendations.

    There are many examples where actual science is surprising, where we discover unanticipated risks, side effects, or benefits from a studied intervention. It is not outside of the realm of possibility that a skull cap is sufficient, that a bouffant results in higher risk of infection,
    or that wearing an undesired head covering has a negative impact on a surgeon's performance. If this is a subject worthy of issuing a guideline then it is a subject worth a well-designed prospective clinical study. One of the dangers of issuing a guideline is the resulting implementation of policy not based on sufficient evidence.

    For some the theoretical underpinnings of the recommendation for bouffant hat is sufficient. Personally, I choose to wear a bouffant under a complete hood, but I do not pretend to know the results of a level one study that hasn't been performed, and don't have sufficient evidence to impose my choice on others.