Association of Surgical Jacket and Bouffant Use With Surgical Site Infection Risk | Infectious Diseases | JAMA Surgery | JAMA Network
[Skip to Navigation]
Sign In
Figure 1.  Demonstration of the Changes in Required Operating Room Attire
Demonstration of the Changes in Required Operating Room Attire

A, No mandate (choice of surgical headwear). B, Surgical jackets only (choice of surgical headwear). C, Surgical jackets and bouffants.

Figure 2.  SSI Risk (%) per 1000 Cases by Month, Divided Into 3 Periods Corresponding With Changes in Required Operating Room Attire
SSI Risk (%) per 1000 Cases by Month, Divided Into 3 Periods Corresponding With Changes in Required Operating Room Attire
Table 1.  Postoperative Complication Rates by Surgical Attire Group
Postoperative Complication Rates by Surgical Attire Group
Table 2.  Patient Demographics and Comorbidities by Surgical Attire Group
Patient Demographics and Comorbidities by Surgical Attire Group
1.
Broex  EC, van Asselt  AD, Bruggeman  CA, van Tiel  FH.  Surgical site infections: how high are the costs?   J Hosp Infect. 2009;72(3):193-201. doi:10.1016/j.jhin.2009.03.020PubMedGoogle ScholarCrossref
2.
Garner  BH, Anderson  DJ.  Surgical site infections: an update.   Infect Dis Clin North Am. 2016;30(4):909-929. doi:10.1016/j.idc.2016.07.010PubMedGoogle ScholarCrossref
3.
Magill  SS, Edwards  JR, Bamberg  W,  et al; Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team.  Multistate point-prevalence survey of health care-associated infections.   N Engl J Med. 2014;370(13):1198-1208. doi:10.1056/NEJMoa1306801PubMedGoogle ScholarCrossref
4.
de Lissovoy  G, Fraeman  K, Hutchins  V, Murphy  D, Song  D, Vaughn  BB.  Surgical site infection: incidence and impact on hospital utilization and treatment costs.   Am J Infect Control. 2009;37(5):387-397. doi:10.1016/j.ajic.2008.12.010PubMedGoogle ScholarCrossref
5.
Ban  KA, Minei  JP, Laronga  C,  et al.  American College of Surgeons and Surgical Infection Society: surgical site infection guidelines, 2016 update.   J Am Coll Surg. 2017;224(1):59-74. doi:10.1016/j.jamcollsurg.2016.10.029PubMedGoogle ScholarCrossref
6.
Anderson  DJ, Podgorny  K, Berríos-Torres  SI,  et al.  Strategies to prevent surgical site infections in acute care hospitals: 2014 update.   Infect Control Hosp Epidemiol. 2014;35(6):605-627. doi:10.1086/676022PubMedGoogle ScholarCrossref
7.
Kirkland  KB, Briggs  JP, Trivette  SL, Wilkinson  WE, Sexton  DJ.  The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs.   Infect Control Hosp Epidemiol. 1999;20(11):725-730. doi:10.1086/501572PubMedGoogle ScholarCrossref
8.
Burlingame  BDB, Link  T,  et al. Guideline for surgical attire. In: Conner  R, ed.  Guidelines for Perioperative Practice. http://www.aornstandards.org/content/1/SEC6.body. Published 2017. Accessed September 15, 2019.
9.
Farach  SM, Kelly  KN, Farkas  RL,  et al.  Have recent modifications of operating room attire policies decreased surgical site infections? an American College of Surgeons NSQIP review of 6,517 patients.   J Am Coll Surg. 2018;226(5):804-813. doi:10.1016/j.jamcollsurg.2018.01.005PubMedGoogle ScholarCrossref
10.
L K. No more surgical caps for surgeons? https://www.bostonglobe.com/business/2016/08/31/hat-wars-flaring/abr7FuB9EZna1FRtECDR1K/story.html. Published 2016. Accessed September 18, 2019.
11.
Salassa  TE, Swiontkowski  MF.  Surgical attire and the operating room: role in infection prevention.   J Bone Joint Surg Am. 2014;96(17):1485-1492. doi:10.2106/JBJS.M.01133PubMedGoogle ScholarCrossref
12.
Shallwani  H, Shakir  HJ, Aldridge  AM, Donovan  MT, Levy  EI, Gibbons  KJ.  Mandatory change from surgical skull caps to bouffant caps among operating room personnel does not reduce surgical site infections in class I surgical cases: a single-center experience with more than 15 000 patients.   Neurosurgery. 2018;82(4):548-554. doi:10.1093/neuros/nyx211PubMedGoogle ScholarCrossref
13.
Rios-Diaz  AJ, Chevrollier  G, Witmer  H,  et al.  The art and science of surgery: do the data support the banning of surgical skull caps?   Surgery. 2018;164(5):921-925. doi:10.1016/j.surg.2018.05.015PubMedGoogle ScholarCrossref
14.
Chow  CJ, Hayes  LM, Saltzman  DA.  The impact of perioperative warm-up jackets on surgical site infection: cost without benefit?   Am J Surg. 2016;212(5):863-865. doi:10.1016/j.amjsurg.2016.02.015PubMedGoogle ScholarCrossref
15.
Hill  J, Howell  A, Blowers  R.  Effect of clothing on dispersal of Staphylococcus aureus by males and females.   Lancet. 1974;2(7889):1131-1133. doi:10.1016/S0140-6736(74)90885-XPubMedGoogle ScholarCrossref
16.
Benediktsdóttir  E, Hambraeus  A.  Dispersal of non-sporeforming anaerobic bacteria from the skin.   J Hyg (Lond). 1982;88(3):487-500. doi:10.1017/S0022172400070340PubMedGoogle ScholarCrossref
17.
Bartek  M, Verdial  F, Dellinger  EP.  Naked surgeons? the debate about what to wear in the operating room.   Clin Infect Dis. 2017;65(9):1589-1592. doi:10.1093/cid/cix498PubMedGoogle ScholarCrossref
18.
AORN. Guidelines for Perioperative Practice: Surgical Attire. https://aornguidelines.org/guidelines/content?sectionid=173717946&view=book#221232892. Published 2019. Accessed September 27, 2019.
19.
Kothari  SN, Anderson  MJ, Borgert  AJ, Kallies  KJ, Kowalski  TJ.  Bouffant vs skull cap and impact on surgical site infection: does operating room headwear really matter?   J Am Coll Surg. 2018;227(2):198-202. doi:10.1016/j.jamcollsurg.2018.04.029PubMedGoogle ScholarCrossref
20.
Mangram  AJ, Horan  TC, Pearson  ML, Silver  LC, Jarvis  WR; Hospital Infection Control Practices Advisory Committee.  Guideline for prevention of surgical site infection, 1999.   Infect Control Hosp Epidemiol. 1999;20(4):250-278. doi:10.1086/501620PubMedGoogle ScholarCrossref
21.
Markel  TA, Gormley  T, Greeley  D,  et al.  Hats off: a study of different operating room headgear assessed by environmental quality indicators.   J Am Coll Surg. 2017;225(5):573-581. doi:10.1016/j.jamcollsurg.2017.08.014PubMedGoogle ScholarCrossref
22.
Huston  JM, Twomey  CL, Duane  TM.  AORN guideline for surgical attire: head coverings.   Surg Infect (Larchmt). 2019;20(6):437-438. doi:10.1089/sur.2019.181PubMedGoogle ScholarCrossref
24.
Elmously  A, Gray  KD, Michelassi  F,  et al.  Operating room attire policy and healthcare cost: favoring evidence over action for prevention of surgical site infections.   J Am Coll Surg. 2019;228(1):98-106. doi:10.1016/j.jamcollsurg.2018.06.010PubMedGoogle ScholarCrossref
25.
Anthony  CA, Peterson  RA, Polgreen  LA, Sewell  DK, Polgreen  PM.  The seasonal variability in surgical site infections and the association with warmer weather: a population-based investigation.   Infect Control Hosp Epidemiol. 2017;38(7):809-816. doi:10.1017/ice.2017.84PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    February 12, 2020

    Association of Surgical Jacket and Bouffant Use With Surgical Site Infection Risk

    Author Affiliations
    • 1University of Alabama at Birmingham
    JAMA Surg. 2020;155(4):323-328. doi:10.1001/jamasurg.2019.6044
    Key Points

    Question  Is the combination of surgical jackets and bouffants in the operating room effective in reducing the risk of surgical site infection?

    Findings  In this cohort study of 34 042 inpatient surgical cases at a large tertiary care academic institution, there was no significant difference in surgical site infections following the mandate of surgical jackets and bouffants.

    Meaning  Institutions should evaluate their own data to determine whether recommendations by outside governing organizations are beneficial and cost-effective.

    Abstract

    Importance  Surgical site infections (SSIs) are associated with increased morbidity and mortality. Various measures have been enacted decrease the occurrence of SSIs involving the regulation of the attire worn by the operating room staff, at times without sufficient peer-reviewed literature to support their implementation.

    Objective  To evaluate whether the combination of mandated surgical jackets and bouffants in the operating room is associated with the risk of surgical site infection.

    Design, Setting, and Participants  A retrospective cohort study of 34 042 inpatient surgical encounters at a large academic tertiary care hospital was performed. Three periods between January 2017 and October 2018 were compared, corresponding with implementation of surgical jackets and the subsequent mandate of surgical jackets plus bouffant head covers. All inpatient surgical cases were included from University of Alabama at Birmingham University Hospital, a single-center, large academic tertiary care hospital. The study comprised a consecutive sample of all inpatient surgical cases over a 22-month period.

    Exposures  No surgical jackets or bouffants mandated (8 months), surgical jackets mandated (6 months), both surgical jackets and bouffants mandated (8 months).

    Main Outcomes and Measures  The primary study outcome was SSIs, which were collected from institutional infection control monthly summary reports, according to the National Healthcare Safety Network definitions for superficial incisional, deep incisional, and organ/space SSIs. Secondary outcomes included wound dehiscence, postoperative sepsis, death, and cost of interventions.

    Results  A total of 34 042 inpatient surgical encounters cases were included in the analysis over the 22-month study period. Of the total patients, 16 380 were women (48%) and 17 638 were men (52%). There was no significant difference in the risk of SSI (1.01% vs 0.99% vs 0.83%; P = .28), mortality (1.83% vs 2.05% vs 1.92%; P = .54), postoperative sepsis (6.60% vs 6.24% vs 6.54%; P = .54), or wound dehiscence (1.07% vs 0.84% vs 1.06%; P = .20) between the 3 groups. Receipts from the first 6 months of the 2018/2019 fiscal year provided an estimated expenditure of more than $300 000 annually on surgical jackets. Bouffants were found to be less expensive than surgical skull caps.

    Conclusions and Relevance  The results of this study suggest that surgical jackets and bouffants are neither beneficial nor cost-effective in preventing SSIs. Institutions should evaluate their own data to determine whether recommendations by outside governing organizations are beneficial and cost-effective.

    Introduction

    Surgical site infections (SSIs) are a difficult problem for both patients and surgeons and are associated with increased morbidity and mortality.1,2 It is estimated that there are as many as 300 000 SSIs annually in the United States.3 These infections account for approximately 20% of all hospital-acquired infections and increase hospital length of stay by a mean of 9.7 days.4,5 The economic consequence of these infections is estimated to be as high as $10 billion annually in the United States alone.6 Additionally, patients who develop an SSI have up to an 11 times higher risk of mortality compared with those who do not.7 Therefore, implementing SSI prevention measures in any surgical setting is the first line of defense in reducing the incidence of this complication.

    Various measures have been enacted to decrease the occurrence of SSIs involving the regulation of the attire worn by the operating room (OR) staff. The Association of Perioperative Registered Nurses (AORN) made several recommendations in 20158 regarding appropriate surgical attire. One notable recommendation for a “clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck” has led to the transitioning from a surgical skull cap to an alternate head covering, such as a bouffant or hood, in many institutions.8,9 Additionally, the AORN advocated that all personnel present in the OR and not scrubbed wear surgical jackets to cover their arms at all times. The joint commission and other accrediting bodies have begun to enforce these recommendations as regulations, citing hospitals for poor infection control practice if they discovered that surgical caps were being worn in the OR.10

    Some evidence exists in support of certain OR attire mandates in the prevention of SSI, such as the use of gloves and impermeable surgical gowns, but there is little information regarding the association of surgical jackets and bouffants with infections.11 Shallwani et al12 compared infection rates before and after the implementation of bouffant head coverings and found a nonsignificant increase in infection rates with bouffants. A similar study found no difference in the rates of SSI with and without the use of bouffant head coverings.13 Chow et al14 evaluated the implementation of surgical jackets and reported no difference in SSI rates. To our knowledge, no study has evaluated whether the combination of bouffants and surgical jackets is associated with the risk of SSI. This study sought to test the hypothesis that the risk of SSI is not associated with the use of bouffants and surgical jackets.

    Methods

    After obtaining institutional review board approval from the University of Alabama at Birmingham, data from all inpatient surgical cases at a large academic tertiary care hospital between January 1, 2017, and October 31, 2018, were collected. The University of Alabama at Birmingham institutional review board granted a waiver of patient consent for this project owing to the volume of patients whose medical records would be retrospectively reviewed. All surgical specialties at our institution were included. The time was split into 3 groups based on changes in hospital policy regarding mandatory OR attire (Figure 1). Quiz Ref IDThe first period when neither bouffants nor surgical jackets were required was from January 1, 2017, to August 31, 2017. The second period when only surgical jackets were required was from September 1, 2017, until February 28, 2018. Finally, the third period began when bouffants were required, starting in March 2018. The periods for each group lasted 8, 6, and 8 months, respectively. Order invoices for surgical jackets, bouffants, and surgical caps were obtained to provide clear dates of when each was implemented in the OR in addition to providing cost information.

    The main outcome of interest was SSIs, which were collected from our institutional infection control monthly summary reports. Surgical site infections at our institution are identified and recorded according to the National Healthcare Safety Network definitions for superficial incisional, deep incisional, and organ/space SSIs.5 Secondary outcomes included wound dehiscence, postoperative sepsis, and death among surgical inpatients, defined based on International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Patient comorbidities and procedure characteristics were also extracted. These included age, sex, length of stay, average case duration, American Society of Anesthesiologists class, prolonged intubation, chronic steroid use, presence of rheumatoid disease, chronic kidney disease, chronic obstructive pulmonary disease, hypoalbuminemia, liver disease (chronic hepatitis C, cirrhosis, and hepatic failure), increased body mass index (≥30; calculated as weight in kilograms divided by height in meters squared), diabetes, tobacco use, requirement of blood transfusion during hospitalization, transfer to intensive care unit, and hospital-associated conditions that did not involve SSIs (foreign object retained, air embolism, blood incompatibility, pressure ulcer, catheter-associated urinary tract infection, vascular-catheter–associated infection, poor glycemic control, deep vein thrombosis/pulmonary embolism, and iatrogenic pneumothorax).

    The proportion of patients who experienced SSIs, wound dehiscence, postoperative sepsis, and death were compared between the 3 groups using a χ2 test. Additionally, potentially confounding patient and procedure characteristics were similarly compared between the 3 groups using χ2 and t tests. Variables demonstrating statistically significant differences between the groups were used to adjust the temporal comparisons in the outcomes using logistic regression. A P value of less than .05 was considered statistically significant, and the P value was 2-sided.

    Results

    A total of 34 042 inpatient surgical encounters were included in the analysis over the 22-month study period. The overall SSI risk was 0.94% and the overall mortality, postoperative sepsis, and wound dehiscence risks were 1.92%, 6.48%, and 1.01% respectively. There was no significant difference in the risk of any outcome over time (Table 1). Quiz Ref IDAdditionally, the SSI risk did not decrease significantly throughout the duration of the study (Figure 2).

    There were 4 potentially confounding variables that differed statistically among the 3 groups: presence of rheumatoid disease, chronic steroid use, poor glycemic control, and American Society of Anesthesiologists class (Table 2), although adjusting for these variables had minimal effect on the difference in the SSI risk over time.

    Quiz Ref IDHospital ordering receipts for the 2017/2018 fiscal year identified $264 760.78 spent on purchasing surgical jackets during the 14 months of the second and third groups. Jackets were purchased for $2.06 per unit for the standard large size ($20.59 for a pack of 10), although cost did increase with larger sizes. Additionally, receipts for the first 6 months of the 2018/2019 fiscal year provided an estimated expenditure of more than $300 000 annually on surgical jackets. Quiz Ref IDBouffants were found to be 57.14% less expensive than surgical skull caps. Bouffants cost $0.04 per unit ($2.72 for a box of 75) while surgeon caps cost $0.07 per unit ($7.44 for a box of 100).

    Discussion

    Surgical site infections place a significant financial burden on the health care system and are a common cause of morbidity and mortality for patients. Prevention of SSIs is of great importance to all members of the health care team. Regulatory bodies have suggested that OR personnel cover their arms with surgical jackets and wear a “clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck.”8 Although not explicitly stated, this has been understood by many institutions as a recommendation for bouffants and against surgical caps in an effort to decrease the risk of SSIs.8 Our data add support to the growing body of literature suggesting that these well-intentioned regulations have not been shown to have an effect on SSIs.

    Covering the arms of OR personnel with surgical jackets or other long sleeves has become a controversial topic over the last decade owing to conflicting recommendations among governing organizations. The rationale behind wearing surgical jackets in the OR is to decrease the shed of bacteria from the arms. This theoretical benefit has been studied by multiple groups and has been demonstrated not to decrease the risk of SSIs or bacterial colonization. Interestingly, this policy is in direct contradiction to the United Kingdom’s, where they instituted a policy in 2007 that restricts any clothing or accessories extending beyond the elbow.11 Older studies have shown that completely unclothed surgeons shed only a fraction of the number of bacteria compared with those wearing scrubs or street clothes, which seems to support this “bare below the elbow” policy.15-17 In 2016, Chow et al14 investigated the rate of SSIs 1 year prior to and 1 year following the institution of a policy mandating cover jackets in the OR. They not only found no significant difference in SSI rates, but their data actually trended toward an increase in SSI rates during the time in which OR jackets were worn. Quiz Ref IDOur study showed similar results, with no significant difference in SSI rates. The 2019 AORN updated guidelines18 regarding surgical jackets state “no recommendation can be made for wearing long sleeves in the semi-restricted and restricted areas other than during performance of preoperative patient skin antisepsis,” stating further research would be needed to evaluate harms and benefits.18

    Similarly, the recommendations regarding surgical head coverings were implemented to cover the ears and decrease the likelihood of bacterial shed to the sterile field. The rationalization stemmed from the idea that this would decrease the release of airborne bacteria into the OR; however, this has not been shown to correlate with increased SSI rates. In a study comparing SSIs in cases of surgeons wearing bouffants vs skull caps, no significant differences were found when adjusting for the type of operation.19 Shallwani et al12 demonstrated no difference in infection rates in neurosurgery cases 1 year after the implementation of bouffants. While the 1999 US Centers for Disease Control and Prevention guidelines strongly recommend the use of caps or hoods in the OR to fully cover the hair on the head and face, no specific headwear was clearly identified in the guidelines or supported by prior literature.20 Interestingly, one article21 that took a more basic science approach to this issue found that bouffants were more permeable and had greater microbial shed than skull caps, concluding that bouffants “should not be considered superior to skull caps in preventing airborne contamination in the OR.”21

    While our study did not evaluate bouffants individually, we did find that the combination of bouffants and jackets did not appear to decrease infection risk. The most recent guideline, published in July 2019, presents a new stance in regard to recommendations about surgical head coverings, as the recommendation that all hair must be “completely covered” has been removed.18 They also redact their stance on requiring the ears to be covered, because although the ears have been shown to be a “potential reservoir for pathogens,” this has not been shown to play a role in the development of SSI.22 In a draft of the guidelines, which prompted a response by the American Society of Anesthesiologists, there was a recommendation that head covering choice should be at the discretion of the surgical team “based on the patient’s risk for developing a surgical site infection and the team member’s risk of exposure to blood, body fluids and other potentially infectious materials.”23 This recommendation was criticized and later removed from the final published guidelines owing to the lack of available evidence to associate surgical headwear and SSIs.

    To our knowledge, there is no evidence that has shown an association between SSIs and certain OR attire, with the exception of sterile gowns and gloves.11 As health care costs continue to increase, we must be cognizant of the cost associated the implementation of these regulations. During the 2017/2018 fiscal year, our institutional expenditures for surgical jackets alone totaled more than $264 000. Bouffants did not have as much of a financial impact and were found to be slightly less expensive than skull caps. A 2019 study24 showed that the cost of attire for one person entering the OR increased from $0.07 to $0.12 to $1.11 to $1.38 after the implementation of the AORN attire policy. The authors estimated that the use of surgical jackets alone in all US hospitals would cost the health care system $540 million annually. The literature appears to demonstrate that no difference in surgical infection rates occur with the use of surgical jackets and bouffants, but result in a substantial cost to the health system.

    Limitations

    We acknowledge several limitations to our study. Although we evaluated many patient demographics and comorbidities to ensure the groups were relatively homogeneous, there were some comorbidities that were not extracted from our institutional database, including surgical specialty/case type and complexity/acuity of cases. However, there is little reason to believe that these characteristics would have meaningfully changed during the study period. While the mandates of surgical jackets followed by bouffant head covers were hospital policy and strictly enforced by OR staff, the numeric degree of compliance was unable to be determined, which is a limitation of our study. Additionally, we were not able to control for differences, such as skin preparation techniques, across different surgeons. For example, surgeons often prefer to use a varying number of preparation sticks or different solutions. Finally, there have been recorded seasonal differences in infection rates that may have affected the study, which we could not control owing to the temporal nature of the implementations of different attire regulations at our institution.25

    Conclusions

    The SSI risk remained relatively constant throughout the duration of the study. There were no significant differences in the risk of SSIs, postoperative mortality, sepsis, and wound dehiscence between the 3 study periods. Therefore, the results of this study suggest that surgical jackets and bouffants are neither beneficial nor cost-effective in preventing SSIs. The results add to the growing body of research that there is no clear benefit to bouffants and surgical jackets in the quest to decrease the incidence of SSIs. Ultimately, institutions should evaluate their own data to determine whether recommendations by outside governing organizations are beneficial and cost-effective.

    Back to top
    Article Information

    Corresponding Author: Brent A. Ponce, MD, University of Alabama at Birmingham, 1313 13th St S, Ste 203, Birmingham, AL 35205 (bponce@uabmc.edu).

    Accepted for Publication: December 1, 2019.

    Published Online: February 12, 2020. doi:10.1001/jamasurg.2019.6044

    Correction: This article was corrected on May 27, 2020, to fix the accepted for publication date.

    Author Contributions: Dr Ponce had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Wills, Smith, McGwin, Ghanem, Ponce.

    Acquisition, analysis, or interpretation of data: Wills, Smith, Arguello, McGwin, Ponce.

    Drafting of the manuscript: Wills, Smith, Arguello, McGwin, Ghanem.

    Critical revision of the manuscript for important intellectual content: Wills, Smith, Arguello, McGwin, Ponce.

    Statistical analysis: Smith, McGwin.

    Administrative, technical, or material support: Wills, Smith, Arguello, Ponce.

    Supervision: Wills, Smith, McGwin, Ghanem, Ponce.

    Conflict of Interest Disclosures: Dr Ponce has stock or stock options in Help Lightning, is a pain presenter/speaker and paid consultant for Tornier, and receives IP royalties from Wright Medical Technology Inc. No other disclosures were reported.

    Additional Contributions: We thank Yvonne Chodaba, MD, for her assistance with demonstrating the surgical attire groups in Figure 1 and granting permission to publish this information.

    References
    1.
    Broex  EC, van Asselt  AD, Bruggeman  CA, van Tiel  FH.  Surgical site infections: how high are the costs?   J Hosp Infect. 2009;72(3):193-201. doi:10.1016/j.jhin.2009.03.020PubMedGoogle ScholarCrossref
    2.
    Garner  BH, Anderson  DJ.  Surgical site infections: an update.   Infect Dis Clin North Am. 2016;30(4):909-929. doi:10.1016/j.idc.2016.07.010PubMedGoogle ScholarCrossref
    3.
    Magill  SS, Edwards  JR, Bamberg  W,  et al; Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team.  Multistate point-prevalence survey of health care-associated infections.   N Engl J Med. 2014;370(13):1198-1208. doi:10.1056/NEJMoa1306801PubMedGoogle ScholarCrossref
    4.
    de Lissovoy  G, Fraeman  K, Hutchins  V, Murphy  D, Song  D, Vaughn  BB.  Surgical site infection: incidence and impact on hospital utilization and treatment costs.   Am J Infect Control. 2009;37(5):387-397. doi:10.1016/j.ajic.2008.12.010PubMedGoogle ScholarCrossref
    5.
    Ban  KA, Minei  JP, Laronga  C,  et al.  American College of Surgeons and Surgical Infection Society: surgical site infection guidelines, 2016 update.   J Am Coll Surg. 2017;224(1):59-74. doi:10.1016/j.jamcollsurg.2016.10.029PubMedGoogle ScholarCrossref
    6.
    Anderson  DJ, Podgorny  K, Berríos-Torres  SI,  et al.  Strategies to prevent surgical site infections in acute care hospitals: 2014 update.   Infect Control Hosp Epidemiol. 2014;35(6):605-627. doi:10.1086/676022PubMedGoogle ScholarCrossref
    7.
    Kirkland  KB, Briggs  JP, Trivette  SL, Wilkinson  WE, Sexton  DJ.  The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs.   Infect Control Hosp Epidemiol. 1999;20(11):725-730. doi:10.1086/501572PubMedGoogle ScholarCrossref
    8.
    Burlingame  BDB, Link  T,  et al. Guideline for surgical attire. In: Conner  R, ed.  Guidelines for Perioperative Practice. http://www.aornstandards.org/content/1/SEC6.body. Published 2017. Accessed September 15, 2019.
    9.
    Farach  SM, Kelly  KN, Farkas  RL,  et al.  Have recent modifications of operating room attire policies decreased surgical site infections? an American College of Surgeons NSQIP review of 6,517 patients.   J Am Coll Surg. 2018;226(5):804-813. doi:10.1016/j.jamcollsurg.2018.01.005PubMedGoogle ScholarCrossref
    10.
    L K. No more surgical caps for surgeons? https://www.bostonglobe.com/business/2016/08/31/hat-wars-flaring/abr7FuB9EZna1FRtECDR1K/story.html. Published 2016. Accessed September 18, 2019.
    11.
    Salassa  TE, Swiontkowski  MF.  Surgical attire and the operating room: role in infection prevention.   J Bone Joint Surg Am. 2014;96(17):1485-1492. doi:10.2106/JBJS.M.01133PubMedGoogle ScholarCrossref
    12.
    Shallwani  H, Shakir  HJ, Aldridge  AM, Donovan  MT, Levy  EI, Gibbons  KJ.  Mandatory change from surgical skull caps to bouffant caps among operating room personnel does not reduce surgical site infections in class I surgical cases: a single-center experience with more than 15 000 patients.   Neurosurgery. 2018;82(4):548-554. doi:10.1093/neuros/nyx211PubMedGoogle ScholarCrossref
    13.
    Rios-Diaz  AJ, Chevrollier  G, Witmer  H,  et al.  The art and science of surgery: do the data support the banning of surgical skull caps?   Surgery. 2018;164(5):921-925. doi:10.1016/j.surg.2018.05.015PubMedGoogle ScholarCrossref
    14.
    Chow  CJ, Hayes  LM, Saltzman  DA.  The impact of perioperative warm-up jackets on surgical site infection: cost without benefit?   Am J Surg. 2016;212(5):863-865. doi:10.1016/j.amjsurg.2016.02.015PubMedGoogle ScholarCrossref
    15.
    Hill  J, Howell  A, Blowers  R.  Effect of clothing on dispersal of Staphylococcus aureus by males and females.   Lancet. 1974;2(7889):1131-1133. doi:10.1016/S0140-6736(74)90885-XPubMedGoogle ScholarCrossref
    16.
    Benediktsdóttir  E, Hambraeus  A.  Dispersal of non-sporeforming anaerobic bacteria from the skin.   J Hyg (Lond). 1982;88(3):487-500. doi:10.1017/S0022172400070340PubMedGoogle ScholarCrossref
    17.
    Bartek  M, Verdial  F, Dellinger  EP.  Naked surgeons? the debate about what to wear in the operating room.   Clin Infect Dis. 2017;65(9):1589-1592. doi:10.1093/cid/cix498PubMedGoogle ScholarCrossref
    18.
    AORN. Guidelines for Perioperative Practice: Surgical Attire. https://aornguidelines.org/guidelines/content?sectionid=173717946&view=book#221232892. Published 2019. Accessed September 27, 2019.
    19.
    Kothari  SN, Anderson  MJ, Borgert  AJ, Kallies  KJ, Kowalski  TJ.  Bouffant vs skull cap and impact on surgical site infection: does operating room headwear really matter?   J Am Coll Surg. 2018;227(2):198-202. doi:10.1016/j.jamcollsurg.2018.04.029PubMedGoogle ScholarCrossref
    20.
    Mangram  AJ, Horan  TC, Pearson  ML, Silver  LC, Jarvis  WR; Hospital Infection Control Practices Advisory Committee.  Guideline for prevention of surgical site infection, 1999.   Infect Control Hosp Epidemiol. 1999;20(4):250-278. doi:10.1086/501620PubMedGoogle ScholarCrossref
    21.
    Markel  TA, Gormley  T, Greeley  D,  et al.  Hats off: a study of different operating room headgear assessed by environmental quality indicators.   J Am Coll Surg. 2017;225(5):573-581. doi:10.1016/j.jamcollsurg.2017.08.014PubMedGoogle ScholarCrossref
    22.
    Huston  JM, Twomey  CL, Duane  TM.  AORN guideline for surgical attire: head coverings.   Surg Infect (Larchmt). 2019;20(6):437-438. doi:10.1089/sur.2019.181PubMedGoogle ScholarCrossref
    24.
    Elmously  A, Gray  KD, Michelassi  F,  et al.  Operating room attire policy and healthcare cost: favoring evidence over action for prevention of surgical site infections.   J Am Coll Surg. 2019;228(1):98-106. doi:10.1016/j.jamcollsurg.2018.06.010PubMedGoogle ScholarCrossref
    25.
    Anthony  CA, Peterson  RA, Polgreen  LA, Sewell  DK, Polgreen  PM.  The seasonal variability in surgical site infections and the association with warmer weather: a population-based investigation.   Infect Control Hosp Epidemiol. 2017;38(7):809-816. doi:10.1017/ice.2017.84PubMedGoogle ScholarCrossref
    ×