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In Reply We appreciate the dialogue that has been generated from our study1 because it shows the continued interest in providing optimal care for surgical patients. While we certainly acknowledge the difficulty with demonstrating efficacious infection reduction techniques, our position for evidence-based policies that are focused on improving patient outcomes, while minimizing financial and environmental burden remain.
Thomas highlighted the ambiguity of operating room policy regarding arm cover between countries. The lack of consensus on the topic stems from a need for quality scientific research regarding the subject matter. Preventing the devastating outcomes associated with surgical site infections (SSIs) should not be left up to guesses.
We acknowledge and commend the Association of Perioperative Registered Nurses for their continued focus in optimizing perioperative care and for modifying their guidelines in July 2019 prior to the publication of our study. However, the new guidelines raise similar concerns of waste without proven patient benefit. The updated recommendations are based off a single study by Markel et al2 that found a statistically significant reduction in airborne particle sizes when arms were covered with disposable sleeves while patients were undergoing preoperative skin preparation. Despite a reduction in particle sizes, there was not a significant difference in bacterial count and the settle plate colony-forming units. They did find a reduction in the bacterial genus Micrococcus vs coagulase negative Staphylococcus aureus and Corynebacterium; however, this genus of bacterium is unlikely to cause SSIs.2
Most causes of SSI are owing to the patient’s endogenous flora.3 Mundhada et al4 investigated the microbiology of SSIs of class 1 and 2 surgical wounds across multiple surgical subspecialties and found the most common bacteria isolated were S aureus (29%), Escherichia coli (21%), Pseudomonas aeruginosa (19%), Klebsiella pneumoniae (15%), Acinetobacter (12%) and Staphylococcus epidermidis (4%). Interestingly, there were no SSIs reported caused by Micrococcus,1,4 supporting the current stance in the literature that the association between airborne contaminants, bacteria, and SSI incidence has yet to be validated. In our opinion, the current recommendations will again lead to economic and environmental waste without patient benefit.
The resultant environmental burden following policy implementation in our study1 is certainly quite significant. The environmentally extended input-output Life Cycle Assessment model provided by Thiel et al showed an estimated 344 613 kg of carbon dioxide (or the equivalent of an additional 73 cars on the road) were produced as a result of the “Blue Jacket Policy.” This analysis provides excellent perspective for readers. The increased trash disposal also bears a financial cost, adding to the already enormous $1.7 million price tag that came with 2 years of disposable jacket use.
We believe our study is bigger than disposable jackets and infection prevention. It serves to call attention to the importance of evidence-based research prior to implementation of new policies, which will undoubtedly help reduce economic and environmental burden without compromising patient care.
Corresponding Author: Erik J. Stapleton, DO, MS, Northwell Health, 888 Old Country Rd, Plainview, NY 11803 (firstname.lastname@example.org; email@example.com).
Published Online: March 4, 2020. doi:10.1001/jamasurg.2019.6380
Conflict of Interest Disclosures: None reported.
Additional Contributions: The authors would like to thank Jonathon Lentz, DO, for his invaluable contribution to this commentary.
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Stapleton EJ, Frane N, Bitterman AD. Use of Disposable Perioperative Jackets and Surgical Site Infections—Reply. JAMA Surg. Published online March 04, 2020. doi:10.1001/jamasurg.2019.6380
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