AORN to Revise Surgical Attire Guideline, Raising Questions

Surgical attire in the perioperative environment has been a source of much debate for at least the past three years, particularly as it relates to head covers. The Centers for Medicare and Medicaid Services (CMS) requires and accreditation organizations expect licensed and accredited facilities to follow "nationally recognized guidelines and standards."

Among the most widely followed standards in the perioperative setting include those published by the Association of peri-Operative Registered Nurses (AORN). Beginning in 2014, AORN's "Guideline for Surgical Attire" included the recommendation that "hair should be covered." The most recent guideline, published for 2018, states the following: "A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp, skin, sideburns, and nape of the neck should be worn."

The guideline further states that "researchers concluded that the ears should be covered by surgical head covers during surgery." Controversy concerning what is appropriate practice in the operating room has continued as resistance to abandoning surgeon's caps or skullcaps for bouffant hats grew. Several complaints from surgeons, surgical assistants and surgical technicians have been expressed over the course of the past two years for reasons including the aesthetics of bouffant caps, discomfort and the inability to contain sweat on the brow.

In August 2016, the American College of Surgeons (ACS) released a statement pushing back on AORN's OR attire guidelines. The ACS addressed the symbolism and what it deemed as "correct use" of skullcaps. Its statement was met by resistance from AORN. In addition, surveyor expectations continued to follow the AORN guidelines, which has extended through today. Facilities, particularly ambulatory surgery centers (ASCs), have received frequent cituations when staff members fail to cover their head, including full scalp and ears, as per the AORN recommendations.

On April 26, 2018, AORN released a statement as a result of its joint meeting with ACS, the American Society of Anesthesiologists (ASA), the Association for Professionals in Infection Control and Epidemiology (APIC), the Association of Surgical Technologists (AST), the Council on Surgical and Perioperative Safety (CSPS) and The Joint Commission (TJC). The meeting took place in February to "review and discuss the literature related to recommendations for OR attire, specifically ear and hair covering."

The conclusions from the meeting, issued in the statement, were as follows:

  • Evidence-based recommendations on surgical attire developed for perioperative policies and procedures are best created collaboratively, with a multi-disciplinary team representing surgery, anesthesia, nursing and infection prevention.
  • The requirement for ear coverage is not supported by sufficient evidence.
  • At present, available scientific evidence does not demonstrate any association between the type of hat or extent of hair coverage and surgical-site infection (SSI) rates. One recent study on head coverings (disposable bouffant or skullcap, cloth cap), identified that the commonly available disposable bouffant hat is the least effective barrier to transmission of particles.
  • Other issues regarding areas of surgical attire need further evaluation.

As a result of this meeting, AORN's "Guideline for Surgical Attire" is currently under revision and will be reviewed by the AORN Guideline Advisory Board. The revised version will be available for public comment from Jan. 2, 2019 through Feb. 22, 2019, and is anticipated to ready for publication in April 2019.

Uncertainty Abound

While the revision is proceeding, the Infection Control Consulting Services (ICCS) team is pondering anticipated issues, particularly those for ASCs as surveyors continue to find non-compliance with surgical attire standards. Questions raised include the following:

  • What will CMS expect during the period of AORN review and prior to publication of the updated guideline in April 2019? While the statement from AORN changes its position on head coverings, its "nationally recognized guidelines and standards" remains the same.
  • Should the perioperative arena continue to enforce use of bouffant caps until the standards change?
  • Should the ears and all hair/scalp continue to be covered, despite the latest findings?

These and many additional questions will undoubtedly arise in the coming months as facilities continue to receive close scrutiny for general infection prevention compliance.

ICCS will reach out to accreditation and state agencies (e.g., CMS surveyors) for information and clarification, with the objective of assisting facilities during these controversial times. Stay tuned for further updates from our team.