Update: Headgear and Surgical Site Infections

Roy H. Constantine  PA-C, MPH, PhD, FCCM, DFAAPA

Daniel Vetrosky, PhD, PA-C, DFAAPA

Former CSPS Representatives and Chair


Article originally printed in Sutureline: Jan/Feb 2018, pg. 6.


Throughout my career skull caps were one of the choices for headgear in the operating room. A marginal amount of hair was exposed, but for the most part the majority of hair was covered under one’s cap.


As we become ingrained in “what the literature says” or “where the evidence is” assumptions can be made on so many levels concerning almost anything that we study, especially in the operating room setting.


The Association of perioperative Registered Nurses (AORN) states that, “The National Guidelines Clearinghouse requires developers to examine the risk and benefit of a recommendation to patients and personnel.” AORN feels that the benefit of totally covering skin and hair can reduce exposure to organisms and can potentially protect patients from harm.


In a recent study presented at a Scientific Forum at the ACS, principal investigator Dr. Troy A. Markel MD, FACS an assistant professor of pediatric surgery at Riley Hospital for Children at Indiana University Health, Indianapolis said, “There really is no definitive evidence that there is a risk of surgical site infections due to exposed hair.” The researchers also studied three common styles of commercially available surgical headgear. “Disposable shower cap-like bouffant hats underwent testing, as did two types of surgical skullcaps.” They found “no apparent infection-control reasons to disallow disposable skullcaps in the OR.” The research team felt that reusable skull caps are probably better (cloth are thicker with lower permeability), but there are problems with laundering that can follow.


I happened to come across a tweet by Dr. Atul Gawande from April 8th 2017. He said, in “My view; patient data says caps aren’t plausibly riskier for infection than other types.” What can we say?  There are differences of opinion and with that being said I would like to close with a quote from Dr. Kamal MF Itani, Chief of Surgery from the VA Boston Health Care System. “Short of having best evidence in any of those areas, myth and reality will continue to co-exist and our common sense augmented by evidence should prevail over emotions.”


Please remember to review your organization’s policy on “Operating Room Attire.”  If you want to affect change then you need to participate in performance initiatives. Remember, you are an important member of the Patient Safety Health Care Team. Your participation as a “Patient Safety Champion” can make the difference in quality outcomes both professionally and personally!


  1. Kamal MF, Itani MD. Headgear and surgical site infection: is the controversy over? Science Daily. Retrieved from https://www.sciencedaily.com/releases/2017/01/170119161551.htm 

  2. AORN Responds to ACS Statement on Attire. Infection Control Today (2016). Retrieved from https://www.infectioncontroltoday.com/operating-room/aorn-responds-acs-statement-attire