Young surgeons speak up: Stringent OR attire restrictions decrease morale without improving outcomes

Nationwide and with increasing frequency, departments of perioperative services have been modifying internal policies regarding appropriate attire in the operating room (OR). This movement has gained momentum since January 2015 when the Association for periOperative Registered Nurses (AORN) published a set of recommendations on OR attire (see sidebar).¹ Despite extensive criticism for lack of scientific rigor and the authors’ own description of many of the supportive studies as “quasi-experimental” or “non-experimental,” these were the first (and only) set of specialty society-endorsed recommendations on this issue to be accepted by regulatory agencies such as the Centers for Medicare & Medicaid Services (CMS).^1,2

The surgical team responds

To comply with AORN’s recommendations, many surgery departments and health systems have adopted increasingly stringent policies designed to minimize the exposed areas of skin and hair of members of the perioperative services team as a means of reducing the risk and incidence of surgical site infections (SSIs).These policies have been implemented with marked variability in hospitals across the country. Furthermore, the rigor with which these policies are enforced has been inconsistent, with some centers lacking any mechanism to verify compliance after implementation. At other institutions, full compliance with attire protocol has been incorporated into the preoperative checklist, preventing the start of a procedure until full compliance is achieved.

Many surgeons have expressed concerns about a lack of data to support these changes, leading in some instances to vocal opposition and frustration.^2,3 Surgeons and nurses alike have complained of significant infringements on their comfort, autonomy, and ability to concentrate. Some members of the perioperative team have refused to comply with these guidelines, whereas others have relented due to a perception of powerlessness.

YFA intercedes

The Young Fellows Association (YFA) of the American College of Surgeons (ACS) is composed of ACS Fellows who are 45 years old and younger.⁴ The YFA is structured to promote diversity, to seek feedback, and to encourage participation among young Fellows so that the ACS leadership can better understand the needs of this important and growing constituency. The YFA Governing Council (GC) comprises 15 members who are carefully selected following open nominations and who reflect the diversity of the College in terms of geography, specialty, gender, and ethnicity.⁵

In response to growing complaints from Fellows regarding restrictions on OR attire, the YFA GC decided to investigate the variability in perioperative policy changes and the rationale and driving forces behind them with an eye toward critical appraisal of the data upon which these policies are based. A key goal was to characterize the perception of young Fellows regarding the effect these changes will have on patient safety, SSI rates, and the morale and overall function of the operative team.

Survey development

Based on existing discussions in the online ACS General Surgery Community, the YFA GC created a Web-based electronic survey designed to collect demographic information, data related to changes in OR attire policies, and the perceived impact of these changes.⁶ To our knowledge, this study is the only formal investigation of surgeon perceptions related to these policy changes.

For this study, we asked the members of the YFA  to share their opinions regarding the recent policy changes. We also asked the leadership of the YFA GC and its three Past-Chairs to voice the opinions of their constituents related to the recent policy changes, in addition to performing an independent critical appraisal of the AORN recommendations and their scientific validity. We then compared the constituent opinions of the YFA GC members with those of the YFA membership at large. The survey also contained open-ended questions to enable collection of qualitative data.

A limited version of the survey was posted online in the YFA Community, which at the time of the survey had 5,736 subscribers. Two reminder messages were posted on the Communities page, and the survey remained open for comment for two weeks.

In addition to completing the survey, members of the YFA GC were tasked with expressing the global viewpoint of their constituency after carefully reviewing the AORN guidelines to appraise their content. They also were asked to interview leaders in their perioperative services departments to determine the key factors that led to recent changes in OR attire policy.

YFA member responses

A total of 317 YFA members completed the survey. Respondents were from a mix of all surgical specialties; the highest response rate was from general surgeons (26.9 percent), followed by colon and rectal (10.4 percent), trauma (7.6 percent), plastic (6.3 percent), and minimally invasive/bariatric surgeons (6 percent). Respondents were distributed fairly evenly among those in private practice (24 percent), part of a multispecialty group (30 percent), or at an academic institution (43 percent). Reflective of the demographics within our YFA community, most surgeons who reported an academic rank were assistant or associate professors (51 percent and 28 percent, respectively). Our surgeons are geographically diverse, representing all regions of the U.S. Of the respondents, 65 percent were male.

Commonly reported new OR attire restrictions imposed in the last year include the following:

• Ban on cloth surgical caps (70 percent)
• Prohibition of home-laundered scrubs (57 percent)
• Requirement that bouffant hats be worn in the OR (37 percent)
• Requirement that OR hats be pulled down to cover the ears such that sideburns and all facial hair are covered (27 percent)
• Requirement that all OR personnel cover arms and exposed skin (12 percent)
• Prohibition on rings (7 percent)
• Mandated use of shoe covers (7 percent)

Other respondents disclosed guidelines prohibiting mesh sneakers or mandates that socks be worn in the OR. Two participants indicated that earrings were banned from the OR. Some respondents reported guidelines prohibiting undershirts, whereas others reported requirements that undershirts be worn. Two surgeons indicated that their hospital had new requirements for plastic bags covering anything brought into the OR, including briefcases and loupe cases.

The respondents were largely skeptical of the potential benefits of these requirements. In fact, 91 percent disagreed or strongly disagreed that “disallowing cloth caps will reduce wound infections.” Similarly, 91 percent of respondents disagreed or strongly disagreed that “mandating complete coverage of ears and sideburns will reduce wound infections.” None of the respondents agreed that “recent changes in OR attire are based upon valid scientific evidence,” and 97 percent strongly disagreed or disagreed with this statement. On the other hand, 79 percent of the respondents agreed or strongly agreed that surgeon comfort is an important safety concern, and 87.5 percent indicated that surgeon discomfort could negatively affect patient outcomes. (See Figure 1.) In all, 31.9 percent indicated that they have operated while uncomfortable because of recent changes in attire regulations, and 52.8 percent indicated that they have operated while uncomfortable because of changes in OR temperature.

Figure 1. YFA member perceptions regarding new OR attire policies

Overall, most respondents said that the changes in OR attire would not affect SSI rates (93 percent) or overall outcomes (96 percent) in their hospitals. Among those respondents who indicated that changes in OR attire would influence wound infection rates and overall outcomes, more believed that infection rates and outcomes would worsen rather than improve. Of the respondents, 69 percent said that these changes lessen surgeon comfort, and most indicated that these regulations lower morale among nurses (58.4 percent), anesthesiologists (52.8 percent), surgeons (71.2 percent), and the surgical team as a whole (67.1 percent). (See Figure 2.)

Figure 2. YFA member perceptions of the impact of OR attire on outcomes and morale

In the comments section of the survey, respondents expressed gratitude that the YFA was conducting this study and a sense of frustration that the recent surge in policies related to OR attire is not evidence-based. Interestingly, one Fellow reported being involved in a prospective study to investigate OR attire policies that was halted because of fear of being “out of compliance” with recommendations.

Other YFA GC and ACS contributors to OR attire study Rebecca C. Britt, MD, FACS Associate professor of surgery, department of surgery, Eastern Virginia Medical School, Norfolk Edie Y. Chan, MD, FACS Associate professor of surgery, department of general surgery, Rush University Medical Center, Chicago, IL Ellen T. Derrick, MD, MPH, FACS Associate professor of surgery, department of surgery, Providence Regional Medical Center, Everett, WA Cynthia D. Downard, MD, MMSc, FACS Associate professor of surgery, Hiram C. Polk, Jr., MD, Department of Surgery, University of Louisville, KY Joseph J. DuBose, MD, FACS Associate professor of surgery, University of California Davis, Fresno John Elfar, MD, FACS Associate professor of orthopaedic surgery, University of Rochester Medical Center, NY Paula Ferrada, MD, FACS Associate professor of surgery, department of surgery, Virginia Commonwealth University, Richmond Gerald R. Fortuna, Jr., MD, FACS Associate professor of surgery, department of cardiothoracic and vascular surgery, University of Texas at Houston School of Medicine David B. Hoyt, MD, FACS ACS Executive Director Joshua M. V. Mammen, MD, PhD, FACS Associate professor of surgery, department of surgery, University of Kansas, Kansas City Joseph Scharpf, MD, FACS Associate professor of surgery, Cleveland Clinic Lerner College of Medicine, and staff, Head and Neck Institute, Cleveland Clinic Foundation, OH Shoaib Sheikh, MD, FACS Assistant professor of surgery, Memorial University of Newfoundland and Labrador, GB Cross Memorial Hospital, Clarenville, NL S. Rob Todd, MD, FACS, FCCM Associate professor of surgery, Baylor College of Medicine, and chief, general surgery and trauma, Ben Taub Hospital, Houston Ashley Vergis, MD, MMEd, FACS, FRCSC Assistant professor, section of general surgery, University of Manitoba, Winnipeg Robert D. Winfield, MD, FACS Associate professor of surgery, department of surgery, University of Kansas Medical Center, Kansas City

Guideline implementation

Another prominent theme suggested by the survey was that surgeons felt poorly positioned to influence the creation and implementation of guidelines in the OR and that many of these policies were being developed by nonphysicians. Moreover, respondents expressed concerns related to differential enforcement of attire policies. One surgeon was concerned that in her hospital, patient care has been delayed because consultants are forced to completely change into scrubs before entering the OR suites (bunny suits have been disallowed), whereas noncompliant contractors and other nonphysicians are routinely seen in the OR without changing into scrubs attire. Another surgeon expressed outrage that, by policy, the infection control personnel who round through the OR at his hospital were exempt from the attire regulations to which all other personnel are required to adhere. Finally, several surgeons expressed concern regarding an increased risk of infection in their patients because of their own perspiration dripping into the wound as a result of uncomfortably warm room requirements.

We also compared the responses of the members of the YFA GC with those of the general YFA membership. We found that the responses of the YFA GC members closely approximated the responses of members of the YFA at large.

In interviews with perioperative services leaders, compliance with regulatory mandates (such as those issued by state health departments or The Joint Commission) emerged as the “most important” reason for instituting new OR attire policies. Of 16 hospitals, 14 cited a visit from a regulatory agency as the “most important” (10) or a “very important” (four) factor in establishing new policies on OR attire. A regulatory visit at a neighboring hospital was considered a “most important” factor in the creation of new OR attire policy changes at four additional hospitals. Efforts to reduce infection rates were cited as a contributing factor in the creation of new policies by nearly all respondents, but were considered “most important” by only five.

All members of the YFA GC carefully reviewed the AORN guidelines document mentioned at the beginning of this article.¹ The survey revealed that 17 of the 18 GC members and Past-YFA Chairs disagreed (10) or strongly disagreed (seven) that “most of the evidence cited in the AORN document is scientifically valid,” and 16 of 18 disagreed or strongly disagreed that “the evidence in that document supports the conclusions and recommendations that were made.” Likewise, 16 of 18 agreed (five) or strongly agreed (11) that the AORN recommendations were published with insufficient consideration for the complex nature of wound infections.

Discussion

In alignment with the College’s mission statement, the YFA is “dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.”⁷ Because SSI is the second most common hospital-acquired infection and associated with increased morbidity, length of stay, and costs, prevention of SSI is an important goal for all ACS members.⁸ However, research shows that SSIs are complex in nature and arise from etiologies that are both intrinsic and extrinsic to the patient.⁹ Although many SSIs are potentially preventable, nearly half are unavoidable using existing evidence-based strategies.¹⁰ It is noteworthy that participation in the ACS National Surgical Quality Improvement Program (ACS NSQIP^®) is related to a significant decline in SSI rates.¹¹

Our study yielded several important findings. First, it is apparent that several changes in perioperative services policies have been implemented in many hospitals or health systems over the past year, but their enforcement varies greatly. Another important finding in our study is that the overwhelming majority of respondents (93 percent and 96 percent, respectively) thought that the recent policy changes would have no impact on wound infections or overall outcomes. More than 90 percent of respondents either disagreed or strongly disagreed with specific statements in support of the implementation of specific new restrictions to attire in the OR.

A majority of respondents believed that the new changes in OR attire would either worsen (approximately two-thirds of all respondents) or have no effect (approximately one-third of all respondents) on morale among surgeons, nurses, anesthesiologists, and the team as a whole. In addition, 70 percent of respondents reported that the comfort of the operating surgeon would be reduced—a significant finding, given that more than 80 percent indicated that surgeon comfort is an important safety factor that could negatively affect patient outcomes.

The survey suggests that the most common driving force in creating new OR attire policies are visits by regulatory agencies. These agencies require OR personnel to follow a nationally recognized set of guidelines. However, when our team of surgical leaders reviewed the guidelines for perioperative practice—standards that are the foundation of most new OR attire policy changes—we were nearly unanimous that the evidence cited does not support the AORN’s recommendations and that much of the evidence lacks scientific validity in the first place. (See Figure 3.)

Figure 3. YFA GC opinions regarding AORN guidelines

AORN guidelines: What is the evidence?

We carefully reviewed the literature used to develop the AORN guidelines. As stated earlier in this article, much of the evidence that formed the basis for the AORN recommendations is “quasi-scientific,” and is founded on the premise that health care workers and their apparel lead to bacterial contamination in the OR. It has been well documented that bacteria are found in human hair, on surgical attire, and on shed skin cells called squames.^12-14 Many of the cited studies looked at colony-forming units (CFUs) produced by the dispersal of bacteria through the air and the number of bacterial species that were found on scrubs, but to date, no study has shown that the use of specific scrub type has a direct effect on SSI.^15-17

Recommendations also were made to completely cover arms with a long-sleeved jacket. This guideline is also based on a theoretical risk of SSI due to squame production from exposed skin. Interestingly, in 2007, the U.K. Department of Health took the exact opposite stance and implemented a “bare below the elbows” policy, which was thought to reduce patient exposure to bacteria by promoting better hand hygiene practices.¹⁸ Again, none of the available evidence supports either policy.

Other guidelines also lack supporting evidence. AORN recommends wearing street clothes when outside the hospital. This restriction emerged from a study comparing bacterial contamination of clothing worn inside and outside the perioperative area, which showed no increased contamination levels.¹⁹ Although that study did not address surgical attire worn outside of the hospital, AORN stated that this recommendation was supported by “moderate evidence.”

The restriction of briefcases and backpacks in the OR is based on data that demonstrated that those items can harbor bacteria despite the fact no data has shown that these personal items contribute to the occurrence of SSI.²⁰ The same is true of cell phones, which the AORN recommendations call for cleaning before being brought into the perioperative setting.²¹ Finally, myriad guidelines call for eliminating cloth caps and replacing them with bouffant-style coverings. Although hair is a carrier of bacteria, no comparative studies exist on head coverings and their impact on SSI.^12,17

We reviewed the relevant scientific evidence related to OR masks and found that in the largest study, by Tunevall and colleagues, 3,088 patients undergoing general surgery showed a slightly reduced rate (3.5 percent versus 4.7 percent; P>0.05) of wound infections and no change in bacterial culture results from SSI when healthy surgeons operated without masks.²²

Further, a Cochrane review, updated in 2014, found only three studies of a total 2,106 patients who underwent clean surgery worthy of inclusion.²³ Interestingly, all three studies showed a trend toward a lower SSI rate in the unmasked versus the masked group.

It is noteworthy that even in the context of prosthetic joint implantation surgery, where extreme measures are taken to prevent infectious complications, supportive evidence is lacking. A recent review of nearly 90,000 joint replacements over 10 years found that the use of space suits and laminar airflow (LAF) systems in the OR was actually associated with an increased infection rate and that the rate of revision surgery was not reduced in cases performed using either or both of these interventions.²⁴ In addition, a recent systematic review included eight studies that evaluated the effect of LAF on SSI rates in patients who underwent knee or hip replacement surgery. In that study, the preponderance of the evidence pointed toward an increased SSI rate with LAF, with summary odds ratios of 1.36 and 1.71 for knee prosthesis and hip prosthesis, respectively.²⁵

Comment

Although our study demonstrated that young surgeons oppose the recent surge of OR attire-related regulations (personal communication with Sara Morse, Manager, Legislative and Political Affairs, ACS Division of Advocacy and Health Policy, May 2016), there remain important opportunities for improved conduct in this regard. Unfortunately, it is fairly commonplace to see surgeons and other members of the OR team wearing surgical scrubs outside the hospital and in public places.^26-28 Such conduct raises questions in the minds of patients as to the cleanliness of the attire worn inside the OR. In addition, unclean personal hospital garb, such as white coats, cloth scrub caps, and OR shoes, is often observed throughout the hospital. Although no studies to date prove that this practice is detrimental to our patients, this behavior fails the “sniff test” and is unprofessional. Moreover, research clearly shows that patients’ perceptions of quality of care, and their trust and confidence in their surgeon, is influenced by his or her appearance.^29,30 Thus, while AORN’s guidelines are overly intrusive and unlikely to improve patient safety, surgeons are encouraged to play a leadership role in restricting OR attire to the perioperative environment.

Conclusion

Our study suggests that the overwhelming majority of young Fellows oppose the wave of new and more restrictive policies related to OR attire. They believe that these guidelines will not improve patient outcomes and may in fact increase surgeon discomfort in the OR, and may demoralize all members of the OR team. Therefore, these policy changes violate both components of the ACS mission statement: “improving the care of the surgical patient” and maintaining an “optimal and ethical practice environment.”

Based on these findings, the YFA GC strongly urged the ACS to take a leadership role in the creation of a comprehensive evidence-based set of guidelines and recommendations related to OR attire. The findings and literature review reported herein ultimately served as background materials and a major stimulus for the ACS position statement, “Statement on operating room attire” (see position statement in this issue of the Bulletin).

We encourage all surgeons to set a positive example by wearing nonsurgical attire outside of the hospital and to seek leadership positions within their own departments of perioperative services so that they can more effectively advocate for their patients and become engaged in the creation and implementation of policies that directly affect surgeons and their patients.

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References

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