The surgical cap: Symbol, science, argument, and evidence

The public argument over the recent ban on the traditional surgical skullcap has divided the surgical community. The Association of periOperative Registered Nurses (AORN) had claimed that the evidence warrants banning the cap in the operating room (OR) in an effort to reduce surgical site infections (SSIs); however, this view disregards personal preference in the name of patient safety.1 The American College of Surgeons (ACS) has defended the cap, noting, among other points, that it is a symbol of the surgical profession and a matter of legitimate personal preference.2 This issue has captured the attention of the mainstream media, prompted numerous blog posts on the topic, and has caused real disruption at many health care institutions around the country, including our medical center, Buffalo General Medical Center, NY.3-5


From 2012 to 2014, AORN advocated banning the surgical cap and promoted the use of bouffant-style caps or hoods. Articles published in the AORN Journal by leaders of the organization described the need to eliminate access to surgical caps in the name of patient safety.6-8 The most recent guidelines for surgical attire do not specifically mention the surgical cap but do describe head attire that covers all hair and the wearer’s ears, which, essentially, prohibits the use of the cap. The initial AORN guidelines did mention the cap, but now the organization says it has not taken an official position on the cap.8

Some institutional reviewers have taken a hard-line position on the use of surgical caps in the OR, where the mere presence of this head covering puts the hospital at risk for immediate repercussions, such as the loss of Centers for Medicare & Medicaid Services certification. For institutions such as our medical school, the Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, and our medical center with 70 residency and fellowship programs and more than 700 residents, the loss of CMS certification is an existential threat. Therefore, the surgical cap was immediately banished at our hospital system. Notably, this action presented an opportunity to review the SSI rates in clean Class I procedures before and after the ban.

In a series of nearly 16,000 clean Class I surgical procedures performed between January 2014 and March 2016 at our medical center, the elimination of the skullcap did not lower SSI rates.9 In fact, after the skullcaps were banned, a small non-statistically significant increase in infections was noted, supporting the fact that a larger study is not needed.


In today’s health care system, which should be reliant on evidence-based medicine, the ban on the surgical cap was a top-down mandate, enforced as a standard, lacking any scientific support. There is no evidence linking skullcaps to SSIs. Case reports of bacterial carriers and studies of cultures of various body parts have been cited as a basis for banning the cap; however, these reports and studies provide weak evidence in comparison with our large institutional series that directly measured cap use and SSIs.9,10 The existing guidelines cite old standards issued by the U.S. Centers for Disease Control and Prevention for banning the surgical cap, which, in fact, make no mention of surgical caps.1,10,11

Why does it matter?

Surgeons who work for many hours wearing head-mounted devices need to have a level of comfort and confidence that these tools will stay in proper, focused position. Those of us who wear skullcaps have personal performance preferences that should not be summarily dismissed. Furthermore, when head-mounted devices are removed or replaced during surgery—as commonly occurs at some stage of a procedure when using an operating microscope—it is important that the surgeon’s head covering remain in place. Those of us who have been required to make the switch to bouffant caps have had them inadvertently removed with our glasses or loupes, leaving us standing hatless next to a sterile surgical field.

The other reason the surgical cap debate is important has to do with how we need to work together to care for our patients. The public discourse, the blog posts, and the discussions in surgical suites around the country regarding this topic and other issues of surgical attire have at times been polarizing.4-9,12 There are subtle and not-so-subtle hints of a battle of the sexes. However, at our institution, caps were popular among both women and men. For many years, the surgical skullcap may have been a symbol of the surgical profession, favored more by surgeons than nurses or scrub technicians. And it may have been favored more by men than women. Those divisions and assumptions about gender, surgeon versus nurse, and male versus female should no longer exist in our ORs.

In response to a letter from AORN leadership regarding our study, we described the issue as follows:8,13

The end result of this policy and its implementation into practice are emblematic of the core problem of the regulatory state: a top-down exercise of power, however well intended, with significant unforeseen consequences. In our case, our hospital system, which is the largest nongovernmental employer in our region, was faced with immediate jeopardy with CMS over surgical head coverings. The time and energy expended by senior leadership, including administration, nursing, and physician leadership, down to all levels of the organization, was immense—and, in our view, wasted. And this occurred in an institution with surgical site infection rates already well below the national average.


SSIs pose serious complications for our patients. All members of the surgical team need to work to reduce the risk of infection. AORN’s stance is that there is no harm in mandating complete hair coverage and that alternatives to skullcaps could result in fewer SSIs. We emphasize that there is, in fact, harm in having an uncomfortable surgeon with a light and loupes out of proper position and with a bouffant hat that will not stay in place. Our study shows no benefit in eliminating the surgical cap to reduce SSIs. Evidence-based guidelines are useful, but they must truly be evidence-based if they are to be elevated to the level of a standard. The evidence does not support banning the use of the surgical skullcap.

The ACS and the AORN are the two primary organizations in the U.S. dedicated to improving the care of the surgical patient. There needs to be greater cooperation and coordination in developing and delivering evidence-based care to our patients.


  1. Association of periOperative Registered Nurses. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc., 2013:51-62.
  2. American College of Surgeons. Statement on Operating Room Attire. October 2016. Available at: Accessed September 5, 2017.
  3. Controversies in Hospital Infection Prevention (blog). The skullcap feud. August 21, 2016. Available at:!/2016/08/the-skullcap-feud.html. Accessed September 5, 2017.
  4. Association of periOperative Registered Nurses. OR NurseLink. Physician surgical attire. Available at: Accessed September 5, 2017.
  5. Kowalczyk L. No more surgical caps for surgeons? The Boston Globe. September 1, 2016. Available at: Accessed September 5, 2017.
  6. Braswell ML, Spruce L. Recommended practices: Implementing AORN recommended practices for surgical attire. AORN J. 2012;95(1):122-137.
  7. Spruce L. Back to basics: Surgical attire and cleanliness. AORN J. 2014;99(5):138-146.
  8. Spruce L, Van Wicklin SA, Conner R, Fearon MC. Letter to the editor. 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. August 5, 2017. Available at: (Log-in required.) Accessed September 5, 2017.
  9. 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. May 10, 2017. Available at: (Log-in required.) Accessed September 5, 2017.
  10. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
  11. Association of periOperative Registered Nurses. Guidelines for surgical attire. Guidelines for Perioperative Practice. Denver, CO: AORN, Inc., 2015:97-120.
  12. The Advisory Board Co. What’s safe to wear in the OR? Surgeon, nurse groups at odds. Critics: Guidelines could ‘give false sense of security.’ Today’s Daily Briefing. August 26, 2016. Available at: Accessed September 5, 2017.
  13. Gibbons KJ, Levy EI. In reply: 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. August 10, 2017. Available at: (Log-in required.) Accessed September 5, 2017.

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