Perioperative Disposable Jackets Unlikely to Curb Surgical Site Infections

By Marilynn Larkin

November 05, 2019

NEW YORK (Reuters Health) - Use of perioperative disposable jackets is not associated with reductions in surgical site infections for clean wounds, a multicenter observational study suggests.

"Our health system adopted the mandated policy from the Association of periOperative Registered Nurses (AORN) recommendations for perioperative attire," Dr. Erik Stapleton of Zucker School of Medicine at Hofstra/Northwell Plainview Hospital in New York told Reuters Health by email.

"Included in these recommendations were that non-scrubbed personnel were to have arms covered in both operative and perioperative areas," he said. "Our health system chose to adhere to these recommendations by using disposable jackets."

"This (study) was prompted after multiple complaints and backlash from surgeons within our health system after implementation of the mandated policy," he explained. "We thought, what is the scientific evidence behind these recommendations, how does this impact surgical site infections, and what is the cost with policy implementation?"

"We found that despite spending over 1.7 million dollars on disposable jackets, there was not a significant reduction in surgical site infections," he said. "After presenting our research at multiple meetings, our health system changed their stance on the mandated policy and discontinued the mandatory requirement for jacket use."

Dr. Stapleton and colleagues analyzed the incidence of surgical site infections in more than 60,000 patients (mean age, 63; 54% male) undergoing clean surgical procedures in 12 hospitals from 2014-2018. About half the patients were treated during the 26 months before implementation of the disposable surgical jacket policy, and the rest were treated in the 26 months after the policy went into effect.

As reported online October 23 in JAMA Surgery, the overall surgical site infection incidence was 0.87% before policy implementation and 0.83% after - a nonsignificant difference (odds ratio, 0.96). After adjustment for potential confounders, a multivariable analysis demonstrated no significant reduction in surgical site infections (OR, 0.85).

However, more than two million disposable jackets had been purchased during the postintervention period, for a cost of $1,709,898.

Dr. Stapleton said, "Our results suggest that surgical attire has no association with surgical site infections in clean operative procedures. In a time of seemingly baseless policies by hospital administrations, scientific investigations that challenge these policies are critical, with the overall goal of optimizing patient outcomes while reducing medical cost."

Stanford University coauthors of a related editorial agreed, noting, "Until we adhere to standards of guideline and policy development that improve the trustworthiness of their recommendations, we remain susceptible to endorsed practices that may adversely affect care, produce waste, and increase the economic burden of health care."

Amber Wood, AORN's Editor-in-Chief, Guidelines for Perioperative Practice, commented by email, "The 2015 AORN Guideline for Surgical Attire did not specifically recommend wearing disposable cover jackets; rather, the recommendation was to cover the arms with long sleeves to prevent skin and hair from shedding into the perioperative environment."

"This guideline was revised, and the updated guideline was released in July 2019," she told Reuters Health. "In this guideline, there is no recommendation for covering the arms with long sleeves in the semirestricted and restricted areas other than when performing preoperative patient skin antisepsis."

"There were many new studies published on the topic of surgical attire that prompted AORN to conduct a systematic literature search and revise the guideline," she noted. "Throughout the revision process, we found that only the Markel study ( supported the recommendation to wear long sleeves and that was only...during preoperative patient skin antisepsis. Thus, the AORN recommendation was modified to 'No recommendation can be made for wearing long sleeves in the semi-restricted and restricted areas other than during performance of preoperative patient skin antisepsis.'"


JAMA Surg 2019.