No Reduction in SSIs With Strict Surgical Attire Policy

Nicola M. Parry, DVM

February 12, 2020

Implementing policies that require surgical staff to wear surgical jackets and bouffants in the operating room (OR) does not decrease the risk for surgical site infections (SSIs), according to a study published online today in JAMA Surgery.

"[T]he results of this study suggest that surgical jackets and bouffants are neither beneficial nor cost-effective in preventing SSIs," write Bradley W. Wills, MD, University of Alabama at Birmingham, and colleagues.

Approximately 300,000 SSIs occur annually in the United States, accounting for one fifth of all hospital-acquired infections and costing the US healthcare system an estimated $10 billion each year.

Although some evidence supports implementation of certain OR attire policies (such as use of gloves and impermeable surgical gowns) to help prevent SSIs, data are lacking on the association between use of surgical jackets and bouffants and infections.

Wills and colleagues performed a retrospective cohort study to investigate whether mandating use of surgical jackets and bouffants in the OR was linked to a lower incidence of SSIs.

The study included 34,042 inpatient surgical encounters at a large academic tertiary care hospital between January 2017 and October 2018. The researchers compared three periods within this time.

During the first period (8 months), no bouffants or surgical jackets were required. During the second period (6 months), surgical jackets were mandated, and during the third period (8 months), surgical jackets and bouffants were required.

Despite the dress code changes, SSI risk remained relatively constant throughout the time frame, with no significant difference between the three periods (1.01% vs 0.99% vs 0.83%; P = .28).

Similarly, the investigators found no significant difference between the periods in risk for mortality (1.83% vs 2.05% vs 1.92%; P = .54), postoperative sepsis (6.60% vs 6.24% vs 6.54%; P = .54), or wound dehiscence (1.07% vs 0.84% vs 1.06%; P = .20).

The researchers calculated that use of surgical jackets during the 14 months of the second and third study periods cost an additional $264,760.78.

"The results add to the growing body of research that there is no clear benefit to bouffants and surgical jackets in the quest to decrease the incidence of SSIs," the authors conclude.

"Institutions should evaluate their own data to determine whether recommendations by outside governing organizations are beneficial and cost-effective."

In an accompanying editorial, Radwan Dipp Ramos, MD, and Kamal M. F. Itani, MD, both from the Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, agree that sufficient evidence now exists to show that these policies, although well-intentioned, do not reduce SSI risk and raise hospital expenditure.

Ramos and Itani, who is also with Boston University and Harvard Medical School, also stress the need to remember common-sense recommendations regarding OR attire. These include frequent laundering of cloth caps, they say.

Staff must remove headgear, mask, and shoe covers outside restricted areas and use new ones if they return to the OR. When leaving restricted areas for another case, staff should also change scrubs or cover them with a protective coat. And they should not be allowed to enter the OR wearing scrubs from home.

"Short of having best evidence in any of those areas, myth and reality will continue to coexist, and our common sense augmented by available evidence should prevail over emotions and careless practices," the editorialists conclude.

The study was supported by the US Department of Health and Human Services' Agency for Healthcare Research and Quality. One author has reported having stock or stock options in Help Lightning, being a pain presenter/speaker and paid consultant for Tornier, and receiving IP royalties from Wright Medical Technology Inc. Itani's institution has received grants from Pfizer, and Itani has received personal fees from Eupraxia. The remaining authors and Ramos have reported no relevant financial relationship.

JAMA Surgery. Published online February 12, 2020. Abstract

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