This has been hotly debated in theatre for a few years. Cloth hats are a difficult topic. So here is a little post all about scrub hats!
It was only in the ACORN standard 2010-2011 that cloth hats were still deemed okay.: S11 Perioperative Attire Standard statement 4 – Head and facial hair shall be completely covered.
Surgical head covers reduce contamination of the surgical field by confining shedding hair, skin particles and microorganisms from the scalp and face.
4.1 Apply a hair covering to ensure that all hair including facial hair, is covered:
4.2 Change head covers daily, and when soiled.
The purpose of the head covering is to contain hair and minimise microbial dispersal.
When the head covering is removed, fiddled with or altered in any way, hair and microbes may be shed into their surroundings and scrub attire. They prevent hair & sweat from dropping and contaminating the sterile field. They provide a clear line of sight for the surgical team.
They are also worn for hygiene purposes and keep health practitioner’s hair free of blood and other contaminants. Visible soiled scrubs and hats should be changed as soon as possible.
Until recently cloth hats could only be worn if contained in a disposable cap (more on this later).
Health-care accredited laundering protects the patient from exposure to pathogens remaining on the attire after home laundering. According to Wright el al there were three cases of Gordonia bronchialis sternal infection after CAGs surgery. The bronchialis was isolated to the scrub attire, axilla, hands and purse of a nurse anaesthetist. Her roommate who was also a nurse had the same microorganism. The authors concluded that the home washing machine was used to clean her entire scrub attire including hat and the bacteria was passed onto her scrubs.
Scrubs in Australia are cleaned daily in special facilities using chemical and high-temperature machines to clean. The type of cleaning is significantly more intense than those of at home machines. It is designed to remove all contaminants. Scrubs are cleaner than personal clothing. By wearing clothing cleaned by the facility it ensures that contaminants are also not taken home.
This is an old photo of some of my work colleagues (Sarah, Stef and Averil) Three different hats, all worn in a PACU area
Home laundering is not monitored for quality, consistency or safety. It may not reliably kill all pathogens that may survive in the forms of biofilms within the washing machine. A biofilm is any group of microorganisms in which cells to each other and often these cells adhere to a surface. Biofilms may form on living or non-living surfaces and can be prevalent in natural, industrial and hospital settings.
Home washing may not be or may not be able to be adjusted to parameters required to achieve the necessary
- Thermal measures (water temperature)
- Mechanical measures (agitation)
- Chemical measures (alkalinity of the water/soap/detergent)
- Transport of laundered items is also a concern
In a recent study was carried out involving 2600 patients. The surgeons involved wore 4 different head coverings. They found no alterations in surgical wound infections. “Surgeons should be allowed to wear the hat of their choice without concern for negatively affecting their patients’ outcomes,” said Michael Rosen, MD, director of the Comprehensive Hernia Center at the Cleveland Clinic and medical director of the Americas Hernia Society Quality Collaborative.
Back to cloth hats – the goal is to contain hair due to microbes. Often cloth hats do a better job than the paper ones at containing hair without constant adjustment. I have only been able to find a few guidelines for at home laundering – separate wash, 60 degrees and iron. All the heat is to kill microbes. I couldn’t find I time length for the wash cycle or what type of detergent. It all seems quite logical.
Skin, shoes, phones, surgeons bags —all harbour bacteria. These are often present in our operating theatres, yet most patients don’t develop infections after surgery.
Everyone knows that the patient whose thyroid gland is removed is at less risk of surgical site infection than the patient whose large intestine is removed because the large intestine is contaminated with faecal bacteria. Everyone knows that patients who are diabetic or immunocompromised are more susceptible to surgical site infections.
So are we placing new rules in place with scrub caps, changes to attire are we really addressing the roots of the infection problem?
Instead of creating more and more rules governing the care of “all” patients, perhaps we need to focus on the subsets of patients and case types that we already know are at higher risk and examine what additional steps we need to take on their behalf.
We logically know that the bacterial count found on surgical scrubs increases as the day wears on, and theatre staff members stop by the preoperative and recovery care areas, the cafeteria, and the toilet. We haven’t yet done a study of bacterial counts at the start of the day and the end of the day. Should the hospital systems pay for fresh disposable scrubs to be worn for cases at high infection risk? Could the system conserve resources by allowing staff the option to select, their own scrub hats for routine use, just as they select, and launder the socks that they wear to the theatre every day?
No one really knows the answer to this basic question: Do higher bacterial counts on scrubs, phones, or nonsterile surfaces, assuming that these are carefully kept apart from the sterile surgical field, actually correlate with a higher risk of surgical site infection? Right now, rule-makers simply assume that they do. We urgently need good science, with prospective, controlled studies, to answer this question. If the answer is no, then we need to look elsewhere for ways to lower infection rates.
If the quest to eliminate all bacteria from the operating room is creating an environment in which the truly dangerous bacteria flourish since they have no competition from the relatively harmless ones. This is the process that takes place when antibiotics and antibacterial cleansers are overused, killing off weak bacteria and allowing the resistant ones to multiply and thrive.
I really enjoy wearing my cloth hats. I have long hair and I feel that it is better enclosed in a cloth hat. I wash it properly at home in a separate hot wash. I also don’t scrub so that is not an immediate priority for me. I feel that when I wear another type of hat I fiddle with my hair and hat more which would potentially cause more movement of hair and therefore microorganisms…. Yes, there are others who don’t wash their hats properly and that is their responsibility. They will also be the people who wear acrylic nails and jewellery. If you are going to be a good theatre nurse you follow the rules based on evidence. I have my evidence and logic. I will be wearing my cloth hats. These kinds of decisions—to get staff to give up the hats they enjoy wearing, are things that decrease morale. If we are making decisions based on non-science, that’s a dangerous decrease in morale.
Australian College of Operating Room Nurses Ltd 14th Edition (2017).ACORN standards for perioperative nursing 2017. Adelaide: Australian College of Operating Room Nurses Ltd.
Frangou, C. “Surgical Caps get Clean Bill of Health”. http://www.generalsurgerynews.com/In-the-News/Article/05-17/Surgical-Caps-Get-Clean-Bill-of-Health/41337?ses=ogst%3Fses%3Dogst%3Fses%3Dogst%3Fses%3Dogst%3Fses%3Dogst%3Fses%3Dogst%3Fses%3Dogst%3Fses%3Dogst%3Fses%3Dogst%3Fses%3Dogst
Wright, Gerry Busowski et al. “Gordonia bronchialis sternal wound infection in 3 patients following open heart surgery”. https://www.ncbi.nlm.nih.gov/pubmed/23143362