Bouffant vs Skull Cap and Impact on Surgical Site Infection: Does Operating Room Headwear Really Matter?

The American College of Surgeons guidelines indicate that skull caps are acceptable, and the Association of Perioperative Registered Nurses recommends bouffant caps. However, no scientific evidence has shown a significant advantage in surgical site infection (SSI) reduction with either cap. The objective of this study was to determine the influence of surgical cap choice on SSIs.

Data from a previously published prospective randomized trial on the impact of hair clipping on SSIs were analyzed. Patients were grouped by the attending surgeons' preferred cap choice into either bouffant or skull cap groups.

Overall, 1,543 patients were included in the trial. Attending surgeons wore bouffant caps in 39% and skull caps in 61% of cases. Prevalence of diabetes and tobacco use were similar between the groups. Bouffant caps were used in 71% of colon/intestinal cases, 42% of hernia/other cases, 40% of biliary cases, and only 1% of foregut cases. Overall, SSIs occurred in 8% and 5% of cases with a bouffant and skull cap, respectively (p = 0.016); with 6% vs 4% classified as superficial (p = 0.041), 0.8% vs 0.2% classified as deep (p = 0.12), and 1% vs 0.9% classified as organ space (p = 0.79); however, when adjusting for the type of operation, no significant differences in SSI rates were observed for skull caps vs bouffant caps.

Attending surgeon preference for bouffant vs skull cap does not significantly impact SSI rates after accounting for surgical procedure type. Future guidelines should consider these clinical outcomes data and surgeon preference should dictate operating room headwear.