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Report ToInfection Prevention Steering Group Date of Meeting22nd August 2018Title Theatre cap challenge: disposable or cloth hats?Agenda itemPresenter of the ReportHolly Slyne, Infection Prevention Clinical Nurse Specialist Author(s) of the Terms of ReferenceHolly Slyne, Infection Prevention Clinical Nurse Specialist PurposeFor information and consideration by the groupExecutive SummaryThe purpose of this paper is provide a balanced researched view on the wearing of disposable or cloth hats in theatreRelated strategic aim and corporate objective1 – Focus on Quality and Safety: We will avoid harm, reduce mortality and improve patient outcomes through a focus on quality outcomes, effectiveness and safety.AssuranceThis paper is supported by research and is for discussion and consideration at the Infection Prevention Steering Group (IPSG)Related Board Assurance Framework entriesBAF – 1.1, 1.2Equality Impact AssessmentIs there potential for, or evidence that, the proposed decision/ policy will not promote equality of opportunity for all or promote good relations between different groups? (N)Is there potential for or evidence that the proposed decision/policy will affect different population groups differently (including possibly discriminating against certain groups)? (N)Legal implications / regulatory requirementsThe Health & Social Care Act (2008): Code of Practice on the Prevention and Control of Infections and Related Guidance (Department of Health, 2015) – the 10 Hygiene Code criteria.Actions required by the GroupThe Group is asked to:Consider the paper and agree a way forwardTheatre cap challenge: disposable or cloth hats?BackgroundTheatre hats are an important part of theatre attire as they act as a physical barrier to both prevent contamination of the surgical site from staff hair and scalp skin, and to protect the staff from hair becoming contaminated with blood or body fluids from the patient (Wilson, 2016).A recent patient safety campaign has promoted theatre staff having their name and job role clearly written on their theatre hat so that everyone in the operating theatre knows who everyone else is. To combat confusion in the operating theatre, Dr Rob Hackett, a Consultant Anaesthetist from Sydney, Australia, began wearing a cap printed with his name and profession. The means of identification was quickly adopted by surgical staff in Australia and internationally and now has an associated hashtag, #TheatreCapChallenge, which was initiated by Alison Brindle, a student midwife in the UK.The initiative is important because being able to identify staff improves patient safety and efficiency. Human factors principles also suggest that displaying names and roles will improve recollection of those names and roles and the WHO emphasise the importance of this concept by including it on the surgical safety checklist (Brindle, 2017). Not knowing the name of a colleague can lead to delays, particularly in health emergencies when the quick transfer of equipment or medications is essential. Names and roles on theatre caps prevent the possibility of mix-ups when staff members have the same first name and also facilitates handover of patients. A side benefit is that it improves camaraderie and collaboration in the operating theatre (Hackett, 2017). The concept has been supported by the Royal College of Surgeons, who say it could combat unconscious bias where people who do not look like a “traditional surgeon” are mistaken for other staff. This simple and cheap practice also has benefits for patients and their families. For patients being wheeled into theatre, knowing the names of everybody and what their role can be reassuring, particularly for women undergoing a caesarean section, or parents escorting their children into theatre in preparation for surgery or a procedure.The issue for Infection Prevention & Control Teams is what type of theatre hat should be recommended: disposable or cloth.The evidence baseThe evidence base is quite sparse and conflicting regarding the effect of disposable or reusable surgical attire in the prevention of surgical site infection (SSI). It is well documented that sterile gloves and gowns have an effect on the reduction of SSI (Salassa & Swiontkowski, 2014), and that hats are also important part of theatre attire (Hubble et al, 1996), but less is understood about the effect of different types of hats or head gear. One study conducted in 1991 suggested that, for non-scrubbed staff the wearing head gear was not associated with a reduction in air counts, but that counts were lower with ventilation. They recommended that scrubbed staff should continue to wear head gear because of the proximity to the sterile field (Humphreys et al, 1991). A subsequent study identified a significant increase in bacterial contamination at random sites in the operating room when hats were not worn, and a 60 fold increase in contamination at the wound bed (Friberg et al, 2001). However this was in a horizontal laminar air flow environment. In 2004 Owers & Bannister studied the sources of bacterial shedding in orthopaedic theatres and found that operating department staff’s ears were significantly more colonised than foreheads or eyebrows. They therefore recommended surgical hood caps in arthroplasty surgery to cover staff ears. Another recent study aimed to compare the two kinds of surgical headwear against each other to observe the comparable differences (Hussain et al, 2017). Infection data was acquired from hospital infection control monthly summary reports from January 2014-March 2016. Researchers obtained a total of just under 15,000 surgical procedures 13 months before and 13 months after surgical caps were banned at a single site with 25 operating rooms. Data was categorized into non-bouffant and bouffant groups. Monthly and infection rates for 13-months before (7513 patients) and 13-months after (8446 patients) the policy implementation was collected and analysed for the groups.Researchers found that there was no statistical significance of infection risk where the surgeon was wearing a bouffant cap or another form of headwear. In this large, single-centre series of patients undergoing surgical procedures, elimination of the traditional surgeon's cap did not reduce infection rates and therefore need not to be mandated.The most recent paper published studied the difference in effect between bouffant style disposable hats, disposable caps and laundered cloth caps in preventing bacterial and particulate contamination in the operating room (Markel et al, 2017). A mock surgical procedure was used in a dynamic operating room environment and airborne particulate and microbial contaminants were sampled. Hat fabric was tested for permeability, particle transmission, and pore sizes. Fabric assessment determined that disposable bouffant hats had larger average and maximum pore sizes compared with cloth skull caps, and were significantly more permeable than either disposable or cloth skull caps. The authors concluded that disposable bouffant hats had greater permeability, penetration, and greater microbial shed, as assessed by passive microbial analysis compared with disposable skull caps. When compared with cloth skull caps, disposable bouffants yielded greater permeability, greater particulate contamination, and greater passive microbial shed. Disposable style bouffant hats should not be considered superior to skull caps in preventing airborne contamination in the operating room (Markel et al, 2017).The limitation of this study is that only clean, freshly laundered cloth hats were evaluated, and that there are multiple brands of disposable and bouffant type hats available that were not evaluated in this study. The authors acknowledge that a dirty, unlaundered cloth hat may had led to different transmission and contamination results.Infection Prevention Standards and PracticesThe American College of Surgeons has now released a statement supporting cloth hats and the Royal College of Surgeons are in the process of considering their stance. The Association for Perioperative Practice Standards (2016) state that disposable headwear is preferable, however cloth caps are permissible if laundered and inspected for holes / imperfections in an approved facility and not at home. However, it is acknowledged that this standard is based on a letter to the Editor and not a research study. The IPC Team contacted the other Trusts in the Trent Region of the Infection Prevention Society. Nottingham University Hospitals NHS Trust have supported cloth hats, staff have been issued with ten cloth hats each with their name and job role on them. The IPC Team supports this, providing that a clean hat is worn each day and changed if it becomes contaminated with blood or body fluids during the day. The team have provided advice to staff regarding what temperature to wash them at (DH, 2010) and recommend reverting to disposable hats when a patient has a suspected or confirmed transmissible infection, such as CPE. Very positive patient feedback has been noted. University Hospitals Coventry & Warwickshire NHS Trust colour code hats to distinguish different staff. The consultants support disposable colour coded hats with a name and job role written on them. If junior medical staff choose to buy their own cloth caps the IPC Team ask them to demonstrate that they have a spare clean hat in the appropriate colour in case of contamination, and often staff do not.The Trust currently spends approximately ?10,000 on disposable hats.Sustainability IssuesNGH Trust is committed to reducing waste and its carbon footprint. The removal of single use items where possible is often supported by staff across the Trust, conversely taking them away and replacing reusable items with single use items is often met with concern (e.g. the move to single use medication transport bags in Pharmacy). The current single use hats are made from Viscose. This is made from hardwood tree pulp, it is estimated that 120million trees are cut down each year for viscose production, some of which are in Indonesia, Canada and the Amazon, deforesting ancient woodland and therefore potentially degrading local ecosystems and adding to climate change. The wood chips from the trees are pulped in a process requiring steam and chemicals such as sodium hydroxide. The pulp is then bleached with further chemicals such as chlorine. This process can result in toxic effluent discharges to local water courses. The bleached pulp is then chemically treated, spun into fibres and bleached again. This process also creates a lot of wastewater. Whilst there are certification standards for some of the production methods and forest management, it is not clear from the packaging or manufacturer’s website that this is the case. Given the low cost of the consumable, this is unlikely.Whilst there are environmental impacts of the reusable items, in terms of use and lifecycle, these are mainly related to the laundering process and are therefore likely to be a result of the energy and water used in the washing process as well as the detergent used. The overall impact will be determined by the original manufacture and material, as well as the number of times an item is used before being replaced.RecommendationsFrom a patient safety perspective, names and job roles or colour coded on theatre hats should be compulsory for all staff in the operating room.The literature suggests that there is no difference in patient outcome from staff wearing a disposable cap with a sticker on compared to a clean cloth hat. The question for IPSG is, if cloth hats are to be supported, what processes are put in place to ensure that only clean hats are both available and worn each day, as if dirty hats are worn then the risk of transmission and SSI may well be higher. The solution needs some careful consideration and potentially a trial in one of the theatres to ensure that a sustainable solution is achieved. Or, as demonstrated in Figures 2 and 3, should disposable hats with labels be supported instead.Figures The following figures demonstrate the different solutions available. Figure 1: cloth hat with printed details Figure 2: disposable hat handwritten stickerFigure 3: disposable hat with printed stickerAppendix 1 – email from Dr French, Consultant AnaesthetistDear Linda and HollyThank you for copying me in and I hope you do not mind me commenting. This comes down to trusting your staff I suppose. If you want to wear a cloth cap, you take responsibility for washing it appropriately. I wash & iron?mine and place them in a plastic bag to bring in. I suspect the Medical Director and his Deputy will do the same. I am not aware that we monitor paper caps or greens either ?nor that those have been examined after several hours in theatre, going back and forward to the coffee room, toilet etc.Paper hats sit in boxes on open shelves beneath open windows, as do our theatre greens, next to the toilets and shoe racks. People put their hands inside the boxes without washing their hands beforehand, after coming in from outside, the wards, the toilet etc. ?I think we are overemphasising the “infection risk”? because there is no evidence that hats (paper or cloth) make any difference anyway! Do we monitor lanyards or badges, bleeps, phones, shoes etc ?which are ever present in theatre yet were introduced without all this scrutiny, yet they are more likely to be dirty? The Colleges of Anaesthetists of Australia and America as has Midwifery have all now given their full support to this initiative and we expect our own UK Colleges to do the same shortly. There are solutions to the expense issue and we underestimate the morale and patient safety boosting aspect of this. A solution would be to allow cloth for those who wish to wear them ?(we can income generate for this and save money on paper) but staff have to be trusted to wash them if they want to have cloth.If staff want paper and don’t want to wash their own hats, then wear paper with labels (I suspect that will not be successful unless you make that compulsory) and frankly a paper label was never meant to be more than a temporary solution. Will you be auditing the cleanliness of the paper labels that are shoved in lockers or carried about the hospital in folders or bags?Do we monitor?religious headgear made of cloth or have we banned those? They are sometimes worn in theatre. ?Again no. ?Do you have any evidence for wound infections in theatre from hats at all? I suspect not and frankly we have now missed the opportunity to lead the way in the UK. Other Trusts have now committed to this initiative and we risk losing the opportunity to be amongst them. I hope this initiative does not fail now.Thank you for your efforts.Kind regardsGordonReferencesAssociation for Perioperative Practice (2016) Standards and Recommendations for Safe Perioperative Practice. AFPP, Harrogate. Brindle, A (2017). Theatre Cap Challenge. The Operation Theatre Journal [online]. Available at Accessed 16.06.18.Department of Health (2010) Uniform and workwear: guidance on uniform and workwear policies for NHS employers. DH, Leeds.Hubble, M.J., Weale, A.E., Perez, J.V., Bowker, K.E., MacGowan, A.P. & Bannister, G.C (1996). Clothing in laminar-flow operating theatres. Journal of Hospital Infection. 32 (1), 1-7.Humphreys, H., Russell, A.J., Marshall, R.J., Ricketts, V.E. & Reeves, D.S (1991). The effect of surgical theatre head-gear on air bacterial counts. Journal of Hospital Infection. 19: 175-180.Hussain Shallwani, Hakeem J. Shakir, Ashley M. Aldridge, Maureen T. Donovan, Elad I. Levy, Kevin J. Gibbons. (2017). 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.Friberg, B., Friberg, S., Ostensson, R. & Burman, L.G (2001). Surgical area contamination – comparable bacterial counts using disposable head and mask and helmet aspirator system, but dramatic increase upon omission of headgear: an experimental study in horizontal laminar air-flow. Journal of Hospital Infection. 47: 110-115.Markel, T.A., Gormley, T., Greeley, D., Ostojic, J., Wise, A., Rajala, J. Bharadwaj, R. & Wagner, J (2017). Hats off: a study of different operating headgear assessed by environmental quality indicators. Journal of the American College of Surgeons. 225 (5), 573-581.Owers, J. & Bannister, B (2004). Source of bacterial shedding in laminar flow theatres. Journal of Hospital Infection. 58 (3), 230-232.Salassa, T.E. & Swiontkowski, M.F (2014). Surgial attire and the operating room: role in infection prevention. Journal of Bone and Joint Surgery. 96: 1485-1492.Wilson, J (2016). Infection Control in Clinical Practice. Bailliere Tindall, Edinburgh. ................
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