American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Study finds new barrier mandates for OR personnel do not reduce infection

OCTOBER 24, 2018
Clinical Congress Daily Highlights, Wednesday First Edition

Although recent guidelines mandate additional barrier attire for all scrubbed and unscrubbed operating room personnel to reduce infection, a new study led by Benjamin Kuritzkes, MD, Columbia University, New York, shows that this mandate does not significantly impact surgical site infection (SSI), hospital readmission, or reoperation.

Research shows that SSI occurs in about 3 percent to 5 percent of patients undergoing abdominal surgical procedures, is the leading cause of unplanned readmission after surgery, and costs nearly $12,000 per patient on average, Dr. Kuritzkes said. Established risk factors for SSI include tobacco use, obesity, and underlying malignancy.

The guidelines, which were issued by the Agency for Healthcare Research and Quality (AHRQ) and the Joint Commission, include bouffant caps covering all hair (preferred to skullcaps) and long-sleeved surgical attire covering all exposed skin.

These guidelines were issued despite the fact that barrier attire has never been shown to reduce SSI or even bacteria in the environment, Dr. Kuritzkes said. In fact, prior studies have shown that:

  • Shoe covers worn by operating room staff do not reduce floor bacteria
  • Surgical scrubs do not reduce airborne bacteria counts when compared with street clothes
  • Naked surgeons shed fewer bacteria than surgeons wearing scrubs or street clothes
  • Disposable face masks do not reduce risk of SSI in patients

Dr. Kuritzkes and team set out to see if the new barrier regulations have had any impact on SSI by gathering data for all elective abdominal surgery patients at a large tertiary institution from the National Surgical Quality Improvement Program dataset before and after March 2016, when the institution mandated universal compliance with the guidelines. Demographic, intraoperative, and postoperative variables were compared for the preimplementation (March 2015–February 2016) and postimplementation (March 2016 - February 2017) groups. Multivariable logistic regression evaluated association between new attire implementation and surgical site infection (SSI) as well as other outcomes.

The researchers found that 1,122 patients (mean age 52.7 years) who underwent abdominal surgery (60.9 percent laparoscopic and 16.4 percent bowel resection) were included. There were 607 patients postimplementation and 515 preimplementation. Postimplementation patients were older, had fewer patients with BMI at or over 30 and ASA physical status at or over 3. Gender and comorbidities were similar. Laparoscopy, bowel resection, and operating time of three hours or more were associated with SSI — but barrier attire was not. In fact, implementation of the new attire did not significantly impact SSI, hospital readmission, or reoperation.

These data call into question the rationale for the new more stringent operating room attire guidelines, which burden hospitals with additional cost, time, and resources and could detract efforts to target other important factors, Dr. Kuritzkes said. His study did not evaluate the cost of the new barrier mandate on hospitals, but Dr. Kuritzkes called it “significant.”

Dr. Kuritzkes said his team is not recommending that OR personnel work without any clothing. He also emphasized that there is no evidence this barrier mandate is reducing potential harm to the provider.

“The reality is, barrier attire has become part of the culture,” he said. “Would the public see (dropping the barrier attire mandate) as a step backward? We don’t know.”

He said his own institution has not lifted the mandate.

View this study’s abstract online here.

Additional information

The Scientific Forum presentation, New Barrier Attire Regulations in the Operating Room: Another Mandate without Basis?, was held October 24 at the 2018 Clinical Congress of the American College of Surgeons in Boston, MA.  Program, webcast and audio information is available online at

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