Wednesday, February 20, 2013

Does OR staff hair cause infections?



“Zlatan” (not his real name) writes:

I just recently found your blog and read about shaving patients and agree with all that you said. My question is about the staff's hair. Sorry if you have addressed this, I couldn't find it. 
I work at a VA hospital in surgery. I have been in the OR environment for 30 years and have seen quite a lot and been through many inspections. We had an independent nurse evaluate us for upcoming JCAHO inspection. We 'failed' due to not covering facial hair and chest hair with scrub attire and in addition were told folks with hairy arms needed long-sleeve scrub tops. Of course this comes from the all powerful AORN. Being an evidence-based person at heart, I began to look for some evidence regarding covering up (that is how I stumbled onto your blog). Do you have any knowledge of evidence based practice regarding hair covering and infection rates? I appreciate your time.
Thanks!

Great question. Where do they come up with these things? Chest hair? Arm hair? Long-sleeve scrub tops?

For the record, I am against wound infections. I would do anything reasonable to try to prevent them.

I suspect your independent nurse evaluator may have over-interpreted the rules. My distaste for the Joint Commission (by the way, it’s no longer called “JCAHO”) runs deep, but I don’t think even they have thought of those wrinkles to the hair issue.

It is possible though as the JC and the AORN seemed to be obsessed with hair.

How does one define "hairy arms"? I assume long sleeve scrub tops would be for the circulating nurse only. If the surgeon and the scrub tech wore long sleeves, they wouldn’t be able to properly wash their hands and arms.

Regarding the chest hair, are we talking male or female staff? (Just kidding.)

As far as I know, there is not one shred of evidence linking shed skin or hair on the head, face, chest or arms of OR staff to patient infections. This is after an exhaustive search of PubMed, CDC, and holding nothing back, I even crowd-sourced the question on Twitter.

In case some readers missed my post on the ritual of clipping the hair of patients before surgery, the link is here. The post was about rules that people make up without any justification to drive us all crazy.

I collected several such rules related to presumed infection prevention in the comments section of that post and elsewhere. Here they are.

No forced-air warming until patient is draped.
No briefcases in the OR.
No one may enter the room without the circulator's permission.
No room warming as it may cause condensation on surgical instruments. (Children and burn victims who may become hypothermic be damned!)
Remove masks every time you leave the OR. And no letting them hang down with just the lower tie done.
Masks must be worn by anyone in the scrub sink area even if that person is not scrubbing but just walking by.
All OR personnel must wear long sleeves because of the potential for "shedding skin."

But the independent nurse reviewer has spoken. I’m betting that long sleeve scrub tops and chest and arm hair police will soon appear in your OR.

34 comments:

  1. Since my only experience with ORs is just before I'm put under and TV/movies my scope is rather narrow but I've never seen anyone (M/F) go topless in the OR or even in the hallways (I have more experience outside the OR). Or even have low cut tops that expose chest hair...maybe Calgary hospitals use higher cut necklines on their official scrubs. And if hair is peeking over the neckline...that is one hairy dude!
    If they keep the temperature down in the OR everyone will want long sleeves! (or hairy arms). Nothing like a surgeon shivering while doing some delicate cutting eh? (some of us feel the cold easily-while others are warm we shiver).
    Some people have too much power and not enough brain cells engaged.
    Interesting topic for my next volunteer shift in Emergency.

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  2. When the room is too cold, the patient's body temperature falls. This is especially true in open abdominal cases and with lots of blood loss. Sometimes the room must be kept warm. We should worry about the patient and not the comfort of the staff.

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    1. Yes but with new SCIP recommendations you should always be irritating with warm fluids and using some type of forced air warmer. The combination of the two will drastically cut down on hypothermia. With warmer room temps. comes increased chance for bacteria and there for increased chance for infection. So cooler rooms do benefit the patient.

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    2. That's why God gave us Bair Huggers!;-)

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    3. Force3d air warming and warm irrigation fluids help but patients will still become hypothermic.

      I do not believe there is any evidence that a warm OR leads to either more bacteria or more infections. For pediatric surgery, rooms are often warmed to more than 75 degrees.

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  3. I agree that the pateint is our number one concern, Although there are other ways to keep the pateint warm besides the temp in the room. You can't proceed in a case when the staff ie... surgeon and scrub are sweating...light headed and/or ready to pass out due to an over warm OR. So comfort of the staff is a little important.

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    1. The room temperature should be adjusted to benefit the patient within reason. The staff should not be profusely sweating.

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  4. Why isn't exposed body hair a concern in a sterile environment? It sheds just like scalp hair. Are head caps overkill then?

    As far as infections go, I have a question. I had a SSI following an open appendectomy some years ago, resulting in 3 extra days in the hospital plus 5 weeks on a portable wound vac machine. Just wondering if that incident would have qualified for one of those withering grillings in a Monday Morning conference.

    Emily

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    1. In over 40 years of surgery, I can't recall any staff shedding hair into the operative field. It may have happened but I didn't see it. If anything, it would have been scalp hair as chest and arm hair are covered by gowns.

      I don't see how the circ RN or anesthesia people would shed hair or skin into a wound.

      Infections after open appendectomy are not rare and are almost always caused by the patient's own colonic bacteria. This would have nothing to do with what the staff is wearing or not wearing.

      That sort of infection would not have been worthy of a "Monday Mornings" M&M.

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    2. Emily, you have to think about where your appendix is and what it is connected to...Your intestines which create the perfect storm for an infection. Your appendix was most likely inflamed and infected resulting in even more chance for infection. No Monday morning meeting here... Jody

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    3. Actually in the operating report my appendix was described as 'gangrenous', so I guess there was a big mess in there. Previously I complained of mild pain, really just an ache, so because of my gyn cancer history, a CT was ordered which showed everything normal. Pain continued so than an MRI was ordered which revealed accute appendicitis. I was able to do normal pre-op prep which included prophylaxis antibiotics, but to no avail. Post surgery day 6 I bled through my incision site. Biopsy said seroma.

      Also, during surgery they discovered a 'mass' in my cecum (thank God, not cancer). So cecum was removed resulting in monthly B12 shots for life (no biggie). But I do wonder about the reliability of CTs and MRIs. One didn't reveal appendicitis, and neither revealed the cecum mass
      (7 x 10.5 cm). I guess surgeons find all kinds of surprises when they open up a patient.

      Well, I'm glad my experience is considered small potatoes in the scheme of things. It all ended well. And I sure wouldn't want to wish M&M angst on my wonderful doctors.

      Emily

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  5. Has this list been proven...evidence based or is it just assumption?

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    1. Everything on that list is not evidence based.

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  6. I think a lot of things are over-kill. In 20 years I've seen a lot of "rules" broken, and our infection rate is extremely low. A lot of studies don't take into account that some patients infect their own wounds.

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    1. You are correct. Some say that at least 80% (it could be more) of wound infections are due to patient-related factors.

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  7. @Anonymous: A short sleeve scrub top is of no matter as the surgeon, first assist, and tech. will all be gowned and gloved(and capped and masked). The only people not gowned and gloved would be the circulating nurse(non sterile and doesn't enter the sterile field) and the anesthetist(non sterile, doesn't enter the sterile field). Caps are worn by everyone in the operating theatre as are masks.

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    1. Here's an interesting study showing that the non-scrubbed OR staff does not even need to wear masks. http://www.ncbi.nlm.nih.gov/pubmed/20575920

      I doubt that this will be adopted by any hospitals in the US.

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  8. Apparently our hairy arms and beards are causing a perceived problem on our OR too! The men with beards (luckily no women) are wearing a hat, mask with a boufount hat across their faces to cover sideburns. Looks hilarious! Almighty AORN has spoken!

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    1. Yes, I have a shaved head. A bouffant cap looks pretty silly on me and I have no hair to shed.

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  9. Dr. Skeptical scalpel, I've never posted here before but I've been a follower for a long time now.

    My colleagues and I couldn't stop laughing when we read this post. We haven't heard of any of this hair causes infection nonsense and most of our staff have trained in North America.

    I live in the Middle east, lots of doctors here have LONG LUXURIOUS FLOWING BEARDS - the GLORIOUS kind. If you have seen Arabs - we are hairier, even more so than our Indian brethren claim to be. My favorite colorectal surgeon would give Chewbacca a run for his money.

    I wonder what the AORN Nurse would say if she saw us in the OT!

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    1. Thanks very much for commenting. You bring a new perspective that I really appreciate. As I said, some people are obsessed with hair.

      I wish you would write a paper about the subject.

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  10. Great info...I just stumbled on this blog and am I ever glad I did..I've been a surgical tech for almost 20 years in a very small hospital..people sometimes relax a little on the rules, maybe not a policy for our facility but just a duh infection control rule for everyone.... what is the new thought on artificial nails..I have a coworker who put them on last year and my boss says its fine because a facility 90 miles away has a policy that says its OK..but I did read recently that an infection had been linked to a scrubs nails..

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    1. This is an instance in which I agree with the AORN. Artificial nails should not be worn in tho OR or ICU settings.There has been several reports of outbreaks of infection due to the inability to adequately clean under artificial nails. Below are some references. Medscape requires registration, but it is free and worth it for you to read the brief article.

      http://www.aorn.org/Clinical_Practice/Clinical_FAQs/Hand_Antisepsis.aspx#c

      http://www.ncbi.nlm.nih.gov/pubmed/12271553

      http://www.medscape.com/viewarticle/547793

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  11. you'd love the USP standards for IV compounding in pharmacies. no jewelry, no make-up. gowns, gloves, masks, head covers (ok, those last four make sense along with shoe covers). it matters not that jewelry on hands will be covered by gloves. no earrings or necklaces (which are under clothing), nothing, the reasons cited were skin/hair shedding. jewelry is banned because of the bio-burden that can be transported on these items into the clean room. when asked for the evidence regarding these standards the answer was there was none but these are the new rules.

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    1. We all have our crosses to bear. I think it's a little different with IV compounding though. If a piece of shed skin falls into an open abdominal wound, it is highly unlikely to cause an infection. If a piece of shed skin finds its way into a TPN solution, the outcome might be different.

      The thing about rings on fingers is also not so outrageous. It is said that as many as 10% of sterile gloves have holes in them when they leave the factory. Couple that fact with the amount of crud that forms under a ring (which can't be cleaned with simple hand washing) and you can see why rings should be removed.

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    2. interesting how how lack of evidence in one situation is not ok for you but ok in others because the outcome "might" be different? crosses indeed.

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    3. You have a point, but then it is my blog.

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  12. I remember during surgery residency one of the CV surgeons used to always sweat, and intraop sweat would drip from his forehead into the pts chest.
    As I became staff, I joke to him about it, he said "sweat is sterile", which it is, until it rolls over your skin.
    Well, he doesn't have a problem with wound infections that I can remember.

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  13. Is P.Acnes most frequently occur from the pts own bacteria? (P.Acnes frequently occurs in shunt infections)

    Erica
    www.rarelydefined.blogspot.com

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  14. Yes, most shunt infections are from the patient's own skin bacteria. Here's a link to a paper about it. http://cid.oxfordjournals.org/content/47/1/73.full

    Read the sixth paragraph of the discussion.

    I read a few of your blogs. I hope you are feeling better.

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  15. On 2/23/13 Skeptical writes: "In over 40 years of surgery, I can't recall any staff shedding hair into the operative field. It may have happened but I didn't see it." This is followed by a subsequent post by someone from the Middle East talking about hairy surgical staff. This leads me to one of my favorite OR stories.

    I was circulating an ortho surgery for a doctor who is from an Eastern European nation. This surgeon is hairy. He typically wears a paper hood to cover head and facial hair, and, yes, hair does stick up from under his scrub top. This day, surgical staff had scrubbed in, the patient was draped and prepped, and the surgeon sat down on the stool to begin. He asked for the scalpal, then a single, large hair began slowly drifting down, wisping back and forth. All eyes watched, breathless, hoping the hair would miss the surgical field. It wasn't to be. This enormous hair lands directly on the surgical site! The room burst into laughter and we proceeded to break down the surgical field to redrape and prep the patient as the surgical team re-scrubbed. And yes, I did go out to the scrub sink and ensure that all the surgeon's hair was safely tucked into the paper hood and scrub top.

    Now you can say that you have heard from someone who actually saw shedding "on" to the surgical field.

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  16. What a great story. Thanks for commenting.

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