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Association of Surgical Jacket and Bouffant Use With Surgical Site Infection Risk

Educational Objective To evaluate the association of mandated surgical jackets and bouffants in the operating room with the risk of surgical site infection.
Key Points

Question  Is the combination of surgical jackets and bouffants in the operating room effective in reducing the risk of surgical site infection?

Findings  In this cohort study of 34 042 inpatient surgical cases at a large tertiary care academic institution, there was no significant difference in surgical site infections following the mandate of surgical jackets and bouffants.

Meaning  Institutions should evaluate their own data to determine whether recommendations by outside governing organizations are beneficial and cost-effective.

Abstract

Importance  Surgical site infections (SSIs) are associated with increased morbidity and mortality. Various measures have been enacted decrease the occurrence of SSIs involving the regulation of the attire worn by the operating room staff, at times without sufficient peer-reviewed literature to support their implementation.

Objective  To evaluate whether the combination of mandated surgical jackets and bouffants in the operating room is associated with the risk of surgical site infection.

Design, Setting, and Participants  A retrospective cohort study of 34 042 inpatient surgical encounters at a large academic tertiary care hospital was performed. Three periods between January 2017 and October 2018 were compared, corresponding with implementation of surgical jackets and the subsequent mandate of surgical jackets plus bouffant head covers. All inpatient surgical cases were included from University of Alabama at Birmingham University Hospital, a single-center, large academic tertiary care hospital. The study comprised a consecutive sample of all inpatient surgical cases over a 22-month period.

Exposures  No surgical jackets or bouffants mandated (8 months), surgical jackets mandated (6 months), both surgical jackets and bouffants mandated (8 months).

Main Outcomes and Measures  The primary study outcome was SSIs, which were collected from institutional infection control monthly summary reports, according to the National Healthcare Safety Network definitions for superficial incisional, deep incisional, and organ/space SSIs. Secondary outcomes included wound dehiscence, postoperative sepsis, death, and cost of interventions.

Results  A total of 34 042 inpatient surgical encounters cases were included in the analysis over the 22-month study period. Of the total patients, 16 380 were women (48%) and 17 638 were men (52%). There was no significant difference in the risk of SSI (1.01% vs 0.99% vs 0.83%; P = .28), mortality (1.83% vs 2.05% vs 1.92%; P = .54), postoperative sepsis (6.60% vs 6.24% vs 6.54%; P = .54), or wound dehiscence (1.07% vs 0.84% vs 1.06%; P = .20) between the 3 groups. Receipts from the first 6 months of the 2018/2019 fiscal year provided an estimated expenditure of more than $300 000 annually on surgical jackets. Bouffants were found to be less expensive than surgical skull caps.

Conclusions and Relevance  The results of this study suggest that surgical jackets and bouffants are neither beneficial nor cost-effective in preventing SSIs. Institutions should evaluate their own data to determine whether recommendations by outside governing organizations are beneficial and cost-effective.

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Article Information

Corresponding Author: Brent A. Ponce, MD, University of Alabama at Birmingham, 1313 13th St S, Ste 203, Birmingham, AL 35205 (bponce@uabmc.edu).

Accepted for Publication: December 1, 2019.

Published Online: February 12, 2020. doi:10.1001/jamasurg.2019.6044

Correction: This article was corrected on May 27, 2020, to fix the accepted for publication date.

Author Contributions: Dr Ponce had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wills, Smith, McGwin, Ghanem, Ponce.

Acquisition, analysis, or interpretation of data: Wills, Smith, Arguello, McGwin, Ponce.

Drafting of the manuscript: Wills, Smith, Arguello, McGwin, Ghanem.

Critical revision of the manuscript for important intellectual content: Wills, Smith, Arguello, McGwin, Ponce.

Statistical analysis: Smith, McGwin.

Administrative, technical, or material support: Wills, Smith, Arguello, Ponce.

Supervision: Wills, Smith, McGwin, Ghanem, Ponce.

Conflict of Interest Disclosures: Dr Ponce has stock or stock options in Help Lightning, is a pain presenter/speaker and paid consultant for Tornier, and receives IP royalties from Wright Medical Technology Inc. No other disclosures were reported.

Additional Contributions: We thank Yvonne Chodaba, MD, for her assistance with demonstrating the surgical attire groups in Figure 1 and granting permission to publish this information.

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