If you don’t work in an operating room, you may not be aware of the controversy going on about OR caps.  To get right to the point – the surgeons think they should be allowed to wear the cloth hats they have worn forever.  The Association of Operating Room Nurses (AORN) developed guidelines which included covering the ears and all hair (which means a bouffant paper hat). These guidelines were then implemented by JACHO which means they became “law” in every hospital in the United States.

Anonymous surgeons demonstrating extremely effective covering of all hair with bouffant hats.

I’m a real believer in evidence based medicine (and policies) so I decided, like others, to look into what is really known about the issue.  Because it is a conflict of interest, I need to disclose that I can’t stand the bouffant hats and I really, really miss my (clean and washed) cloth hats. (which BTW cover all my hair!)

What do the data say about the use of bouffant hats and infection rates?  


Why don’t surgeons like bouffant hats?

It’s harder to keep them in place when wearing loupes or headlamps. If the goal is to keep the hair covered, this is a real problem.  When moving headlamps, operating microscopes or loupes, the bouffant hat often moves substantially – or even comes off entirely.

They are hot. Many surgeons feel (me included) that the bouffant hats are uncomfortable and are hot.  One can argue that anything that increases surgeon discomfort could affect concentration, which might be reflected in less focus on the operation.

Bouffant hats are expensive and bad for the environment.  On Amazon, 100 bouffant hats cost $7.45.  There were 48 million inpatient operations performed in 2009.  When you add the 48 million outpatient procedures performed, that means there are roughly 100 million operations performed per year.  (Mind you, these data are almost 10 years old, so it’s likely to be more now).  If we assume an average of 4 cases/day by an average surgical team (nurses, CRNA, anesthesiologist, assistants/resident) and they all wear their hat for the day, the number of hats needed per year would be 100 million cases x 6 members of the team = 600 million hats/yr. 600 million hats divided by 100/box = 6 million boxes x $7.45 = $44,700, 000.  Over 44 million dollars a year for the bouffant hats… all of which (600 million/year) end up in a land fill or are incinerated.  p.s. Given that hats are often changed during the day, this number is probably on the low side.

It affects morale.  In a survey of young (<45 years of age) surgeons, 71.2% stated that the new rules had affected surgeon morale.

They are inferior in blocking bacteria when compared to other caps.  In a study of bouffant hats, disposable skull caps and cloth hats, the bouffant hat was the worst in preventing airborne bacterial contamination in the operating room.  “I expect our findings may be used to inform surgical headgear policy in the United States,” he said. “Based on these experiments, surgeons should be allowed to wear either a bouffant hat or a skullcap, although cloth skull caps are the thickest and have the lowest permeability of the three types we tested.” Troy A. Markel, MD, FACS


Photo credit

I’m confident that in the very near future we will be back to wearing our clean, cloth hats.   When you look at the data, and weigh the pros and cons, it seems pretty obvious what needs to be done….







19 thoughts on “#BanTheBouffant

  1. Great review of the available data. I hope Evidence based practice matters to JACHO, nurses and OR teams. Improperly implemented ‘rules’ can actually cause harm to the people we are trying to protect. Well thought out rules and policies are imperative.

  2. Disposable caps go into landfill. Cloth hats are cost effective to hospital. Once this gets to the accountants it will change quickly.

  3. I agree completely with the evidence presented. I wore cloth OR caps for 45 years and did not find they were a significant factor OR bourne infections. There are many more causative factors that are more significant that should be addressed.

  4. The flimsy bouffant hats that move around the head, don’t effectively cover all loose hairs from escaping and so incredibly thin that easily can produce holes..is not the most helpful in promoting infection control.
    Perhaps for a lunchroom .

  5. The cloth hats in the article are laundered at the hospital facility. We cannot do that at our facility. That is the reason our personnel are not allowed to wear them according to our management. Does anyone else run across this at their facility?

  6. You need to include sweat. bouffants are completely non absorbent. I have had to redo a prep on several occasions because sweat pooled in my bouffant cap then dripped

  7. As long as these so called “clean” hats get laundered from time to time.
    I have worked with surgeons who did not do this regularly, as well as “duck taped” their OR shoes!! Many many years old..

    • Couldn’t agree more! I don’t think, however, they need to be laundered in the hospital. There is zero evidence (which is also supported by common sense!) that commercial cleaning would make a difference.

  8. Mandated by AORN. So typical of non-scientific rules (aka magical thinking) that invoke “Best Practices” as a reason to enforce changes. Best practices so frequently whittles down to “everyone else is doing this, so we should probably do it too”.

  9. They never said you could not wear them but they had to be put in a regulated laundry by regulations in the hospital with the temperature set by the CDC. We all know they are poked in the lockers and worn over and over again with out being cleaned and put on a clean one daily. This could have been put in a policy. Who wants to stand over a patient with a cap that has not been cleaned correctly and worn numerous times over a open wound. We all know that was happening.

    • I do think they need to be clean and washed! I don’t think the super hot temps set by the CDC are excessive for caps, though. As long as they are laundered, I don’t think where makes a difference.

  10. This stuff is a great review. The bonnet is a bunch of crap and data proves it. JHACO is a joke and always will be. We need to just get rid of the JHACO nonsense or at least publish their conflicts and consulting agreements.

  11. After 20 years, since I started, latex allergies became an issue and everyone had to go latex free. I became horribly allergic to the to the non latex, which was also in the caps. So for me to wear cloth hats I had to have them laundered and sterilized for each day. What a waste. Every OR personal should ask for a complete list of ingredients of what those new gloves, hats gowns are made of, it’s shocking. My dermatologist showed me after mystery rashes and horrible hands. But as always our safety comes last.

  12. Pingback: Association of Women Surgeons » Blog Archive » #BanTheBouffant

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