Infection control

Many UK hospitals have already implemented reusable theatre caps into their operating theatre departments in place of disposable caps. To enable this change in protocol, it is advised to pass the project through the hospital’s Infection Control team first because this approval is often compulsory prior to going down the procurement route which is another requisite.

Every NHS trust has a different infection control department who may have a varying opinion. IPC teams may have contrasting opinions to each other and have their own experiences and beliefs so their priorities, thoughts, and rules can be different: even to other hospitals local to them.

Some Infection prevention teams allow staff to take their theatre hats home to wash and some do not.

Rationale for home washing is that staff in all other parts of the hospital take their uniforms home to wash as a part of their daily routine and the counter to this is that some staff may not effectively wash their own theatre hats so this could be a cross-contamination risk.

We have worked with NHS trusts who have tried and tested infection control policies in place, and these have been working well for several years now. We are more than happy to share our customers’ policies (subject to permissions) with anyone interested in making the switch to reusable scrubs hats.

One of our main goals is to share best practice across the board, so that trusts who hope to implement this change do not need to ‘reinvent the wheel’ each time.

Female doctor waiting for the emergency entry

In the fast-paced environment of surgical procedures, infection control is of paramount importance. One often overlooked aspect of infection control in healthcare settings is the use and reusability of theatre hats. These hats, worn by surgical staff, play a crucial role in maintaining a sterile environment in the operating room.

However, concerns have been raised about the potential for contamination and infection transmission associated with the reuse of theatre hats.

Theatre hats, also known as surgical caps or scrub hats, are worn by surgical teams to prevent the shedding of hair and scalp bacteria into the sterile field during surgical procedures. They form a part of the personal protective equipment (PPE) worn by healthcare professionals in the operating theatre, alongside surgical masks, gowns, and gloves.

By containing hair and reducing the risk of bacterial contamination, theatre hats are essential in maintaining a hygienic surgical environment and reducing the risk of surgical site infections (SSIs) in patients. For many years, general hospital policies have been to wear disposable theatre caps and then throw them away at the end of each shift.

This however is contributing to millions of hats going to landfill each year, so hospitals are making sustainable changes by moving away from throw away consumables to items which can be simply washed and reused.

Helpful research links

Infection Control

Haskins IN, et al. Hernia. 2017.‘There is no association between the type of surgical hat worn and the incidence of postoperative wound events.’
Hussain S, et al. Neurosurgery, Volume 82, Issue 4, 1 April 2018, Pages 548–554.‘Mandatory Change From Surgical Skull Caps to Bouffant Caps Among Operating Room Personnel Does Not Reduce Surgical Site Infections in Class I Surgical Cases.’
Markel T et al, Journal of the American College of Surgeons. October 2017. Volume 225, Issue 4, Supplement 2, Pages e29–e30‘When compared to cloth skull caps, disposable bouffants had greater permeability, greater particulate contamination, and greater passive microbial shed.’
Kothari SN, et al. Journal of the American College of Surgeons. 2018.‘Attending surgeon preference for bouffant vs skull cap does not significantly impact SSI rates after accounting for surgical procedure type.’
Elmously et al. Journal of the American College of Surgeons. 2018.Implementation of the AORN guidelines has not decreased SSIs and has increased healthcare costs.
Journal of Hospital Infection 2002 – There is no need for non scrubbed theatre staff to wear disposable headgear

Policy review

Collaborative statement from AORN, ACS, ASA, APIC, AST and TJC – at present available scientific evidence does not demonstrate any association between the type of hat and SSI rates.
ACORN standards reference Australian Standards which don’t actually relate to headwear.
Excellent review of ACORN Standards as they relate to theatre caps by Dr Rhys Thomas
Information for Trusts about TheatreCapChallenge hats – Draft policy presented to Royal College of Surgeons by Mrs Scarlett McNally

Are disposable caps more hygienic than reusables?

During our research phase in 2022, we had a Microbial Study conducted. Eco Ninjas (formerly Warwick Med) led the study and we worked in collaboration with Birmingham University and Liverpool Royal Hospital under Dr.Diwan. We investigated microbial contamination on theatre caps. The study found an interesting result: non-worn disposable theatre caps actually contained more microbes than fabric hats that had been worn for an entire shift.

This outcome was hypothesised to be due to cross-contamination that occurs when healthcare workers retrieve disposable caps from a box. Since hand washing is not always mandatory before taking a cap, bacteria can transfer from the hands to the caps, increasing microbial contamination.

The study highlights a key point: disposable caps can become contaminated due to cross-contamination when healthcare workers handle them without washing their hands beforehand, especially when selecting caps from a box. Without proper hygiene practices, such as hand washing, the act of dipping dirty hands into boxes of disposable caps can transfer bacteria and other pathogens from hands to the caps, undermining their intended hygienic function.

In contrast, fabric hats, which can be regularly cleaned and laundered, may actually offer a more hygienic choice in certain circumstances. These hats are less likely to carry hidden pathogens, as they are cleaned on a regular basis, ensuring that they do not become reservoirs for bacteria.

We would also recommend that handwashing should be a mandatory practice, particularly before riffling through scrubs to choose the correct size. This simple action can significantly reduce the risk of contamination and enhance infection control protocols, ensuring that healthcare environments remain as safe as possible.

Lanyards

When clinicians ask how the badges from the badge hats are cleaned (once detached from the hats) my reply is always “How do you wash your current name badges?” to which the initial response often is a paused silence combined with a confused expression on the person's face, closely followed by “Well I have never (or rarely) clean my current name badge” which I at first found surprising but this appears to be a standard reply by many theatre staff.

“Lanyards are rarely if ever, cleaned. In a study where only 16% of lanyards had ever been washed, those cleaned recently had lower bacterial counts. In another study conducted on lanyards, ‘The mean age of lanyards was 22 months and 91% had never been laundered. Nine staff (8.8%) had laundered their lanyard ranging from one week to one year previously.

Hygiene and Infection Control of the badges:

The badges attached to the hats can be cleaned with a hard surface wipe or soap and water. Additionally, the hats can be laundered like scrubs, improving infection control when staff adhere to the recommended cleaning practices. The use of press studs, which are simple and lack intricate parts, reduces the likelihood of pathogen buildup compared to traditional buttons, making them a hygienic choice in healthcare environments where cleanliness is critical. Press studs are also easy to fasten and unfasten, providing convenience for busy healthcare staff.

To demonstrate the durability and safety of the badges attached to the hats in healthcare environments, several rigorous tests were conducted to ensure their performance and reliability.

These tests included:

A Peel Test: An independent test centre TWI in Cambridge conducted a peel test to assess the strength of the badge attachment to the hats. Engineers measured the force, in Newtons, required to remove the badges, and the results showed that the force needed for removal remained consistent even after multiple (up to 400) uses. Importantly, none of the press studs failed during these tests, confirming that the fixation method used for attaching the badges was secure, reliable, and simple without the need for complex mechanisms. View full test results

A Degradation Test: Experts at Birmingham University performed a degradation test by submerging the badges in various cleaning chemicals for 25 hours. The badges maintained their quality without any degradation of material or fading of the print. The stainless-steel press studs also remained unaffected by the cleaning chemicals, with no weakening or corrosion observed. This test demonstrated the badges' durability, even after prolonged exposure to harsh substances, making them suitable for repeated use in healthcare settings. View full test results

Conclusion

The comprehensive testing conducted on the badges, the hats, and their components proves that these products are durable, hygienic, and suitable for repeated use in healthcare environments. The results from the peel, degradation, wash, and microbial tests, along with the ease of maintenance, demonstrate their practicality and safety, ultimately contributing to improved infection control in healthcare settings.