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Proper surgical attire is essential in decreasing surgical site infections; however, the effectiveness of the different types of headwear is a controversial topic. We conducted a narrative review based on studies identified through a focused literature search to summarize and critically assess evidence and opinions on the most appropriate type of headwear for OR personnel. We included 48 articles: 17 original research studies and 31 non–peer‐reviewed articles of various types. Research published before 2014 mostly supports the complete coverage of all hair, which aligns with the 2015 AORN guidelines. However, more recent literature rebuts these guidelines and emphasizes the importance of clean headwear. Although earlier studies (published before 2017) lacked scientific rigor, later studies (published after 2017) have other various limitations, including missing data on compliance, surgery‐related techniques, and surgical attire other than headwear. The findings from this review highlight the importance of solid evidence‐based guidelines and expert collaboration.

Introduction The aim of this discussion paper is to consider three issues regarding perioperative attire: 1. whether cloth hats or disposable hats are better for reducing patient risk of acquiring a surgical site infection (SSI) 2. whether the risk of infection is different for the bouffant style of hat compared to the skullcap style of hat 3. whether there is enough evidence available to support a statement that cloth hats are safe to wear in the operating suite. Background Hats have been routinely worn in operating suites since the 1950s. The intention of covering the hair has been to reduce the risk of the patient developing an SSI from bacteria that may be shed from the hair and skin of health care workers. Discussion A literature search was conducted yielding limited results (five), primarily controlled trials and case studies. Australian Standards dictate how cloth hats must be made and laundered. These standards are referenced in ACORN's Standards for Perioperative Nursing in Australia (the ACORN Standards) and should aid health care professionals in appropriate manufacture and laundering of personal perioperative attire. Studies obtained from the literature did not conclusively prove that cloth hats posed an increased risk to patients. However, the literature cites risks to staff when non-hospital laundering has occurred. There was also no evidence-based research suggesting that the incidence of SSIs was influenced by either bouffant or skullcap style hats. Regulation If we choose to allow staff to wear cloth hats, the biggest challenge is ensuring that they are changed daily and meet the Australian standards for manufacture and laundering. While cloth hats may look clean, microscopic blood contamination may not be visible. Recommendation Audits illustrating contamination could be used to educate staff about cleanliness. Education about Australian standards and the risks of infection associated with home laundering must be provided. Conclusion Ultimately, there is not enough research available to indisputably state whether disposable hats or cloth hats pose a greater risk of our patients developing a surgical site infection due to contamination from health care workers. There is also not enough evidence to determine whether the risk of infection is different for the bouffant style of hat compared to the skullcap style. The facility should decide whether they will ban cloth hats, based on the evidence or standards of best practice that are available, or whether they will set up appropriate hospital laundering for staff member's scrub attire. The evidence indicates that the risk from contaminated cloth hats is not a risk to patients but to health care workers and their cohabitants through home laundering of contaminated attire.

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