Authors: Jason S. Chi, MD

After much anticipation, the Association of periOperative Registered Nurses (AORN) published its updated “Guidelines for Surgical Attire” on July 1, 2019.1 The previous version, published in 2014, caused controversy due to its recommendation that bouffant hats be worn instead of skull caps. The guidelines also mandated the covering of arms and prohibited personal clothing underneath scrubs. Skull caps were banned from operating rooms, and regulatory agencies (i.e., the Joint Commission and Centers for Medicare & Medicaid Services) audited compliance with the AORN’s surgical attire guidelines.

Debate about head covers created waves within the health care community, and physician pushback led the American Society of Anesthesiologists (ASA) and American College of Surgeons (ACS) to sit down with the AORN and other stakeholders with the goal of creating revised guidelines based on sound scientific evidence. Details about the surgical attire controversy can be found in the April 2019 issue of this publication.2

Broadly speaking, the updated guidelines are a reversal of the 2014 guidelines with regard to head covers, long sleeves and clothing underneath scrubs.


The updated guidelines state: “No recommendation can be made for the type of head covers worn in the semi-restricted and restricted areas” (section 5.3). Recent studies have not found any correlation between head cover types (i.e. bouffant hat vs. skull cap), surgical site infection rates, and airborne contamination. However, it is recommended to “cover the scalp and hair when entering the semi-restricted and restricted areas” (section 5.1).

Long Sleeves

“No recommendation can be made regarding wearing long sleeves in the semi-restricted and restricted areas” due to a lack of evidence showing either benefit or harm of covering the arms (section 3.2). However, a “conditional recommendation” is made to cover the arms while performing skin antisepsis (“skin prep”), based on a single study that found decreased airborne contaminants when wearing long sleeves while prepping a patient (section 3.1).3

Clothing Underneath Scrubs

“No recommendation can be made” regarding clothing underneath scrubs due to a lack of evidence of either benefit or harm. Facilities are encouraged to create and regulate their own policies regarding clothing underneath scrub attire (section 1.7).


Implications of Change

The new guidelines demonstrate what can be achieved when anesthesiologists and surgeons demand that policy be based on sound scientific evidence. The controversy over head covers may subside for now, but research into surgical attire and patient outcomes must continue in order to provide a solid evidence base for future guidelines.

A question that remains is why the AORN should continue to be the authoritative source of perioperative policy, particularly on issues directly affecting physicians. Previous guidelines and statements from the AORN have been based on low-level scientific evidence, and some have even been contradictory.4,5 Most of the recent studies on surgical attire and surgical site infection were performed by our surgical colleagues, and given the successful collaboration of surgeons and anesthesiologists in responding to the 2014 guidelines, there is no reason to think that future surgical attire guidelines couldn’t simply be created and published by our organizations.

In the meantime, anesthesiology groups should feel empowered to use the new guidelines to bring about changes in local OR policies, knowing that the latest updates have been vetted by the ASA and ACS and are based on the highest-quality evidence available. Implementation of the new guidelines will have an immediate financial and environmental impact: As one example, elimination of disposable OR jackets at a university medical center could save more than $1 million annually.6

Anesthesiologists have been underrepresented in hospital policy and regulatory issues, perhaps because we feel more at home in an OR than a conference room. So it’s a bit ironic that these updated guidelines, which were created in a conference room, represent our efforts to reclaim ownership of the OR. Whether or not we will continue to own that space is entirely up to us.


  1. Association of periOperative Registered Nurses. Guidelines for perioperative practice: surgical attire. AORN Facility Reference Center. guidelines/ content?sectionid=173717946&view=book#221232892. Accessed July 18, 2019.
  2. Chi JS. Skull cap versus bouffant cap: why it matters. Anesthesiology News. 2019;45(4):1,20-21.
  3. Markel TA, Gormley T, Greeley D, et al. Wearing long sleeves while prepping a patient in the operating room decreases airborne contaminants. Am J Infect Control. 2018;46(4):369-374.
  4. Spruce L. Back to basics: surgical attire and cleanliness. AORN J. 2014;99(1):138-146.
  5. Spruce L. Association of periOperative Registered Nurses clarifies position on surgical attire. J Am Coll Surg. 2019;228(2):207-208.
  6. Elmously A, Gray KD, Michelassi F, et al. Operating room attire and healthcare cost: favoring evidence over action for prevention of surgical site infections. J Am Coll Surg. 2019;228(1):98-106.